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. 2002 Jan 12;324(7329):115. doi: 10.1136/bmj.324.7329.115

Endometriosis

Emphasis on medical treatment is misleading

Kevin D Jones 1, Christopher Sutton 1
PMCID: PMC1122004  PMID: 11786466

Editor—In his review on endometriosis, Prentice sets out management strategies for treating painful symptoms resulting from endometriosis.1 He concludes that the first line treatment should be medical and that surgery should be reserved for cases in which medical treatment has failed or for patients with severe disease. We believe that the emphasis on medical treatment and the assertion that controversy exists over the precise role of surgery are misleading and may be responsible for physicians mismanaging their patients.

The evidence from randomised controlled trials for the medical and surgical management of endometriosis has recently been reviewed.2 A critical summary of the medical management has shown that there is little difference in effectiveness of various medical treatments, which only last while patients remain on treatment. The review also showed that surgical management is effective in the treatment of both painful symptoms and subfertility. Furthermore, there is a wealth of grade II and III evidence in the literature which supports laparoscopic surgery as the primary treatment modality for all stages of endometriosis.3

We believe that in the United Kingdom endometriosis is misdiagnosed in many patients who are having a laparoscopy, and many are not treated adequately because of the emphasis on medical management strategies.3 This almost certainly reflects the fact that only a few surgeons in the United Kingdom have the advanced endoscopy skills required to diagnose and then treat the disease laparoscopically. This is in marked contrast to the situation in the rest of Europe and North America, where surgical techniques using minimal access were first developed.

We recommend that medical treatments be used by primary care doctors for the short to medium term to control painful symptoms, before referral to hospital for surgery or while the patient is on the waiting list for surgery. Patients should be referred to units where laparoscopic diagnosis and surgery can be carried out during the same operation. Conservative, excisional, or ablative endoscopic surgery and not medical treatment should be the first line management of patients with endometriosis. This applies to women with any stage of the disease, but particularly those with endometriotic cysts, or infiltrating rectovaginal disease.4,5

References

  • 1.Prentice A. Endometriosis. Regular review. BMJ. 2001;323:93–95. doi: 10.1136/bmj.323.7304.93. . (14 July.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Farquhar C, Sutton CJG. The evidence for the management of endometriosis. Curr Opin Obstet Gynaecol. 1998;10:321–332. doi: 10.1097/00001703-199808000-00007. [DOI] [PubMed] [Google Scholar]
  • 3.Garry R. Endometriosis: an invasive disease. Gynaecol Endoscopy. 2001;10:79–83. [Google Scholar]
  • 4.Jones KD, Sutton CJG. Laparoscopic management of ovarian endometriomas: a critical review of current practice. Curr Opin Obstet Gynaecol. 2000;12:309–317. doi: 10.1097/00001703-200008000-00008. [DOI] [PubMed] [Google Scholar]
  • 5.Jones KD, Sutton CJG. Arcus taurinus: the mother and father of all LUNAs. Gynaecol Endoscopy. 2001;10:83–91. [Google Scholar]
BMJ. 2002 Jan 12;324(7329):115.

Clinicians and patients should be aware of association between endometriosis and malignancies

Nazar N Amso 1

Editor—Prentice's review highlights the difficulties encountered in clinical practice in relation to endometriosis.1-1 Clinicians should use abdominal or transvaginal ultrasound imaging of the pelvis when women present with pelvic pain, dysmenorrhoea, or dyspareunia to ascertain whether the ovaries are normal or contain endometriotic cysts. The presence of these cysts may indicate more widespread disease in the pelvis. This is important for women about to undergo major gynaecological surgery as unexpected extensive and severe endometriosis may lead to more surgery than had been discussed preoperatively or consented to by the patient. This has medicolegal implications.

Another issue is that of the association between endometriosis and ovarian cancer. So far this has not been a subject that is discussed in full with patients. But a study of 1000 cases of endometriosis reported that, in 8.8% of cases, malignancy and endometriosis were both present in the same organ, but not necessarily microscopically contiguous, and higher if the lesions were located in different organs.1-2 Malignancies were also more commonly found in ovaries that contained endometriosis. Clear cell and endometroid carcinomas were the malignancies most commonly seen in endometriotic ovaries, and there was clear association between these histological types and endometriosis. Clinicians and patients must be made aware of this association, especially when surgery is contemplated in comparatively young women.

Footnotes

Competing interests: None declared.

References

  • 1-1.Prentice A. Endometriosis. Regular review. BMJ. 2001;323:93–95. doi: 10.1136/bmj.323.7304.93. . (14 July.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-2.Stern RC, Dash R, Bentley RC, Snyder MJ, Haney AF, Robboy SJ. Malignancy in endometriosis: frequency and comparison of ovarian and extraovarian types. Int J Gynecol Pathol. 2001;20:133–139. doi: 10.1097/00004347-200104000-00004. [DOI] [PubMed] [Google Scholar]

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