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Can endometriosis recur following hysterectomy? (New Article)From: Amalia (anonymous@obgyn.net)Wed Nov 10 17:42:58 2004
Can endometriosis recur following hysterectomy? - Professor Ray Garry, Dr David Redwine, Dr Enda McVeight, and Dr Tom Lyons Lone Hummelshøj: We are at the eighth regional meeting of the International Society of Gynaecological Endoscopy. The theme for this congress is endometriosis, which indeed is a challenge of our time. This afternoon we have been discussing hysterectomy and basically the treatment of recurrent endometriosis pain following hysterectomy and surgery. With me is Dr. Ray Garry, from Perth, Australia; Dr. David Redwine, from Bend, Oregon; Dr. Enda McVeigh from Oxford University in England; and Dr. Tom Lyons from Atlanta, United States. Dr. Garry, can it be true if a woman has been told that she's been cured from her endometriosis pain after hysterectomy that she still has pain? Dr. Ray Garry: It is certainly true. A number of patients have had hysterectomy but have not had all the disease removed, and for a variety of reasons that disease can continue. It can persist as severe symptoms: there can be pain, there can be bleeding, there can be bowel obstruction, or problems with the urinary tract. All these things can, and do, happen. It is a very unfortunate situation because both many doctors, as well as many patients, believe that removing the uterus and the ovaries is a complete treatment for endometriosis. Sadly, it often isn't. Lone Hummelshøj: Do the rest of the panel agree with this? Dr. David Redwine: I absolutely agree. I've seen over a 175 patients that I have performed surgery on, who still have endometriosis after having their uterus, tubes and ovaries removed. As Ray says, there are several reasons, but one of the simple anatomic reasons is that endometriosis is predominantly a disease of peritoneal surfaces away from the uterus, and not involving the ovaries. So, if you remove the uterus, tubes and ovaries you are going to be leaving disease behind in about 96% or 97% of the patients. Just anatomically the procedure does not make good sense, even though in actuality it may be relatively effective in some sorts of pain. Dr. Enda McVeigh: Looking specifically at the removal of the ovaries, and the case where the rationale is to create a hypooestrogenic state that will lead to atrophy of the ectopic endometrial tissue, in theory that sounds very good. However, when we look at this chemically, by giving GnRH analogues, we don't actually find this is the result. If you carry out surgery and give an analogue, if you remove all of the disease, then there is no difference in pain. If you carry out surgery and don't remove all of the disease, then you may still have pain with your analogue. I think the rationale is flawed and we forget about the body image in that we're actually castrating a woman, and we are removing a very important organ that may do more than simply give oestrogen replacement. There are all the facts that the ovary may work on, and all we do when give HRT is give oestrogen easily. So I think that our rationale is flawed and thankfully we are seeing a change in that. Dr. Tom Lyons: I think the other part of this issue, and the other part of the discussion this afternoon, is of course, those patients who have felt a pain that is specifically related to their uterus in addition to having endometriosis. Those patients of course may very well benefit from hysterectomy at the time of surgery. But if their endometriosis is not removed at that time, then consequently the patient may very well persist with pain. It's a very sad state when the patient has had, at a premature age, a radical procedure removing the uterus, tubes and ovaries, and unfortunately sometimes missing their endometriosis. Now the patient persists with pain and it is a very sad affair, particularly if that patient has not had an opportunity to experience child bearing, etc. Those are the patients unfortunately who have been relegated all too often to the psychiatrist. They have been told that they are crazy when of course any patient who has persistent pain, for any prolonged length of time, and certainly a patient who has pain for over a year's duration, is going to certainly have some psychiatric difficulty. If nothing else, depression is very closely associated with these types of things. These are patients that have a good right to be crazy in point of fact, and they have to be listened to, and their disease has to be treated appropriately. Dr. Ray Garry: I think it's important to emphasise however that a lot of women with endometriosis do have other conditions, which means the hysterectomy is of value. We are certainly not saying that people should never have a hysterectomy as part of the treatment program. However, for most women the principle arm of the treatment program would be the removal of the endometriosis outside the uterus and then a careful assessment, both of the woman's wishes, her fertility requirements particularly, and also the disease that is there. In the ideal world we should now be assessing the uterus separately from the endometriosis and deciding which bit of the entire treatment package each individual should have. Dr. Tom Lyons: I think that's one of the things that makes laparoscopy the tool of choice in this disease process. It uniquely gives you the opportunity to assess that disease process very carefully, and remove that disease process as we do, before embarking upon a hysterectomy, as that is also an indicated procedure. That gives you the opportunity to do that clearly in, I think, the most effective manner, and probably the most aggressive manner, for the patient and her disease process. Dr. Enda McVeigh: I think it is very important that we listen to the patient as you said and that we individualise the treatment of the patient. Listening to the patient, talking to her, and ascertaining what is the most important outcome that she wants, and listening to what the evidence is that we can give that outcome, and then applying the surgery properly. That may well be a hysterectomy for the lady who is finished with fertility and who has heavy long periods and no longer wants those. Certainly hysterectomy combined with removal of endometriosis is the appropriate form of therapy. So listen to the patient, apply on her evidence based procedures for that individual case. I think that is most important. Dr. David Redwine: One of the things that a general gynaecologists may be worried about, or interested in at the time s/he is doing a hysterectomy and removal of the ovaries, is how likely is this particular patient going to be possibly symptomatic after this from retained endometriosis? I have found in my series of patients that had post-castration and post-hysterectomy endometriosis that they had intestinal involvement, obliteration of the cul de sac or invasive disease at the time of their previous hysterectomy and removal of the ovaries, then those manifestations of the disease were very commonly found among my patients that I was re-operating on for pain. So that can be a marker that surgeons can use to say, "Well, I really need to take that disease out". If they can't, at least note it was present. If the woman has continuing pain he'll already be ahead of the game knowing that she had obliteration of the cul de sac, so this is to be expected. Dr. Tom Lyons: I think we can wrap it up and say that certainly hysterectomy is an effective procedure when it is indicated. But generally speaking, in treating endometriosis, we need to treat that disease first, and treat it effectively. Listen to our patients, they'll tell us what is wrong with them. And I think we can better serve them in that manner. Lone Hummelshøj: Thank you very much. Drs. Ray Garry, David Redwine, Endo McVeigh, Tom Lyons: Thank you very much.
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