Is it necessary to always diagnose endometriosis with laparoscopy?

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Endometriosis is very common, and certainly under-diagnosed, in reproductive age women.  Endometriosis is known to cause two major problems: infertility and progressive pelvic pain (often with gastrointestinal problems like constipation and/or diarrhea and urinary problems like sharp subrapubic pain around the time of urination) that is initially worse during the active menstrual flow.  Some endometriosis appears to be asymptomatic; it does not seem to cause either of these problems.

 

If a woman is known to have endometriosis, possibly diagnosed incidentally at the time of surgery for an unrelated condition, and she has been successful in getting pregnant and she has no pelvic pain, then it is unclear why she would need to treat the endometriosis.  In other words, treatment for endometriosis is usually initiated in order to minimize or eliminate the problems that it is causing.  Endometriosis is a benign condition so it doesn’t need to be treated aggressively, as one would a malignancy.  Endometriosis almost always progresses during the reproductive years (after menarche and prior to menopause) so symptoms may develop as the disorder grows.  Of course, treatment can be delayed until the symptoms associated with endometriosis are severe enough to warrant treatment with either medications or surgery.

 

In plain language, from a strictly clinical (rather than academic or research) point of view endometriosis needs to be positively identified when that diagnosis will change the patient’s management plan (change her treatment).  When there are no symptoms of endometriosis that require treatment, then a positive identification is not clinically relevant.  When there are problems that need treatment, such as infertility or pelvic pain that is interfering with the woman’s activities of daily living, then diagnosis is clinically relevant.

 

Research has shown that infertility associated with endometriosis is only treated effectively using surgical removal.  Medications for endometriosis do not improve fertility.  Therefore, laparoscopy can identify and treat endometriosis during the same surgical (laparoscopy) procedure.  Of course, the training and experience of the surgeon is of utmost importance to improve the chances for a positive outcome.

 

Research has shown that pelvic pain associated with endometriosis is effectively treated with either medications or surgery.  When endometriosis is presumed to cause progressive pelvic pain, some physicians would suggest starting treatment with medications to see if they are effective even prior to confirming the diagnosis of endometriosis with laparoscopy.  This has the benefit of being noninvasive.  However, the medications that are used to treat endometriosis, including but not limited to Lupron, Danazol, and Provera, all have significant potential side effects and/or complications and they usually begin to effectively reduce the pain only after months of administration.  These issues should be discussed with the woman seeking treatment for pelvic pain.  Laparoscopy is also able to effectively reduce the pain that is associated with endometriosis, laparoscopy removes endometriosis so the benefit from the treatment is rapidly realized, and diagnosis and treatment can be performed during the same laparoscopic surgical procedure.

 

With regard to laparoscopy and endometriosis, the European Society of Human Reproduction and Embryology (ESHRE) has stated “In women with symptoms and signs of endometriosis there is an argument for starting medical treatment before embarking on an invasive procedure like laparoscopy to obtain histological proof of the disease (as mentioned above).  Arguments to perform a laparoscopy include the woman’s wish to have a definitive diagnosis, infertility and/or symptoms and signs of advanced disease (ovarian endometrioma or deep infiltrating disease.” (Management of women with endometriosis: September 2013, page 17).

 

At The NJ Center for Fertility and Reproductive Medicine, Dr. Eric Daiter, MD has performed over a thousand laparoscopic procedures over a 20 year time period for the diagnosis and treatment of endometriosis and he is expert in minimally invasive surgical pelvic repair.  If you want an experienced, caring and cost considerate surgeon to help you with the treatment of your endometriosis, then you should call Dr. Daiter’s office to arrange a consultation.  Dr. Daiter would be happy to help you.

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