Endometriosis Persisting After Castration -- Removing Disease, Not Organs, Key To Long Term Relief...
From: Helen Dynda (olddad66@runestone.net)
Sun Mar 18 10:59:39 2001
[] Endometriosis Persisting After Castration - Removing Disease, Not Organs,
Key To Long Term Relief...By David B. Redwine, MD
http://www.scmc.org/endo/html/reprint7.html
Doctor to patient: "So. You have endometriosis. Well, let's remove your
uterus, tubes and ovaries. This is the only known cure for the disease. You
see, it works this way: the endometriosis comes from refluxed menstrual
blood flowing out of the ends of the fallopian tubes into your abdominal
cavity, carrying with it living cells from the lining of the uterus. These
refluxed endometrial cells attach to various pelvic, intestinal or abdominal
surfaces and begin to grow. Removing your uterus will stop the reflux
problem, and removal of the ovaries will cause the endometriosis which
remains behind to go away forever."
Why would you treat a disease surgically by leaving the disease in place and
removing something else?
Patient: "I don't quite understand. Why would you treat a disease surgically
by leaving the disease in place and removing something else? Could we just
try to remove the disease first and see what happens?"
Doctor to patient: "That's not the conventional approach to this disease. In
fact, I think it's entirely inappropriate. What I have outlined is the
accepted, definitive therapy for the disease. If you're going to question my
recommendations, perhaps you would be more comfortable finding another
physician."
Patient: "Well, I guess you're the doctor. I haven't had any children yet,
but my pain is so bad it looks like I have no alternatives. If you say so, I
guess it's okay."
~ ~ ~ ~
Most gynecologists are taught that the definitive or permanent treatment of
endometriosis is to remove the uterus, tubes and ovaries, but not the
endometriosis.
How many women have heard this or some variation? What scientific evidence
supports this dialogue? How effective is castration for relief of pain
related to endometriosis? What happens to patients with continuing pain
after castration, the "definitive cure" for endometriosis? These are
important questions.
The notion that castration physically destroys endometriosis stems directly
from the observations by Sampson in the 1920's that endometriosis was rarely
seen after the menopause. From that observation 70 years ago, Sampson, and
other physicians, jumped to the conclusion that menopause therefore must
destroy the disease.
In explaining this leap of faith, Sampson extolled the supposed virtues of
menopause and castration: "I hope and expect that the cessation of ovarian
function will cause any (endometriosis) tissue which was left in the pelvis
to atrophy"1 and that ". . the implantations will usually, possibly always,
atrophy after all ovarian tissue is remove...All of them probably cease to
grow and actually atrophy after the menopause."2
The notion that menopause physically eradicates or cures endometriosis is so
powerful that no one has thought it important enough to go to the trouble to
prove this point, and not one scientific study to date has proven that the
menopause eradicates endometriosis. This is particularly significant since
modern pseudomenopausal medical therapy is based on the presumption that
endometriosis is physically destroyed and eradicated (not just suppressed)
by some as-yet-undescribed magical effect of low estrogen levels which
duplicate the curative effects of menopause.
Most gynecologists are taught that the definitive or permanent treatment of
endometriosis is to remove the uterus, tubes and ovaries, but not the
endometriosis. It is not commonly taught that the endometriosis should be
removed instead of or in addition to this primary procedure.
A review of the literature of treatment of endometriosis-associated pain did
find that the more pelvic structures/organs that were removed surgically,
the more likely pain relief was to occur. 3 While this seems to validate the
functional utility of removal of the pelvic organs with retention of
endometriosis, there is no question that endometriosis can remain
symptomatic after the menopause, even without estrogen therapy. 4 How, then,
can a physician know at the time of removal of the pelvic organs whether the
endometriosis left behind will be symptomatic? The answer is: he or she
can't with absolute certainty. However, there are some clues that might help
predict the possibility of continuing symptoms after such "definitive"
surgery.
...removal of the pelvic organs will remove all endometriosis in only about
4% of patients.
It has been shown that patients with invasive disease of the pelvic floor,
including obliteration of the cul de sac, were over-represented in a group
of patients with pain and endometriosis persisting after castration.5
Obliteration of the cul de sac means that the rectum has become adherent by
scar tissue to the back of the cervix. This implies the possible presence of
invasive endometriosis of the rear of the cervix, both uterosacral
ligaments, the cul de sac, and the front wall of the rectum. Complete
surgical treatment must take all of this into account.
Ninety-six percent of patients with endometriosis have disease in areas that
would not be removed by removal of the pelvic organs alone. 5 In other
words, removal of the pelvic organs will remove all endometriosis in only
about 4% of patients. If the retained disease is superficial, this may cause
no problem. If the disease is invasive, it may be more likely to remain
symptomatic after removal of the pelvic organs.
Invasive endometriosis of the pelvic floor and front wall of the bowel
represents a treatment problem for many gynecologists, however. Not all
surgeons are experienced in the identification of severe endometriosis or
the efficient en bloc resection technique. 6
Not all patients are bowel prepped at the time of their hysterectomy, so
even if the severity of bowel involvement is apparent, it may be unsafe to
treat it surgically. A general surgeon called into the operating room may
decline to operate on such a patient since they may not have met the
patient, or because of lack of a bowel prep, or because they consider
removal of the pelvic organs to be adequate treatment.
While removal of the pelvic organs and retention of endometriosis may
frequently relieve pain, why does it work? We still don't know why
endometriosis causes pain. Since many lesions are not associated with
adjacent hemorrhage, however, it is clear that pain is not due to bleeding
adjacent to endometriosis. Being a glandular structure, presumably
endometriosis secretes something which irritates the surrounding tissue,
promotes local fibrosis, and occasionally destabilizes nearby capillaries
resulting in bleeding adjacent to the endometriotic lesions.
Although lack of estrogen has never been shown to eradicate endometriosis,
there is no question that endometriosis can be responsive to estrogen,
although the response of individual lesions frequently differs. The degree
of response of endometriosis probably depends on the level and activity of
estrogen receptors in the lesions. This could explain why endometriosis can
look and behave differently even in the same pelvis, with some lesions
remaining superficial, while others become invasive and surrounded by
fibrosis or hemorrhage.
The ovaries produce estrogen which directly bathes adjacent endometriosis
with high levels of this hormone. When the ovaries are removed, this direct
bathing ceases, so the lesions decrease in activity. Even if estrogen is
given by pills, patches, or shots, the blood level reaching the
endometriotic lesions is lower, so they aren't stimulated as much. The end
result is less pain for many women undergoing hysterectomy and castration,
even if the endometriosis is left in place.
It is important to keep in mind, though, that not all pelvic pain is
necessarily due to endometriosis. Some of the pain which may be relieved by
hysterectomy/castration might have been due to problems with the uterus or
ovaries, not due to endometriosis. Therefore, hysterectomy/castration for
"endometriosis pain" seems better than it really is. This helps to
artificially magnify the apparent benefit of this procedure in the eyes of
busy surgeons, who view it as a very effective and helpful procedure.
However, this may be viewing the response of symptoms rather than the
response of the disease.
How often does hysterectomy/castration for endometriosis work? Experience
and some preliminary study indicate that this approach actually usually
works, although perhaps not well enough. It has been found in a follow up
study 7 that 7% of women undergoing hysterectomy/castration for
endometriosis had recurrent symptoms and 1.7% required reoperation.
...around 9,000 women annually may be left symptomatic after hysterectomy
and castration for endometriosis
Between 1982 and 1984, approximately 130,000 hysterectomies were done
annually for endometriosis. 8 This means that around 9,000 women annually
may be left symptomatic after hysterectomy and castration for endometriosis,
and over 2,000 annually may be at risk for reoperation. If, every year,
several thousand elderly patients or men were not being helped by a surgical
procedure, there would be a tremendous political fallout, even if the
majority were being helped. Since women in pain due to endometriosis are not
valued as highly by society as are the elderly or males, things just keep
trudging along.
What happens to a patient with continuing pain after removal of the pelvic
organs and retention of her endometriosis? Many try to live through it, some
are placed on drugs to suppress ovarian function (even though they have no
ovaries), others are referred to pain clinics or psychiatrists because they
are told "it's impossible to have endometriosis after this type of surgery."
These patients usually had been through multiple medical or surgical
attempts to treat their disease before removal of the pelvic organs, so
these women have literally had everything done to them and to their disease
except one thing: the disease has not been removed from their body. When
this is finally done, most women will achieve significant pain relief. 5
Am I against hysterectomy or surgeons performing them? Of course not. It is
a very useful procedure for uterine problems which do not respond to
conservative treatments. The Maine study on hysterectomy found a very high
rate of success and patient satisfaction following the procedure for
whatever reason it was performed.9 I perform my share on patients with or
without endometriosis. However, I try to reserve hysterectomy for patients
with symptoms suggesting that the uterus is a problem, such as adenomyosis.
Although it may be successful in relieving symptoms, performing a
hysterectomy with the idea of curing endometriosis is not scientifically
sound, particularly if no attempt has been made to remove the endometriosis
completely.
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