Diagnosis & Treatment
Diagnosis of Endometriosis
The main technique for diagnosis is a laparoscopy, which involves a small camera being passed though the umbilicus (belly button) under anaesthetic to allow direct inspection of the organs of the pelvis. Because of this, and often a lack of awareness, there is frequently a delay in diagnosis with the average delay from first presentation to diagnosis being 3-11 years.
Treatment of Endometriosis
Treatments of the condition broadly speaking are broken down into medical treatments (drugs) and surgical treatments.
Medical Treatment
The aim of medical treatments is to improve symptoms by suppressing the endometriosis. Drugs used include the combined oral contraceptive pill, progestogens (eg norethisterone, provera), depo provera injection, danazol (rarely) and gonadotrophin releasing anologues (eg Zoladex, Prostap).
Around 80-90% of patients will have improvement of their pain symptoms and all have similar efficacy. Relapse rates on stopping however are high with up to 50% relapsing at one year and 33-74% relapse rate at 3-5 years. This is due to the fact that these treatments suppress disease rather than irradicate it. Side effects are relatively frequent and very from treatment to treatment and none of these treatments are suitable for patients trying to conceived as they are relatively contraceptive.
Surgical Treatment
Surgical treatment is either conservative, aiming to treat the disease and leave the gynaecological organs (or as much of the gynaecological organs as possible) or radical with hysterectomy and removal of the ovaries. This classification however is often confusing as most endometriosis experts will perform ‘radical’ excision of endometriosis where by all the disease is excised with electrosurgery or ablated / vapourised with the laser rather than simply being superficially burnt with diathermy. At present less than 20% of UK consultant gynaecologist perform excisional laparoscopic surgery for endometriosis and even fewer laser surgery. Conservative treatment is usually carried out by keyhole surgery and most often as a day case procedure, however this does depend on the severity of the disease. Severe disease involving the bowel will usually require the gynaecologist to operate with a colorectal surgeon who specialises in keyhole surgery.
Overall symptomatic improvement following excisional / laser surgery occurs in 62-80%. Further laser surgery in those who relapsed or did not achieve significant benefit the first time gives similar results with nearly two thirds having symptomatic improvement.
In patients with sub- fertility and endometriosis laparoscopic surgery has been shown to increase fertility. A large study comparing laparoscopic treatment with no treatment showed those treated had nearly a doubling (90%) of their chances of falling pregnant. Based on this the National Institute of Clinical Excellence (NICE) in the UK advice all women with sub-fertility an endometriosis should be offered laparoscopic treatment. In summary endometriosis is a relative common condition whose exact cause is unclear. Drug for pain symptoms is effective but symptoms usually recur on stopping. Surgical treatment is effective for pain and sub-fertility with the aim of long term cure of the condition.