 |
Evidenced based approach to treating endometriomas
Professor Cindy Farquhar,
Dr. Michael Cooper,
and Deborah Bush QSM,
Deborah
Bush QSM: Good afternoon, my name is Deborah Bush
and I’m the Chief Executive of the New Zealand Endometriosis Foundation. I’m
also on the Advisory Board for the Endometriosis Zone and I’m talking this
afternoon to Dr. Michael Cooper, who is the Clinical Senior Lecturer at Sydney
University, and head of General Gynaecology at the Royal Prince Albert Hospital
in Sydney. With me also is Professor Cindy Farquhar, from the University of
Auckland and National Women’s Hospital. What we’re going to discuss this
afternoon is the evidenced based approach to treating endometriomas. Professor
Cindy Farquhar:
By way of introduction tell us how common endometriomas are when you are
doing laparoscopic surgery for, say, dysmenorrhea or pelvic pain? Dr. Michael Cooper:
Endometriomas are actually reasonably uncommon. To put that in context,
endometriosis per se, nobody’s exactly sure how common it is, but
it’s probable that something in the order of ten percent of the female
population will have endometriosis. Now, for many of those people it won’t be
so severe and a lot of them will be undiagnosed. In fact we know that the time
to diagnose for many people can take several years, so the subset of people with
endometriomas is only a small percentage of that group. I guess it’s difficult
to be sure of the overall numbers of the decided endometrioma per se is
reasonably rare, although if you do have an endometrioma, that probably puts you
into the more severe category of disease. So
if you do have a scan that suggests you’ve got an endometrioma, then
unfortunately that puts you at the more severe end. Professor
Cindy Farquhar:
Are they only ever in the ovary? Dr. Michael Cooper:
Endometrioma per se is just a collection of, from a definition
point of view, blood arising from endometriosis. You can get endometriomas in
lots of different areas. The ovaries are the most common place, but you can see
isolated swellings of tissue pretty much throughout the abdominal cavity and
lymph nodes, the liver, and similar things within the bowel and possibly the
bladder. Although a lot of those tend to be more solid and fibrotic nodules and
they’re not exactly endometriomas. Professor
Cindy Farquhar: What
sort of symptoms would a patient with an endometrioma present with? Dr. Michael Cooper:
Mostly they would have the same symptoms as people with general types of
endometriosis. Those symptoms by and large are in several groups, pain-type
symptoms, which are usually cyclical, so dysmenorrhea, painful periods, painful
intercourse, and just general pelvic pains. Then there’s a group of symptoms
relating to fertility, so that a large number of these people will have had
difficulties conceiving. Another group will also have irregular spotting and
bleeding, characteristically there is an issue of what’s termed premenstrual
spotting, which is classically a brown sort of stain just prior to the menses.
If patients have that then that’s a reasonably good sign that they are likely
to have endometriosis. Professor
Cindy Farquhar: So,
turning to how they should be managed, perhaps you could describe some of the
options for a woman with endometriomas. Dr. Michael Cooper:
I suppose in the first instance it’s really a question of diagnosis.
Unfortunately, the only real way to make a formal diagnosis is to do a
laparoscopy. There are some
alternatives in that people with infertility, for example, who are having
assisted conception, will have natal guide procedures through the vagina that
pick up and retrieve oocytes. Under those circumstances if chocolate fluid is
encountered, then it’s probable that those people have endometriomas, but by
and large, laparoscopy is the mainstay of diagnosis. In the first instance, ultrasound is required and from
there, laparoscopy. I think at that stage they then should be managed
surgically. Professor
Cindy Farquhar: I
understand that there is a bit of debate about the best approach surgically? Dr. Michael Cooper:
I suppose it’s worth just stepping back a little bit in that if a
patient has what looks like an endometrioma on an ultrasound, particularly if
it’s in the order of 5 centimetres, in the first instance it might be worth
taking a conservative approach. A lot of these things on ultrasound may in fact
disappear if they’re functional. But
if you have a persistent cyst over the space of several months, and particularly
if that’s occurred in the setting of someone who has had ovulation
suppression, then there are really three problems: 1.
The first problem is “what is it”? Even though it’s rare, they can
be malignant. 2.
The second problem relates to torsion, that is if the ovary itself has a
cyst, which is persistent for some time, then the ovary can twist and you can
lose the whole ovary as it dies. 3.
The third problem relates to rupture. Depending on the contents in the
cyst, rupture can cause widespread adhesions, and problems with the bowel, and
ongoing fertility issues. So there are three reasons, if you have a persistent cyst,
as to why it should be managed. The options in management would then be either
medical therapy, conservative therapy with guided natal procedures, or formal
surgery. The reality is that medical treatment has, I would think,
almost no role, because you need to make the diagnosis. So I think medical
therapy is really not of value, and ultrasound and guided drainage, there is
very clear evidence that if you simply drain these cysts there’s a very high
rate of recurrence. Depending on how you do the drainage, because often the
cysts are associated with more severe disease, the bowel can be damaged in an
attempt to drain them. You can then end up with abscesses and quite significant
infections. So really the mainstay of treatment is surgical. Professor
Cindy Farquhar: One
of the challenges for us in our own hospital is to make sure that all patients
with these sorts of cysts are being offered the opportunity of having them
managed laparoscopically. We still have a tendency for many people to think that
large ovarian cysts should be operated on by an open procedure; a laparotomy. Do
you think there are lots of advantages with going for a laparoscopic procedure? Dr. Michael Cooper:
Yes, I don’t think there’s any question that if the skill of the
surgeon, and if the equipment is available, then laparoscopy is the better way
to go for the patient. There is very good evidence in the literature that dates
back over a decade now to concur with that. So I believe that laparoscopy is the
way to go. The next issue of course is what do you do from a surgical
perspective when you get there? There are a number of different alternatives.
Simply just draining the cyst will result in very high recurrence rates. So
really the issue comes down to opening the cyst and draining the fluid away.
Then, either removing the cyst wall, a technique that we call stripping or
excision, or alternatively, attempting to ablate the cyst wall after having
drained the fluid away. There are proponents of both theories, and at this point
in time I don’t believe there are significant amounts of data to push us one
way or the other. Professor
Cindy Farquhar: Some
of our fertility specialists are worried about stripping out; that it might
reduce the amount of ovarian tissue available for IVF stimulation. Some of our
patients after stripping had presented with evasive FSH levels. What do you
find? Dr. Michael Cooper:
These concerns have been voiced within the literature, although there are
a number of papers, which suggest that stripping does not necessarily impede
fertility, and that it doesn’t necessarily impair ongoing ovarian function.
We’ve actually looked at this with our pathologist, Peter Russell, and
we’ve taken the last 20 or so patients we’ve done, and we’ve been terribly
impressed by the fact that there’s minimal numbers of primordial follicles in
the stripped tissue, which I think would probably concur with the experience of
those reporting in the literature; that not overly impacting on ovarian
function. Having said that of course, you clearly are removing a
degree of ovarian tissue, and you’ve got an ovary that has a problem
originally. So it’s hard to say definitively that you’re not impairing but I
think, by definition you are. Professor
Cindy Farquhar: What
about the FSH levels? Dr. Michael Cooper:
We’ve not specifically looked at that part of it anecdotally, and that
would fit, I think, even if you were to ablate the tissue. The means of doing
ablation are reasonably limited. I don't believe that it’s possible to be
definitive in terms of not damaging tissue adjacent. I would think with ablative
procedures you can just as likely damage a number of primordial follicles, and
additionally you probably run the greater risk of leaving areas of endometriotic
tissue behind, and possibly increase the recurrence. It would seem within the data that has been published at
least, that stripping is better for recurrence rates, rather than ablating. If
you take the next leg of it, and then if you’ve got a recurrence, you need
further surgery. Then you’ve got more surgery on the ovary, and that must
clearly impair even more on fertility. Professor Cindy Farquhar:
One of the questions that we often have in
our clinic is when we get young women with endometriomas, say in their 20s, and
they’re not planning to start a family for say maybe five to ten years. We
want to offer them some sort of management that would prevent recurrence of
endometriosis, so that they can protect their ovaries from further damage. I
imagine you have the same sort of concerns? What strategies do you have in
managing those ones, say 20 to 23 or 24? Dr. Michael Cooper:
Sure, we have the same problem. The same issues run through our minds.
Again, I’m not aware of anything in the literature to support things one way
or the other; other than to say there have been trials just looking at
endometriosis per se. If you take just an oral contraceptive then that is
protective for people as distinct from the people who don’t take oral
contraceptives. Ovarian suppression by whatever means is probably likely to be
beneficial for most people. So we
would take the view that if you’ve got an endometrioma and you’re young, and
you clearly wish to preserve your fertility, then you probably should have the
ovary dealt with surgically, and then be put on probably long-term ovarian
suppression until such stage that you’re likely to want to fall pregnant. There has been talk anecdotally, and I’m aware of some
people who’ve actually undergone procedures of having a portion of ovary
removed at the time of cystectomy, and then frozen, in the hope that possibly
you might be able to use that ovarian tissue for subsequent fertility. The
difficulty at this stage is that we’ve been able to freeze embryos and achieve
successful pregnancies, but nobody has been able to freeze ovarian tissue and
then graft it back and get a successful pregnancy. The science, at this point in
time, hasn’t caught up with us and it’s probably fair to say that it’s a
long way off. The commercial units that I’m aware of within Australia that
were offering those sorts of services have re-thought that, and most of them I
think have stopped offering the service. Professor
Cindy Farquhar: We
would also use the contraceptive pill, although my view is that a better
approach might be some sort of suppression, where you don’t actually
menstruate at all. We have used quite a lot of Provera, in a medium dose, like
30 to 50 mg daily. More recently we’ve been using quite a lot of Mirena
post-operatively, which is the levonorgestrel intrauterine device. But we have
had recurrences of endometrioma with the Mirena, and I suspect it’s because
they don’t get sufficient ovarian suppression, only about 30 to 40% get
suppressed, whereas with Provera it seems to be a more suppressive dose. Dr. Michael Cooper:
We’ve used all those strategies as well, and I would agree that with
the Mirena, unfortunately, probably, the dose is not sufficiently high enough to
adequately suppress ovulation. The difficulty with the progesterones, which Deb
you’ve come across as well, is that for a lot of people it results in weight
gain, fluid retention, breast discomfort, and a lot of people stop because they
are not comfortable staying on those sort of preparations. The Pill I suspect is probably the best of the choices
that we have available. There are, within Australia at least, people who have
been using Implanon and that’s perhaps another alternative. But Implanon, of
itself is a great product, but it’s just a question we’ve had, there has
been some problems within Australia in terms of insuring that the Implanon
device is actually being placed correctly. And it’s been placed in situations
where it can be removed easily. As long as that’s done then it’s probably a
great alternative as well. Professor
Cindy Farquhar: We
don’t have Implanon in New Zealand, so I have no experience with that, but I
think it probably would be a more suppressant dose. As you know there is a lot of recurrence with patients
with endometriosis, somewhere between 20 to probably 50% in the real world
getting a recurrence of their endometriosis within about five years. Is that a
particular problem for ovarian endometriomas? Dr. Michael Cooper: Yes, I think this is a big problem. All the published literature would suggest 8 to 25%. But you’re perhaps right in the real world it gets bigger than that. The difficulty is what do you do with these people who may have multiple surgeries on their ovaries, and in my experience, the ovary has a particular tendency to want to get stuck here to this pelvic side wall, so there may be a place for some of the new adhesion barriers, such as Spraygel, in that particular instance. But I suspect unfortunately if you have individuals who have clearly had recurrent surgery on their ovaries with trapped ovaries adhering to the side wall, and cyclical symptoms, unfortunately for those individuals, it may be that oopherectomies are the way to go. Professor
Cindy Farquhar: Well,
I think we’ve probably
exhausted our evidence based approach to this. Deborah
Bush QSM: Thank
you very much Professor Cindy Farquhar and Dr. Michael Cooper for coming along
and discussing it this afternoon. We look with interest to see if there are any
developments in the treatment of endometriomas in the future. Thank you very
much doctors. Professor
Cindy Farquhar: Just
going back to the issue of whether or not we should strip or ablate the cyst
wall, I have a bit of a problem with the current studies that have been done, in
that I’m not quite sure that could be clear about having strictly just
stripped, and not done some sort of ablation. I wonder what they do when they
get to the point where you can’t actually strip out, and then it sort of
becomes an ablation anyway. I’ve been wondering whether we could do a
randomised control trial because of the problems with the surgery. Is it
possible to actually put a group of patients into one arm of a study or not? Dr. Michael Cooper:
I guess that’s an operator issue and that’s the problem with trials
of surgery. In my experience the most difficult bit of the procedure is actually
dissecting down onto the cyst wall, and then stripping that through the cleavage
plane. Once the cysts are of any size greater than probably three to four
centimetres, then, in my experience, you can nearly always find a cleavage plane
and you can strip out the cyst wall. You can then be reasonably comfortable that
you’ve stripped the whole cyst wall lining. The smaller cysts, people who have been on Zoladex and the
like, it can be more difficult to find the cyst wall. In our experience we can
nearly always identify the cyst wall with reasonable clarity. I guess for the
purposes of study and research, I see no problem why you couldn’t actually
take a short video sequence, or in fact you could just photograph it, then you
could show the cleavage plane. If you can’t strip it, then my concern would be
that either you’re dealing with something that’s not an endometrioma, or
it’s something nasty, like a cancer, which is clearly rare. Professor
Cindy Farquhar: That’s
great Michael because you could do a randomised, controlled trial! Dr. Michael Cooper:
Possibly, yes. Deborah
Bush QSM: Thanks
very much doctors, once again! See also the EndometriosisZONE.org section on the surgical management of endometriosis
Feedback/Questions:
Dr. Simon Ewen FRCOG
Feedback:
Dr. Carlos Isaia Filho MD
|
