Friday, 28 March 2014

Endometriosis Awareness Month – Part 3

Endometriosis awareness month marches forward, quite literally. As you may have seen there have been awareness events taking place in many countries. Women with endometriosis and their supporters have been marching through major cities all over the world to help raise awareness for endometriosis and they have done an exemplary job.

Unfortunately I couldn’t make it to the UK event, but seeing the great turnout in all the cities and all the people who talked about it on Twitter/Facebook/blogs/forums etc, really showed just how much endometriosis awareness has changed for the better in the last decade. It certainly makes me hopeful for the future wellbeing of women with endo.

Speaking of the future, let’s have a look through some of the current research that will hopefully contribute to better prospects for women with endo everywhere.

We start then with a study from Denmark, which assessed the long-term reproductive status of women with and without endometriosis. To do this investigators examined medical records from tens of thousands of women across four national registries from 1977 to 2009.

 What they found was that, over the time course examined, women with endometriosis had around 7% fewer childbirths and 8% fewer naturally conceived children than women without endo. Not a massive surprise there; it’s well known that women with endo can find it difficult to get pregnant. Interestingly though the researchers found that as time went on (from 1980 to 1998), more women with endo had children, suggesting that it takes a long time for women with endo to conceive naturally (of course we must also remember that assisted reproduction wasn’t introduced until 1980). What is quite interesting is that they found that women with endometriosis were more likely to get pregnant with ART than women without by a small percentage.

This study also found that, for women with endo, the risk of ectopic pregnancy was twice that of women without. In addition, there were 21% more miscarriages in the group of women with endo. The reasons as to why this was the case remain unclear, it may be that the presence of active endometriosis in the pelvic area negatively affects pregnancy outcome somehow. Although, as the authors point out, there are other studies that have shown no increased risk of ectopic pregnancies in women with endo, so the jury is still out. In addition this study found that women with endo undergoing ART were at an increased risk of miscarriage, however another recent study found no increase in miscarriage risk. So whilst these studies are informative, they only represent the experiences of a certain population of women. 

One of problems with this study was that some of the women said to be diagnosed with endo, were only suspected to have it, not because they had laparoscopic diagnosis, meaning they may have had endo, or not, or another condition. Another issue is that this study wasn’t able to follow women throughout their entire reproductive life, so they didn’t have a complete picture of all the women’s reproductive history.

Nevertheless, what this study does tell us is that women with endo may require special prenatal care. If results such as these are the same in other countries it certainly suggests that additional provisions need to be made for women with endo (such as better monitoring of foetal and maternal health) and the medical community needs to be aware of this.

Moving on then, from the problems women with endo have to suffer with, to the ways in which the medical community is trying to solve those problems. Laparoscopic surgery is considered the best way of surgically removing endometriosis, but you need a good surgeon at the helm. Another problem is that not all endometriosis can be found and removed easily. One of the most troublesome forms of endo is deeply infiltrated endometriosis (DIE). This type of endo is very commonly associated with the most painful symptoms, such as chronic pelvic pain, painful sex, painful urination and painful bowel movements (depending on where the DIE is and how deep it has infiltrated).

Removing DIE is quite a challenge then, even for a skilled surgeon, which is why some surgeons are now trying robot assisted laparoscopy. Using ‘the robot’ does offer several advantages, such as better precision, better visualisation and more freedom to manoeuvre the instruments. Of course the downsides are that a surgeon will have to learn to use the robot and it is very, very expensive. Another point raised it that using the robot lacks a ‘tactile response’, that is, surgeons cannot feel the resistance or tension of some organs/tissues that might give them an idea of how to proceed with the surgery.

Therefore studies are needed to assess how well robot assisted surgeries fair in removing DIE. That is the subject of a recent paper from centres across the world.  This study looked at robot assisted operative results from 164 operations on women with DIE in different places to see how well the surgeons and patients faired.

Overall the average time for surgery was 180 minutes and the average hospital stay was 4 days, which, given the low rate of complications, seems like a long stay to me, but that may be due to different approaches to post-operative care in different centres/countries. 113 patients were followed up after an average of 10 months and 86.7% were found to be pain free, which is a god result by anyone’s standards.  

Other studies have shown that while robot assisted surgery takes slightly longer and is comparable in outcomes to conventional surgery with respect to stage I and II endometriosis, it may be beneficial for advanced stage endometriosis and has a lower risk of needing laparotomy.  

At the moment then the current evidence suggests that robot assisted and normal laparoscopy perform equally well in some respects, but that robot assisted surgery may be beneficial for women with advanced stage disease. However, more studies directly comparing the two surgical approaches are needed.

I will leave you then with an unusual case of endometriosis. A 52 year old man was sent for a CT scan after complaining about pelvic pain. What the doctors found was an inch long ‘cyst’ that, upon closer examination was found to be a tube like structure, with a muscular layer on the outside and an endometrial layer on the inside. Essentially this was a small uterus, but as it is displaced endometrium it still classifies as endometriosis (or endomyometriosis, to be technically correct). Unlike other male endometriosis cases, this patient hadn’t been undergoing any hormonal therapy and the man in question had no genetic or hormonal abnormalities that could account for this finding. In addition the patient had previously undergone surgery for a hernia near the area in which the ‘uterus’ had been found, so one would think this area of the body would have been examined thoroughly previously, indicating this problem may have arisen quite recently.

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