Treatments

Can’t Endometriosis be Diagnosed without Surgery?

In a word, no. It is simply not possible to definitively diagnose pelvic pain effectively based on history alone, as endometriosis presents with a unique constellation of symptoms and may be accompanied by other pelvic pain generators in many patients, nor should non-classic signs be undervalued i.e. soft tissue, lung or diaphragmatic disease; bowel or bladder-only symptoms. Dismissing these indications and hindering access to timely surgical diagnosis and treatment only confound the patient’s scenario further. It is of course prudent to rule out differential diagnoses, but physical examination, imaging and lab studies related to an endometriosis diagnosis have extremely poor sensitivity, specificity and predictive values. Hence, they cannot be used to diagnose or rule out the disease. The same holds true for ‘medical diagnosis’ – a popular yet flawed trend using a trial course of GnRH agonist or antagonist to ‘see if symptoms are stemmed’ by medical suppression; assuming they are, this is considered by some to be a “diagnosis” and treatment. It is neither. At best, such a course of therapy provides only a temporary means of symptom improvement, not definitive diagnosis or treatment – and often, side effects are significantly negative and intolerable, and may last far beyond the cessation of therapy. Absence of evidence is not evidence of absence.

In short, true diagnosis is only achieved by surgical intervention; that is to say, Laparoscopy.

Who performs the surgery, how and when is of critical importance, however; excision is a highly advanced surgical technique requiring extensive training. Likewise, accuracy in diagnosis and treatment is dependent on the ability of the surgeon to recognize disease in all its different manifestations. This means, if the surgeon is not familiar with all signs of endometriosis including those less common such as subtle areas of peritoneal tension, atypical clear vesicles, extrapelvic endometriosis, etc. then disease will be missed and left behind untreated; surgeons can only see and treat what they recognize.

In the general healthcare community including at the OB/GYN level, it is taught (and hence practiced) that the most frequent mainstays of treatment are medical suppressives and incomplete surgery. Medication does not eradicate endometriosis, however, and the disease does not simply ‘go away’ as a result of drug suppression. At best, such a course of therapy provides only a temporary means of symptom improvement, not definitive treatment. Often, side effects are significantly negative and intolerable, and may last far beyond the cessation of treatment. Poor outcomes on suppression therapies are routine: drug therapy that can destroy endometriosis permanently has yet to be discovered. Hormonal suppression has “no effect on adhesion of endometriotic cells and cannot improve fertility” [Aznaurova et al.], and success of said therapies may be dependent on localization/type of lesions, with superficial peritoneal/ovarian disease responding better than deep/infiltrative disease. Still, despite evidence to the contrary, some providers prefer medical management and even “diagnosis” by adopting a strategy of ‘treat without seeing’ through medical suppression.

In the majority of such cases, further diagnostic and definitive treatment delays – and patient dissatisfaction – are highly common. The best such medications can do is (sometimes) suppress the disease on a short-term basis, and symptoms undoubtedly recur at cessation of therapy. Suppressive therapies are further limited in usefulness by the length of time they can be safely taken (usually six-twelve months), their high cost, and commonly incapacitating side effects. Hence, the sooner in an individual’s life the disease can be correctly diagnosed and truly eradicated, the better their long-term outlook becomes.

Poor surgical outcomes also remain commonplace. Limited surgery – usually followed by medical suppression – means the patient undergoes both surgery and medical treatment. The patient must still deal with any residual symptoms of the endometriosis left behind. Many times, “limited surgery” results in skimming/burning the top off the area of deep disease, leaving behind the bulk of endometriosis. This is not excisional, and allows for subsequent adhesion formation to bury remaining disease. Disease covered by new adhesions increases pain, leaving a very dissatisfied patient. Burning/ablation, coagulation and other superficial approaches – without or without medical suppression – routinely result in poor outcomes and inevitably require costly reoperation in the future, subjecting the patient to additional procedures, increased expense and surgical risks – yet this sadly remains the ordinary approach to endometriosis.