Let’s use two large treatment categories:
- Definitive Treatment
- Non-definitive Treatment
‘Definitive Treatment’ includes all treatments intended to completely remove all areas of endometriosis.
- Laparotomy with excision of all areas (using the technique and energy source chosen by the surgeon)
- Laparoscopy with excision of all areas (using the technique and energy source chosen by the surgeon)
- Hysterectomy/Oophorectomy only if all areas of ‘endo’ are also completely removed at the same time
- Possible future techniques using external energy sources to remove ‘endo’
‘Non-definitive treatment’ includes treatment options intended to control the disease.
- Observation: is really not in either category, but is still a ‘non-treatment’ choice if a patient’s diagnosis is uncertain, examination is normal, and pain is easily manageable
- Disease Suppression:
- Simple ovulation inhibition
- Progesterone therapy
- Anti-estrogen therapy
- Advanced ovulation inhibition resulting in medical castration
- Aromatase Inhibitors
- Disease Reduction:
- Laparotomy with removal of some, but not all, ‘endo’
- Laparoscopy with removal of some, but not all, ‘endo’
The standard treatment for ‘endo’ today has not changed significantly during my professional career. This approach is predominately ‘non-definitive.’ It begins with simple suppressive treatments, using stronger suppressive treatments when pain or infertility persists, and may include surgery with some disease removal, then ultimately leads to hysterectomy when the disease remains uncontrolled.
Sadly, I see many of these hysterectomized patients who actually needed only to have their ‘endo’ actually removed – excised – to achieve a satisfactory quality of life. Even worse, if all ‘endo’ is not removed at the time of hysterectomy, pain may continue despite the absence of the uterus or even ovaries if the patient is placed on hormone replacement (basically a good idea in the castrated woman of premenopausal age).
Why has the non-definitive treatment of the disease remained standard? Blog #2 will continue this discussion, along with my approach to treatment. Stay tuned!