Blog #2: My Suggested Treatment Plan

In most cases, I favor treating patients definitively (I will list the exceptions to this recommendation in following commentary).

This means that I recommend all endometriosis is completely excised from the body. Up to this point in time, the only way that I am aware of that this can be done is by surgical excision. While I favor doing this Laporoscopically (using small umbilical and accessory ports for instrument insertion), this treatment can also be done by laparotomy (open incision). The energy source used for excision is best left to the experience and confidence of the surgeon, but I use the carbon dioxide laser as my energy source (why will be the discussion of another blog; see also http://centerforendo.com/dr-albee-on-excision).
china6There is one critically important aspect of excising all disease that is often overlooked by surgeons. Subtle ‘endo’ can hide in peritoneum that looks atypical, but does not have one of the ‘classic’ appearances of ‘endo’. In order to have low recurrence rates, surgeons must not leave any disease behind. This means that the surgeon must be committed to removing abnormal/atypical peritoneum even when it does not have a ‘classical’ appearance. For more on this discussion, refer to one of my academic papers on the subject: https://www.ncbi.nlm.nih.gov/pubmed/18262141.

Definitive treatment in my experience is the most effective treatment because it:

– Results in the longest intervals of time before retreatment is required (our data continues to indicate that 80-85% of our patients are currently free from any clinical indication of recurrent ‘endo’);
– Results in a significant improvement in ‘quality of life’ and pain reduction scores on follow-up surveys; and
– Fertility rates improve in stage 2, stage 3,and stage 4 cases after excision

The emotional burden of being told that you have an incurable disease is enormous. I do not tell patients that I am going to cure them, but I do tell them that if they have any more ‘endo,’ they will be the exception and not the rule (understanding that not all pelvic pain is the result of endometriosis and there are often comorbidities which also need to be addressed). Please note my above figure on our percentage of clinically disease-free patients after excision.

In following blogs, I will discuss the current objections to definitive treatment, and the reasons that I feel it is not more commonly used. But up next, let’s talk about ‘when I do not recommend definitive treatment.’ Stay tuned!

Disclaimer: any and all material(s) presented herein are offered for informational purposes only. Such material is not intended to offer or replace medical advice offered by your personal physicians or healthcare professionals. No information herein should be considered as party to any doctor/patient relationship. All contents herein are © copyright by Robert B. Albee, Jr., MD except where otherwise explicitly noted. All rights reserved. This material may not be reproduced or utilized in any form, including electronic or mechanical, photocopying, recording, or by any information storage and retrieval system except for personal or teaching use with prior permission. Thank you.

Blog #1 July, 2017 “The Great Treatment Debate:” first, lets define some important terms…

Let’s use two large treatment categories:

  1. Definitive Treatment
  2. 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!

Disclaimer: any and all material(s) presented herein are offered for informational purposes only. Such material is not intended to offer or replace medical advice offered by your personal physicians or healthcare professionals. No information herein should be considered as party to any doctor/patient relationship. All contents herein are © copyright by Robert B. Albee, Jr., MD except where otherwise explicitly noted. All rights reserved. This material may not be reproduced or utilized in any form, including electronic or mechanical, photocopying, recording, or by any information storage and retrieval system except for personal or teaching use with prior permission. Thank you.

My Endometriosis Experience…

Welcome! A brief introduction to my blog:

I began specializing in the treatment of patients with endometriosis (and unexplained pelvic pain) in 1990. At that time, I stopped seeing obstetric patients (something I dearly loved) altogether and launched the Center For Endometriosis Care, one of the first tertiary referral centers in the world dedicated to the disease. The Center, and the addition of a partner, provided me with a unique opportunity to personally have long term follow-up of a large group of patients diagnosed and treated for endometriosis through Laparoscopic Excision, or what I termed, “LAPEX.” I made the decision to focus on this group of patients because effectively treating the ‘endo’ patient was, in my mind, one of the greatest challenges that I faced year after year. I knew in my heart that there had to be a better method of treatment – LAPEX – and practitioners needed to stop failing our endo patients. Today, that group of patients has grown to over 5,000 hailing from more than 50 countries.

As I retired from surgery (in 2013), I have had more time to devote to helping the endo community with understanding the ‘modern concepts’ of the disease and to aiding patients with informed decision making. This blog is part of that effort.

Using a blog makes it possible for many people to get answers to the commonly asked questions I have received over the years (and still do today), in a manner that is easy to understand and at no expense. I also think will be a personally rewarding experience for me as well, and I am delighted to have you along for journey!

Disclaimer: any and all material(s) presented herein are offered for informational purposes only. Such material is not intended to offer or replace medical advice offered by your personal physicians or healthcare professionals. No information herein should be considered as party to any doctor/patient relationship. All contents herein are © copyright by Robert B. Albee, Jr., MD except where otherwise explicitly noted. All rights reserved. This material may not be reproduced or utilized in any form, including electronic or mechanical, photocopying, recording, or by any information storage and retrieval system except for personal or teaching use with prior permission. Thank you.