At some point in your treatment for endometriosis, your doctor will likely recommend surgery. What type of surgery, how the surgery is performed and, most importantly, the reason for the surgery should all be part of your decision as to whether or not to undergo any operation.
Typically, experts agree that an integrative approach—one that uses both medical and surgical treatments—works best for managing endometriosis. As to which is better, well, no one knows. There have been no head-to-head clinical trials comparing the two.
The most commonly used surgeries for endometriosis are:
Laparoscopy. This is a minimally invasive procedure to remove the "lesions" of endometriosis. During a laparoscopy, the surgeon views your abdominal area and reproductive organs through a tiny lighted telescope inserted through one or more small incisions in your abdomen. From there, the surgeon can either cut out the endometrial tissue or destroy it with heat or laser.
Laparotomy. This is a more involved surgery requiring an abdominal incision. The major negative of this type of surgery is that it typically requires a much longer recovery time involving more pain and disability.
Studies are mixed as to which type of surgery is best. Some show lower rates of recurrence and higher rates of pregnancy with laparotomy; others show just the opposite. Both types of surgery carry a risk of scar tissue and adhesions, which could lead to infertility, make pain worse, require additional surgeries or damage other pelvic structures. Adhesions form as a result of injury or trauma to the peritoneum, the clear membrane that covers the inside of the abdomen and all abdominal and pelvic organs, except the ovaries. When healthy, this membrane is slippery. Once injured, however, the immune system kicks in to repair things, leading to inflammation and the production of sticky scar tissue called a fibrin matrix.
Normally, these bands of scar tissue dissolve through a biochemical process called fibrinolysis, the process that enables a cut on your finger and any resulting scab to heal. But surgery reduces levels of blood chemicals needed for fibrinolysis, meaning these fibrous bands may not dissolve; instead, they develop into adhesions. Adhesions may form within a couple of weeks after surgery, within months or even after a year or more.
Other, less common surgeries for endometriosis include:
Presacral neurectomy (PSN). This surgery is performed to help with menstrual pain, not to get rid of the endometrial lesions. It basically cuts the presacral nerve, which provides sensation to the uterus and pelvic floor. One study comparing PSN with laparotomy or laparoscopy found a much higher "cure" rate in those undergoing PSN, although women undergoing the more conservative surgery had no complications compared to 11 in the 60 women undergoing PSN. The complications were primarily constipation and some urinary urgency (suddenly feeling like you have to go to the bathroom). None of the women experienced any sexual dysfunction or urinary retention (when urine is left in bladder after urinating).
Laparoscopic uterosacral nerve ablation (LUNA). In this procedure, the nerves that provide feeling to the cervix and lower part of the uterus are destroyed laparoscopically.
A review of studies on PSN and LUNA found they worked best for women whose pain was not caused by endometriosis. The review also found that combining PSN with a laparoscopy relieved pain better than laparoscopy alone, although there was a higher rate of complications in women undergoing PSN. The primary adverse effects were constipation and urinary urgency.
Hysterectomy. Hysterectomy involves the removal of the uterus. Sometimes, the cervix is also removed. In a hysterectomy with bilateral oophorectomy, the ovaries are also removed. Although hysterectomy is often performed in women with endometriosis, results are mixed. If the ovaries are left and so continue to provide estrogen (which stimulates the growth of endometrial tissue), then women have a sixfold greater risk of developing recurrent pain, and an 8.1 times greater risk of having another operation than if they had their ovaries removed.
Plus, women who retain their cervix have a 10 percent risk that they will need another surgery to remove the cervix because of bleeding, pain or cervical cancer, particularly if they also have endometriosis and adhesions.
The bottom line is that although medical treatments for endometriosis can have side effects, stopping the medication typically stops the side effects. But surgery is permanent; if a surgical procedure leaves adhesions, you may have to cope with further surgeries and pain for years.
Only you and your doctor can decide which options are best for treating your endometriosis. Make sure you consider your options carefully, ask lots of questions, get a second opinion if necessary and are aware of all the potential benefits and risks of treatment.
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© 2008 National Women’s Health Resource Center, Inc. (NWHRC) All rights reserved. Reprinted with permission from the NWHRC. 1-877-986-9472 (toll-free). On the Web at: www.healthywomen.org.