Page 42 - WALS Journal

Laparoscopic Excision of Endometrioma
concentration, and the guidelines from the Royal College of study only 10% of women who had a levonorgestrel intrauterine
Obstetricians and Gynecologists described CA125 as having system after surgery for endometriosis had moderate or severe
only limited value as either a screening or a diagnostic test. 6 dysmenorrhea compared with 45% of the women who had
12
Laparoscopy is the only diagnostic test that can reliably surgery only. In a trial of 82 women with endometriosis the
rule out endometriosis. It is also accurate in detecting levonorgestrel intrauterine system had similar effectiveness to
endometriosis and is considered the standard investigation. 6 GnRH analogues, but the potential for long-term use of this
system is advantageous if the woman does not want to
13
What are the Indications for Laparoscopy? conceive. It has also been used in women with rectovaginal
14
disease. In the future aromatase inhibitors may have a
Many young women experience dysmenorrhea (about 60-70%),
and unless there are other features to indicate endometriosis therapeutic role in endometriosis as they inhibit estrogen
16
laparoscopy is not recommended. Some women will require production selectively in endometriotic lesions, without
25
further investigation to guide management. For adolescents affecting ovarian function.
who present with dysmenorrhea, the recommended approach
is to first prescribe non-steroidal anti-inflammatory drugs Is Surgery or Medical Treatment More Effective?
(NSAIDs) and oral contraceptives. 17,18 The lack of measurable There are no randomised controlled trials comparing medical
pain relief with these drugs is usually an indication for further versus surgical treatments for the management of endometriosis,
19
investigation. Other indications for laparoscopy include and the decision about medical or surgical treatment at the time
severe pain over several months, pain requiring systemic of diagnosis will depend on several factors including patient’s
therapy, pain resulting in days off work or school, or pain choice, the availability of laparoscopic surgery, the desire for
requiring admission to hospital. fertility, and concerns about long-term medical therapy.
Treatment options for medical therapy include oral Surgery for endometriosis can be performed
contraceptives, progestogens, androgenic agents, and laparoscopically or as an open procedure. It entails excision or
gonadotrophin releasing hormone (GnRH) analogues. All ablation (by laser or diathermy), or both, of the endometriotic
suppress ovarian activity and menses and atrophy of tissue with or without adhesiolysis. There are few trials of
endometriotic implants, although the extent to which they laparoscopic treatment. 14,15 Surgical excision of endometriosis
achieve this varies. There have been few randomised controlled results in improved pain relief and improved quality of life after
14
trials of medical treatment versus placebo, although many trials six months compared with diagnostic laparoscopy only. In
have compared different types of medical treatment. 7-10 All one of the trials laparoscopic treatment also included uterine
15
medical treatments are similarly effective in relieving pain during nerve ablation (LUNA), and pain improvement persisted for
26
treatment. up to five years in more than half of the women. About 20% of
The side effect profiles are important in deciding treatment women do not report any improvement after surgery. 14
choices. Progestogens are associated with irregular menstrual No randomised controlled trials have compared laser versus
bleeding, weight gain, mood swings, and decreased libido. The electrosurgical removal of endometriosis, and only one small
side effects associated with danazol include skin changes, trial, with inconclusive results, compared excision versus
weight gain, and occasionally deepening of the voice, and it is ablation. 27
infrequently prescribed now. GnRH analogues dramatically
lower estrogen concentrations, and side effects include the How often does Endometriosis Recur after Surgery?
development of menopausal symptoms and the loss of bone Recurrence of endometriosis after laparoscopic surgery is
mineral density with long-term use (both reversible). Estrogen common. 16,26 Even with experienced laparoscopic surgeons,
therapy in an add back regimen is useful for preventing side the cumulative rate of recurrence after five years is nearly 20%. 17
10
effects with GnRH analogues. In the randomised controlled Another study reported recurrence of dysmenorrhea in almost
trials comparing subcutaneous depot medroxyprogesterone a third of women within one year of laparoscopic surgery in
acetate (SC-DMPA) with GnRH analogues the bone loss was women who received no other treatment. 16
less with the progesterone during treatment. 20-21 Recurrence of
painful symptoms after six months of medical treatment may be What is the Evidence for Surgery in Women with
as high as 50% in the 12-24 months after the treatment is Endometriomata?
stopped. 22-23 Recurrence may in part be because large lesions
respond poorly to medical treatment. It is generally accepted Randomised controlled trials comparing excision or drainage
that endometriomata are not amenable to medical treatment, and ablation for endometriomata 3 cm reported that recurrences
although temporary clinical relief may be achieved. were reduced and subsequent spontaneous pregnancy
19
The levonorgestrel intrauterine system (LNG-IUS) is an increased in the women who underwent excision. Though
established treatment for heavy menstrual bleeding but can excisional surgery of the capsule could lead to removal of normal
also be used for dysmenorrhea and endometriosis. 11,24 In one ovarian tissue and result in reduced ovarian reserve, 20,28 there
45