Dr. Theodosis Arkoulis’ insights on endometriosis
Endometriosis remains a tough issue for gynecologists, whether manifested as pelvic pain (cyclical or chronic) or as infertility. Diagnosis as well as treatment is difficult.
This is why doctors in European and international conferences suggest the establishment of endometriosis centers where women will be provided with thorough screening and management.
In this short article, I’d like to point out the importance of diagnosis. Screening methods are the first step to diagnosis with ultrasound imaging being used the most. Magnetic resonance imaging, or MRI, is also very important as it allows us to obtain images from the retroperitoneal space, the Douglas space, and the uterine ligaments (transvaginal or transrectal U/S also help in this case) Lesions around the ureter (seen via genitourinary MRI) or retroperitoneal nodules need to be identified either through screening or palpitation so that the doctor can plan the best surgical approach. Laparoscopy is, of course, a major diagnosis tool for endometriosis.
Endometriosis is treated either through classic laparotomy or through invasive laparoscopy. With the aim to remove all endometriosis foci, the doctor shall choose the appropriate approach based on his specialization and expertise. This is why pre-operative assesment is of the utmost importance as the gynecologist must be prepared for any eventuality.
This means that a general surgeon may be called to assist if there is suspicion that endometriosis has invaded the bowel wall. Likewise, a urologist will scrub in if ureteral lesions are identified. In this context, surgery involves more than one surgeon (gynecologist and/or general surgeon and/or urologist) who is called to deal with extensive endometriosis. By following this approach, repeat surgeries are avoided.
The importance of the first operation should be stressed, as the surgical field during the initial procedure is cleaner and seen with less adhesions, i.e. the surgeons are most likely avoiding the so-called “frozen pelvis.”
There is also hope that new drugs, such as aromatase inhibitors, that have the advantage of peripheral action, or selective progesterone receptor modulators (SPRMs) or angiogenesis inhibitors, will help relieve women who are suffering from extensive endometriosis.