Pelvic Organ Prolapse
Treatment of Endometriosis
Currently there are two ways to treat endometriosis – hormonal
therapy and surgery.
Depending on the patient’s expectations and the extent of
the disease, we may prescribe hormonal therapy, surgery, a combination
of surgery and hormonal therapy, or occasionally a just “wait
and see” approach.
Hormonal therapy is based on the knowledge of the response of existing
estrogen and progesterone receptors on ectopic endometrial tissue
to certain hormonal agents. Since endometrial lesions are not all
the same with regard to the number and response of receptors to
the hormonal agents, the result of the hormonal treatment may vary
from patient to patient. Hormonal therapy is considered as suppressive,
thus temporary. Endometriosis will recur after the treatment is
discontinued. Following are some of the currently available hormonal
agents for treatment of endometriosis.
- Birth Control Pills: Birth control pills, or oral contraceptives,
are the combination of estrogen and progestin pills to regulate
a patient’s hormonal levels and suppress endometrial growth.
While a patient is on birth control pills, ovulation usually ceases
and endometrial lesions shrink. The common side effects of taking
birth control pills are weight gain, nausea, headache, mood changes,
depression, irregular vaginal bleeding, and loss of sexual desire.
- GnRH Agonists: This agent works by suppressing the pituitary
hormones (FSH and LH) to stop the ovary from producing estrogen,
putting the patient into a menopausal state, and thus shrinking
the endometrial lesions. The names of GnRH agonists include Lupron
Depot, Synarel, and Zoladex. The drug can be given by injection
or nasal spray. The main side effects of menopausal syndromes
are hot flashes, cold sweat, insomnia, vaginal dryness, loss of
sexual interest, and depression. The FDA has approved GnRH agonists
for no longer than six months in a lifetime due to the risk of
- Progestins: Progestins work by keeping the ovarian hormone
(estrogen and progesterone) levels low to prevent ovulation and
suppress endometrial growth. Common names of progestins are Provera,
Cycrine, Megace, Micronor, Amen, Nor-Q.D., and Depo-Provera. The
main side effects include irregular vaginal bleeding, depression,
breast tenderness, moodiness, weight gain, headache, and fluid
- Danazol: Danazol exhibit some androgen (male hormone)
effect and reduces ovarian hormonal production. Most women will
stop ovulation and menstruation when they are on Danazol, and
their endometrial lesions will shrink and become inactive. The
main side effects of Danazol are weight gain, decrease in breast
size, acne, oily skin, male-pattern hair growth, and deepening
of the voice.
Laparoscopic surgery is the main and definite way to diagnose and
treat endometriosis. Ideally, all the endometrial lesions should
be excised through the laparoscope at the initial diagnosis of endometriosis.
Unfortunately, most gynecologists are not well trained in treating
extensive endometriosis through laparoscopy. Thus many women with
extensive endometriosis often require more than one surgery and
suffer from many undesirable sequelae of poorly performed surgery.
It can not be emphasized more the importance of finding a well trained
gynecologist at initial diagnosis and treatment of endometriosis.
The definite treatment of endometriosis is NOT hysterectomy and
bilateral salpingo-oophorectomy (remove both uterus and ovaries)
– Many gynecologists now a days still mistakenly believe that
remove both uterus and ovaries are the cure for endometriosis. In
our center we believe strongly that the correct way of treating
endometriosis is the complete excision of the endometrial lesions,
whether it appears on the pelvic organs or on the bowel, ureter
(draining tube between the kidney and the bladder), and bladder.
The decision of whether to perform hysterectomy or oophorectomy
at time of endometriosis surgery will purely based on whether there
are any coexisting uterine or ovarian pathology in addition to the
presence of endometriosis and patient’s desire for future
childbearing. For example, if patient is known to have severe endometriosis
and no longer desires to bear a child, and meanwhile fibroids (benign
tumor of womb which may cause heavy menstrual bleeding and cramps)
are found on her uterus, then hysterectomy along with excision of
all endometriosis should be recommended for patient. Throughout
years,we have performed numerous laparoscopic surgeries for extensive
endometriosis with excellent results without removing either normal
uterus or ovaries.
The Role of Presacral Neurectomy in Conservative Surgical Treatment
We sometimes perform Presacral Neurectomy (resection of part of
presacral nerve which is in charge of pain sensation in the midline
pelvic area. The procedure will reduce the pain and cramps in the
midpelvic area and it does not affect the sexual feeling or sensation
of the patient) along with the excision of endometrial implants
for those patients desire to have future childbearing but suffer
from severe midline pelvic pain and cramps.