Endometriosis: the challenge of our times

Professor Jacques Donnez and Professor Harry Reich
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Lone Hummelshoj:  We are at the 8th regional meeting of the International Society for Gynaecological Endoscopy. It is in Cape Town, South Africa, and this meeting is focusing specifically on endometriosis. With me is the President of the ISGE, Professor Jacques Donnez from Belgium, and the in-coming President, Professor Harry Reich from the United States. What have been the highlights of this meeting? 

Professor Harry Reich:  In my opinion the highlight is to see so many people from so many different countries being able to do the more advanced operations. Ten years ago this would have been impossible. Today we find many surgeons from South America, Australia, Asia, and from Europe are doing extensive operations to help women with endometriosis get rid of the major portion of their disease.  

In the past we had meetings where people would talk about medical treatments that really didn’t work very well in these cases. Today we see this, especially in the places I named. Did you notice that I didn’t say too much about the United States? From the United States we had one of our top people here: Dr. David Redwine, who gave an excellent presentation and kept everybody very well informed. But, we look at the United States, David [Redwine] and myself, as a place where we have very few disciples; very few people have taken up the training necessary to be able to do these difficult operations themselves. So it is great for us to come to a meeting like this and see how people in the rest of the world are doing this at a very high level. 

Professor Jacques Donnez:  I said to Professor Reich that we were surprised to see so many people, so many surgeons, trying to remove surgically not only peritoneal lesions or ovarian cysts, which was the routine for many years, but also the deep lesions. Most important in my opinion is that experts like Redwine, Harry [Reich] and all the people and myself, are able to debate about the type of surgery we should recommend to the patient, taking into account not only the disease, but the symptoms of the disease.  

I think that we should clarify and separate clearly women suffering from infertility from women suffering from pain.  The surgical approach should be different. What we have heard for the past three days is really how different types of diseases, different phenotypes, whatever the name which is used to classify peritoneal, ovarian, or deep disease, we are not only trying to excise it, but trying to understand what we are doing and not just excise, excise, excise. When Harry [Reich] published for the first time a series of 32 cases of deep endometriosis in the Journal of Reproductive Medicine, it was in 1989, I remember that very well, we didn’t know exactly what this disease was. But we are moving more quickly in understanding this disease to better help our patients. 

And the second point, which was stressed in Harry’s lecture was the other problem created by surgery:  the problem of adhesions. We should find in the future a solution for that. 

Professor Harry Reich:  I thought that a major concept that came out of this meeting that was so important for many of the speakers was the involvement of the cervix in so many of the endometriosis cases. This brings a lot of concerns when surgeons do supracervical type surgeries on people with endometriosis, leaving all that disease behind on the cervix. As you emphasise: in over 75% of cases of endometriosis in the deep the cul-de-sac the cervix is going to be involved and special care should be taken in that direction. 

It was exciting for me just to see how you and David [Redwine], at the end of your debate, began to agree more and more! 

Professor Jacques Donnez:  This is true! I was surprised to see, Harry, that you put up your hand in favour of debulking. I think that in young patients we have to accept a recurrence rate. As you also said, it is impossible to cure endometriosis. We have to admit that a certain percentage of women, even after surgery done by the best expert in the world, will have a recurrence of the disease. So I think the first step is the debulking approach. 

Professor Harry Reich:  Yes, surgeons do not have microscopic eyes revealing the condition that has accumulated over many years. By taking most of it out many patients will have tremendous relief of their pain, and many who desire to get pregnant, will be able to. 

Professor Jacques Donnez:  When I see the success of this type of meeting, a regional meeting of the International Society with nearly 300 participants, and not only participants who are there to get a certificate, but participants who are really present the room! I think we should organise another meeting for endometriosis in the United States. As you stress, and I’m surprised, there are in fact not so many gynaecologists in the United States who are expert in endometriosis surgical treatment. 

Professor Harry Reich:  I already talked to David Redwine and we are going to Bend [Oregon, USA] next year! 

Lone Hummelshoj:  So with this new, or better, understanding of endometriosis, are you seeing as a way forward that the next step is to train more disciples - or what is the next step? 

Professor Harry Reich:  I believe that’s the right direction. The people we saw here at this meeting are not people who just come here to learn a little bit about how to get rid of the endometriosis, how to debulk it, I think most of these people are doing the work, which is exciting.  We talked to them:  the doctors from Czechoslovakia, from Sao Paulo, Brazil, from Argentina, they are excising they are doing the work. In many cases they are working with a colon and rectal surgeon, that’s okay. But I found many who are not, which surprised me. I think that many gynaecologists are becoming complete surgeons and are able to handle even the difficult areas around the intestine and the ureter. 

Professor Jacques Donnez:  I think also, that can be important for your EndoZone. In fact, there are more and more experts, but there are still too many gynaecologists, who are unable to diagnose this deep disease. As you have mentioned Harry in your lecture, when you see the delay between onset of  symptoms and the diagnosis, it is totally unacceptable. That is the other lesson that we have to take from this congress! I’m sure that we have to learn not only the surgical steps, but also the diagnosis. And the diagnosis is made by clinical evaluation and too many gynaecologists, even in Belgium; and I give a lecture in Belgium almost every month, and yet, every week we still have patients who have been to the gynaecologist many times, and still we have to treat nodules 3-4 cm in size, which were not diagnosed.  

Professor Harry Reich:  That’s hard for us to believe who have worked with endometriosis all these years. We see patients very frequently on the other side of the spectrum, which have endometriosis treated, but never truly diagnosed. I like to emphasise that endometriosis diagnosis does for sure require biopsy to show it is endometriosis and not just old blood that is present. But I agree that it was brought out so well on many talks at this meeting, and that there’s such a gap between when a patient first presents to the doctor and when she is finally diagnosed. I think everybody who attended the meeting got that message, along with the message about the tremendous involvement of the cervix in many of the cases where it was unexpected. 

Lone Hummelshoj:  It sounds like it has been a very exciting meeting for you. Thank you very much for your time, I look forward to the next one. 

Professor Harry Reich and Professor Jacques Donnez:  Thank you.