It may be reasonable to delay the ‘gold standard’ (‘definitive’ treatment) in some cases. These include:
1. THOSE UNDERGOING OBSERVATION WITH OR WITHOUT SUPPRESSION
Particularly in young patients who experience symptoms suggestive of ‘endo’, I often observe them over a period of time (6-18 months). I may do this if they are managing their pain without narcotics, and their physical exam and pelvic ultrasound are normal without subtle findings suggestive of ‘endo’ (subtle findings to be discussed further in a later blog). I often suppress ovulation with a low dose oral contraceptive if tolerated well by the patient. During the interval of observation, I want to rule out other potential causes of the symptoms, and carefully monitor the trends in the patient’s pain levels, other symptoms, and any changes on examination or ultrasound.
Although fertility rates increase (in our data) after ‘excision’ in all but stage 1 patients, I advise practitioners to work with ‘reproductive endocrinologists’, and make the decision to advise surgical excision jointly. We will discuss the rationale for delaying surgery in certain infertile individuals in a later blog. However, it is true that I have delayed ‘excision’ in patients in order to continue a specific infertility treatment on a trial basis.
3. ASYMPTOMATIC PATIENTS WITH DOCUMENTED ENDOMETRIOSIS WHO ARE CLINICALLY STABLE
The patient that presents with documented ‘endo’ but is clinically stable is a candidate for delaying ‘excision’ if they can be followed by an experienced ‘endo’ doctor. They must be careful to report changes in symptoms, and have office reevaluation at 6 month intervals. The doctor must be one that actively looks for any indication that the endo is advancing. A thorough history and careful examination are important to recognizing signs of progressive disease. Ovarian suppression is certainly an option in these individuals. Postmenopausal patients (with known ‘endo’) that are asymptomatic are in this group, and are slightly more at risk if on hormone replacement.
4. PATIENTS THAT HAVE HAD ENDOMETRIOSIS SURGERY RECENTLY THAT WAS NOT ‘DEFINITIVE’
Many patients are referred to an ‘endo’ specialist after a diagnostic surgery, or a surgery that left endo behind. They may need time to evaluate benefits from the surgery just performed, or additional time to plan for a ‘definitive’ surgery that may have additional risks.
5. PATIENTS WITH CO-MORBIDITIES THAT MAY INCREASE RISK
Important to the decision to perform any surgical procedure is the ‘risk’ to ‘benefit’ balance. The existence of other diseases, conditions, and genetic factors can significantly increase surgical risks. The decision to avoid or delay surgery is best made by each individual and her doctor after taking into account the possible increases in risk due to a ‘co-morbidity’. See also: Surgical Risks: What’s the Big Deal?
STAY TUNED FOR MORE TO COME!