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Recurrent endometriosis pain following hysterectomy
Dr Enda McVeigh, Professor Ray Garry, Dr David Redwine and Dr Tom Lyons Lone
Hummelshøj:
We are at the eighth regional meeting of the International Society of
Gynaecological Endoscopy. The theme for this congress is endometriosis, which
indeed is a challenge of our time. This afternoon we have been discussing
hysterectomy and basically the treatment of recurrent endometriosis pain
following hysterectomy and surgery. With
me is Dr. Ray Garry, from Perth, Australia; Dr. David Redwine, from Bend,
Oregon; Dr. Enda McVeigh from Oxford University in England; and Dr. Tom Lyons
from Atlanta, United States. Dr.
Garry, can it be true if a woman has been told that she’s been cured from her
endometriosis pain after hysterectomy that she still has pain? Dr.
Ray Garry: It
is certainly true. A number of patients have had hysterectomy but have not had
all the disease removed, and for a variety of reasons that disease can continue.
It can persist as severe symptoms: there can be pain, there can be bleeding,
there can be bowel obstruction, or problems with the urinary tract. All these
things can, and do, happen. It is a very unfortunate situation because both many
doctors, as well as many patients, believe that removing the uterus and the
ovaries is a complete treatment for endometriosis. Sadly, it often isn’t. Lone
Hummelshøj:
Do the rest of the panel agree with this? Dr. David Redwine:
I absolutely agree. I’ve seen over a 175 patients that I have performed
surgery on, who still have endometriosis after having their uterus, tubes and
ovaries removed. As Ray says, there are several reasons, but one of the simple
anatomic reasons is that endometriosis is predominantly a disease of peritoneal
surfaces away from the uterus, and not involving the ovaries. So, if you remove
the uterus, tubes and ovaries you are going to be leaving disease behind in
about 96% or 97% of the patients. Just anatomically the procedure does not make
good sense, even though in actuality it may be relatively effective in some
sorts of pain. Dr.
Enda McVeigh:
Looking specifically at the removal of the ovaries, and the case where
the rationale is to create a hypooestrogenic
state that will lead to atrophy of the ectopic endometrial tissue, in
theory that sounds very good. However, when we look at this chemically, by giving GnRH
analogues, we don’t actually find this is the result. If you carry out surgery
and give an analogue, if you remove all of the disease, then there is no
difference in pain. If you carry out surgery and don’t remove all of the
disease, then you may still have pain with your analogue. I think the rationale
is flawed and we forget about the body image in that we’re actually castrating
a woman, and we are removing a very important organ that may do more than simply
give oestrogen replacement. There are all the facts that the ovary may work on,
and all we do when give HRT is give oestrogen easily. So I think that our
rationale is flawed and thankfully we are seeing a change in that. Dr.
Tom Lyons: I
think the other part of this issue, and the other part of the discussion this
afternoon, is of course, those patients who have felt a pain that is
specifically related to their uterus in addition to having endometriosis. Those
patients of course may very well benefit from hysterectomy at the time of
surgery. But if their endometriosis is not removed at that time, then
consequently the patient may very well persist with pain. It’s a very sad
state when the patient has had, at a premature age, a radical procedure removing
the uterus, tubes and ovaries, and unfortunately sometimes missing their
endometriosis. Now the patient persists with pain and it is a very sad affair,
particularly if that patient has not had an opportunity to experience child
bearing, etc. Those are the patients unfortunately who have been
relegated all too often to the psychiatrist. They have been told that they are
crazy when of course any patient who has persistent pain, for any prolonged
length of time, and certainly a patient who has pain for over a year’s
duration, is going to certainly have some psychiatric difficulty. If nothing
else, depression is very closely associated with these types of things. These
are patients that have a good right to be crazy in point of fact, and they have
to be listened to, and their disease has to be treated appropriately. Dr.
Ray Garry: I
think it’s important to emphasise however that a lot of women with
endometriosis do have other conditions, which means the hysterectomy is of
value. We are certainly not saying that people should never have a hysterectomy
as part of the treatment program. However, for most women the principle arm of
the treatment program would be the removal of the endometriosis outside the
uterus and then a careful assessment, both of the woman’s wishes, her
fertility requirements particularly, and also the disease that is there. In the
ideal world we should now be assessing the uterus separately from the
endometriosis and deciding which bit of the entire treatment package each
individual should have. Dr.
Tom Lyons: I
think that’s one of the things that makes laparoscopy the tool of choice in
this disease process. It uniquely gives you the opportunity to assess that
disease process very carefully, and remove that disease process as we do, before
embarking upon a hysterectomy, as that is also an indicated procedure.
That gives you the opportunity to do that clearly in, I think, the most
effective manner, and probably the most aggressive manner, for the patient and
her disease process. Dr.
Enda McVeigh:
I think it is very important that we listen to the patient as you said
and that we individualise the treatment of the patient. Listening to the
patient, talking to her, and ascertaining what is the most important outcome
that she wants, and listening to what the evidence is that we can give that
outcome, and then applying the surgery properly. That may well be a hysterectomy
for the lady who is finished with fertility and who has heavy long periods and
no longer wants those. Certainly hysterectomy combined with removal of
endometriosis is the appropriate form of therapy. So listen to the patient,
apply on her evidence based procedures for that individual case. I think that is
most important. Dr. David Redwine:
One of the things that a general gynaecologists may be worried about, or
interested in at the time s/he is doing a hysterectomy and removal of the
ovaries, is how likely is this particular patient going to be possibly
symptomatic after this from retained endometriosis? I have found in my series of
patients that had post-castration and post-hysterectomy endometriosis that they
had intestinal involvement, obliteration of the cul de sac or invasive disease
at the time of their previous hysterectomy and removal of the ovaries, then
those manifestations of the disease were very commonly found among my patients
that I was re-operating on for pain. So that can be a marker that surgeons can
use to say, “Well, I really need to take that disease out”. If they can’t,
at least note it was present. If the woman has continuing pain he’ll already
be ahead of the game knowing that she had obliteration
of the cul de sac, so this is to be expected. Dr.
Tom Lyons: I
think we can wrap it up and say that certainly hysterectomy is an effective
procedure when it is indicated. But generally speaking, in treating
endometriosis, we need to treat that disease first, and treat it effectively.
Listen to our patients, they’ll tell us what is wrong with them. And I think
we can better serve them in that manner. Lone
Hummelshøj:
Thank you very much. Drs.
Ray Garry, David Redwine, Endo McVeigh, Tom Lyons:
Thank you very much.
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