Both medication and surgical treatments for endometriosis-related pain are effective, and the choice of treatment must be individualized.
Reduced pelvic pain in women with endometriosis: efficacy of long-term dienogest treatment
Felice Petraglia, Daniela Hornung, Christian Seitz, Thomas Faustmann, Christoph Gerlinger, Stefano Luisi, Lucia Lazzeri and Thomas Strowitzki
Long-term use of dienogest showed efficacy and safety of the drug, with progressive reductions in pain and irregular uterine bleeding during treatment; reductions in pelvic pain persisted for at least 24 weeks after stopping treatment.
- Petraglia F, Hornung D, Seitz C, Faustmann T, Gerlinger C, Luisi S, Lazzeri L, Strowitzki T. Reduced pelvic pain in women with endometriosis: efficacy of long-term dienogest treatment. Arch Gynecol Obstet. 2012 Jan;285(1):167-73. doi: 10.1007/s00404-011-1941-7. Epub 2011 Jun 17. PMID: 21681516; PMCID: PMC3249203
- Römer T. Long-term treatment of endometriosis with dienogest: retrospective analysis of efficacy and safety in clinical practice [published correction appears in Arch Gynecol Obstet. 2019 Jan;299(1):293]. Arch Gynecol Obstet. 2018;298(4):747-753. doi:10.1007/s00404-018-4864-8
Surgery versus hormonal therapy for deep endometriosis: is it a choice of the physician?
Berlanda N, Somigliana E, Frattaruolo MP, Buggio L, Dridi D, Vercellini P.
Hormonal treatment of deep endometriosis with progestins such as norethindrone acetate or dienogest, or with OCs, is effective in controlling pain in over 90% of women at one year follow-up.
Progestins and OCs can be safely prescribed for long periods of time, are inexpensive, and are usually well tolerated. Consequently, these medications may serve as first-line treatment for pain associated with advanced endometriosis in women not seeking natural conception.
However, hormonal treatment is ineffective or not tolerated in about 30% of women, with the most common side effects being disordered bleeding, weight gain, decreased libido and headaches.
Efficacy of dienogest treatment of clinical symptoms of rectovaginal endometriosis
Z Papíková, R Hudeček, P Ventruba, M Szypulová
Continuous use of dinonegest for a 24-week period reduces symptoms of dyspareunia by 62%, diffuse pelvic pain by 44%.
Continuous therapy with 2 mg of dinovenogest daily for 24 weeks is effective in reducing clinical symptoms such as dyspareunia and diffuse pelvic pain in patients with endometriosis of the rectovaginal septum in the reproductive age.
Peritoneal defects and the development of endometriosis in relation to the timing of endoscopic surgery during the menstrual cycle
Karl-Werner Schweppe, Dieter Ring
Surgery to treat peritoneal endometriosis should not be performed during the luteal phase!
The overall recurrence rate after 2 years was 9.6%. The recurrence rate in group III (15%) was twice as high as in group I (7%) and group II (8%), as evidenced by subjective complaints, clinical findings, macroscopy, and histology.
Laparoscopic surgery in infertile women with minimal or mild endometriosis. Canadian Collaborative Group on Endometriosis.
Marcoux S, Maheux R, Bérubé S.
Minimal or mild endometriosis is often diagnosed with infertility.
Laparoscopic resection or removal of minimal or mild endometriosis increases fertility in infertile women.
Excision of endometriosis foci of the pelvic peritoneum
The operation was performed for infertility. During the operation, foci of endometriosis on the pelvic peritoneum, endometriosis of the left ovary were identified and removed. Four months after the operation, the pregnancy occurred independently.
Isolated Ovarian Endometrioma: A History Between Myth and Reality
Caterina Exacoustos, Giovanna De Felice, Alessandra Pizzo, Giulia Morosetti, Lucia Lazzeri, Gabriele Centini, Emilio Piccione, Errico Zupi
T-vag ultrasound showed:
rectal DIE in 55 patients (21.5%)
thickening of at least 1 uterosacral ligament 93 patients (36.4%)
186 patients (73%) had adhesions
134 patients (53%) showed signs of myometrial adenomyosis
39 patients (15%) showed only one isolated endometrioma with a mobile ovary and no other signs of pelvic endometriosis/adenomyosis
The distinguishing cellular and molecular features of the endometriotic ovarian cyst: from pathophysiology to the potential endometrioma-mediated damage to the ovary
Sanchez AM, Viganò P, Somigliana E, Panina-Bordignon P, Vercellini P, Candiani M.
There is sufficient molecular, histological and morphological evidence, in part deriving from knowledge of the pathophysiology, to support a deleterious effect of the endometrioma on the adjacent ovarian cortical tissue, independent of the mere mechanical stretching owing to its size
Enhanced follicular recruitment and atresia in cortex derived from ovaries with endometriomas
Kitajima M, Dolmans MM, Donnez O, Masuzaki H, Soares M, Donnez J
In the ovaries with endometriomas, there is increased follicular growth (recruitment), and at the same time, the death of early follicles, which leads to focal depletion of the ovarian reserve.
The potential contribution of inflammation to follicle burnout in endometriomas is discussed.
According to the "invagination" theory, an endometrioma formed as a result of invagination contacts the cortical layer of the ovary. The best place to excise the cyst is the contact site (indicated by the red arrow on the diagram). The most gentle and bloodless method of removal will be obtained when it hits this layer. In this case no coagulation is necessary, because the ovary does not bleed. To open the cyst and get into the layer, it is necessary to "tear off" the ovary from the peritoneum of the ovarian fossa. If the layer is not clearly visible, a small incision can be made at the edge of the opened cyst to better differentiate the layers.
The surgeries below show this technique.
When removing an endometrioma it is also necessary to take into account the blood supply to the ovary. After all, not only thermal and mechanical damage to the ovarian tissue leads to a decrease in ovarian reserve and can lead to the loss of ovarian function, but also damage to the blood vessels. Small blood vessels go to the ovary along the mesasalpinx and the broad ligament of the uterus. These areas must be gently touched and damage must be avoided
Involvement of mesosalpinx in endometrioma is a possible risk factor for decrease of ovarian reserve after cystectomy: a retrospective cohort study.
Ai Saito, Akira Iwase, Tomoko Nakamura, Satoko Osuka, Bayasula, Tomohiko Murase, Nao Kato, Chiharu Ishida, Sachiko Takikawa, Maki Goto, Fumitaka Kikkawa
«pre-existing mesosalpinx disturbance, in combination with adhesiolysis, may be involved in the medium and long-term decrease in ovarian reserve after endometrioma surgery.
A disturbance in ovarian blood supply via the mesosalpinx may underlie this»
Effect of laparoscopic excision of endometriomas on ovarian reserve: serial changes in the serum antimüllerian hormone levels
Celik HG, Dogan E, Okyay E, Ulukus C, Saatli B, Uysal S, Koyuncuoglu M
«We did not find any correlation between the histopathologic analysis of the removed ovarian tissue and the reduction in the AMH levels.
This suggests that other mechanisms are also involved other than healthy ovarian tissue removal»
One-year follow-up of serum antimüllerian hormone levels in patients with cystectomy: are different sequential changes due to different mechanisms causing damage to the ovarian reserve?
Celik HG, Dogan E, Okyay E, Ulukus C, Saatli B, Uysal S, Koyuncuoglu M
«Our results suggest that removal of ovarian cortex might be involved in the decrease of the ovarian reserve just after surgery, and that a continuous decrease of the ovarian reserve after cystectomy might be attributed to other mechanisms»
Gentle endometrioma removal
Removal of an endometrioid ovarian cyst by subcapsular injection of terlipressin followed by excision of the cyst without the use of a coagulator.
Bilateral endometriomas
Cyst capsule excision
Deep infiltrative endometriosis is one of the most complicated surgeries in operative gynecology and is on the same level with oncological diseases. These surgeries require a thorough understanding of the pelvic floor anatomy and tremendous experience of the surgeon.
Adenomyosis: review of the literature
Garcia L, Isaacson K.
If the patientʼs family planning is complete, hysterectomy represents the most effective treatment.
Progestogins, oral contraceptives and progestin-releasing intrauterine systems are used as an alternative to hysterectomy. The therapeutic effect is based on the induction of amenorrhea. Contraceptives (monophasic products) and progestins should be taken continuously.
The effect of pregnancy on endometriosis-facts or fiction?
Leeners B, Damaso F, Ochsenbein-Kölble N, Farquhar C.
Pregnancy in women with endometriosis is not always associated with an improvement in symptoms. While some foci shrink, others remain stable or increase.
Moreover, there is increasing evidence that endometriosis can prevent a successful pregnancy outcome.
The only clear beneficial effect is the absence of new endometrial fragments entering the abdominal cavity as a result of amenorrhea
Endometriosis is a chronic disease that requires a long-term management plan to maximize the use of medication and prevent repeated surgical interventions.
Endometriosis of the scar after cesarean section in the area of rectus abdominis muscle (photo + short video)
Year: 2017 Endometrioma with uterine tube fimbriae inside
An interesting clinical case. A patient applied for a decision on the issue of surgery for an ovarian cyst. The cyst was first identified in 2016. On my examination according to the ultrasound findings: 36x40 mm cyst with a fine-dispersed suspension, with a 5x7 mm wall hyperechogenic component with active blood flow. MRI was recommended. MRI conclusion: a high probability endometrioid cyst of the left ovary, endometriosis of the left fallopian tube?
During the operation: the ovary was tightly fused to the abdominal ovarian fossa, the left fallopian tube was wrapped around the ovary and involved in the adhesion process, the fimbrial section of the left fallopian tube was revealed inside the endometrioid cyst, which gave the picture of a walled component and was part of the cyst wall.
