Endometriosis and Pain Endometriosis is Not Generally Progressive aka What I think I have learned...

Endometriosis and PainEndometriosis and PainEndometriosis is Not Generally Endometriosis is Not Generally

ProgressiveProgressiveakaaka

What I think I have learned about endometriosis and pain.What I think I have learned about endometriosis and pain.

Dan C. Martin, M.D.Dan C. Martin, M.D. Clinical ProfessorClinical Professor

University of Tennessee Health Science CenterUniversity of Tennessee Health Science Center

Martin Center for Women's Health & FertilityMartin Center for Women's Health & Fertility

Memphis, TennesseeMemphis, Tennessee

Monday, October 24, 2005Monday, October 24, 2005

Learning ObjectivesLearning Objectives

Following the presentation Following the presentation “Endometriosis “Endometriosis and Painand Pain,” participants should be able to:,” participants should be able to:– Discuss the concepts of progressive, Discuss the concepts of progressive,

stable and regressive endometriosis.stable and regressive endometriosis.– Identify the risks of surgery associated Identify the risks of surgery associated

with increasing depth of endometriotic with increasing depth of endometriotic disease.disease.

Pain TherapyPain Therapy

•This talk will concentrate on the This talk will concentrate on the diagnosis, appearance, changes and diagnosis, appearance, changes and histology of endometriosis.histology of endometriosis.

•But success in pain therapy is But success in pain therapy is having the patient refocus her life having the patient refocus her life away from pain and effectively away from pain and effectively resume her roles as wife, mother, resume her roles as wife, mother, and/or career woman!and/or career woman!

Pain EvaluationPain Evaluation

•On a scale of 0 to 10, 0 being no pain and 10 being the worst pain imaginable, How is your pain today and how was your pain 2 weeks ago?” It is important to provide a reference for 10 such as “pain that is so bad that you cannot care for your children, who are in imminent danger (II-B).– SOGC, JOCG 164:787 2005SOGC, JOCG 164:787 2005

Addiction vs. DependenceAddiction vs. Dependence

•A patient brings in a bag of A patient brings in a bag of several narcotics. She also has several narcotics. She also has them at home, at work and in them at home, at work and in her car. Is she:her car. Is she:– probably probably an addictan addict or or– probably probably not an addictnot an addict??– I do not know.I do not know.

Addiction vs. DependenceAddiction vs. Dependence

•Addicts don’t hoard.Addicts don’t hoard.•Dependents store medicine Dependents store medicine

everywhere for when the pain everywhere for when the pain hits.hits.

•Some of the medicine may be 5 Some of the medicine may be 5 years old. They are like mothers years old. They are like mothers who keeps all left over who keeps all left over medication for when it is needed.medication for when it is needed.

Quality of LifeQuality of Life

•The addict's quality of life is The addict's quality of life is severely impaired by the use of severely impaired by the use of narcotics.narcotics.

•The quality of life of the The quality of life of the dependent patient is improved dependent patient is improved through the use of the drug.through the use of the drug.– Sidney SchnollSidney Schnoll

Progression / RegressionProgression / Regression

Sutton JG. Fertil Steril 68: 1070-1074, 1997Sutton JG. Fertil Steril 68: 1070-1074, 1997

Harrison RF. Fertil Steril 74: 24-30, 2000Harrison RF. Fertil Steril 74: 24-30, 2000

Murphy AA. ANYAS 995: 1-10, 2002Murphy AA. ANYAS 995: 1-10, 2002

Degree of InvolvementDegree of Involvement

• Asymptomatic in 70% to 100% of women.Asymptomatic in 70% to 100% of women.– Pimple ModelPimple Model

• Symptomatic in 0.1% to 8% of women.Symptomatic in 0.1% to 8% of women.– 0.1% if definition requires:0.1% if definition requires:

•Cyclic PainCyclic Pain

•Focal TendernessFocal Tenderness

•Response to Surgical RemovalResponse to Surgical Removal– 8% if definition is surgical visualization.8% if definition is surgical visualization.– Increases if definition is based on exam and lab.Increases if definition is based on exam and lab.

Rectovaginal EndometriosisRectovaginal Endometriosis

• Adamyan Adamyan RetrocervicalRetrocervicalStaging - 1991Staging - 1991

• Netter’s AnatomicNetter’s AnatomicError - 1954Error - 1954


• RV Pouch is toRV Pouch is tothe middle thirdthe middle thirdof the vagina in of the vagina in 93% of women.93% of women.– Kuhn 1982Kuhn 1982


• RectovaginalRectovaginalendometriosisendometriosisis moreis morerectocervicalrectocervicalthanthanrectovaginal.rectovaginal.– Martin 2001, 2005Martin 2001, 2005


Futh 1903Futh 1903 Sampson 1918Sampson 1918


• Involvement of Involvement of the mid-vaginathe mid-vaginais rare.is rare.

• 1 in 80 to1 in 80 to1 in 300 1 in 300 bowel cases.bowel cases.– Martin 2005Martin 2005


• Fistulas afterFistulas aftersurgery are insurgery are inthe lower thirdthe lower thirdof the vagina.of the vagina.– Martin 2004Martin 2004


Referral PracticeReferral Practice MinimumMinimumMaximumMaximum

EndometriosisEndometriosis 5%5% 70%70%

Deep EndometriosisDeep Endometriosis 5%5% 53%53%

Bowel EndometriosisBowel Endometriosis 6%6% 12%12%

Mid-Vaginal EndometriosisMid-Vaginal Endometriosis 0.1%0.1% 0.2%0.2% Martin 1997, 2005Martin 1997, 2005


Referral PracticeReferral Practice MinimumMinimumMaximumMaximum

Asymptomatic Asymptomatic endometriosisendometriosis76%76% 100%100%

Symptomatic endometriosisSymptomatic endometriosis0.1%0.1% 8%8%

Deep endometriosisDeep endometriosis 0.03%0.03% 0.6%0.6%

Bowel endometriosisBowel endometriosis 0.01%0.01% 0.2%0.2%

Mid-Vaginal endometriosisMid-Vaginal endometriosis0.0002%0.0002% 0.003%0.003% Martin 1997, 2005Martin 1997, 2005

Endometriosis and PainEndometriosis and Pain

• ““There is no correlation between the stage There is no correlation between the stage of endometriosis and the degree of pain.”of endometriosis and the degree of pain.”

• Treatment of endometriosis in a location Treatment of endometriosis in a location that correlates with pain mapping is more that correlates with pain mapping is more successful than treating endometriosis successful than treating endometriosis that does not correlate.that does not correlate.

• There is a correlation between depth and There is a correlation between depth and volume with tenderness and fibrosis.volume with tenderness and fibrosis.– Ripps 1991 and Ripps 1992Ripps 1991 and Ripps 1992

Indications for SurgeryIndications for Surgery

• Generally Accepted IndicationsGenerally Accepted Indications– Bowel StenosisBowel Stenosis– Ureteral ObstructionUreteral Obstruction– Mass of Uncertain NatureMass of Uncertain Nature

• Relative IndicationsRelative Indications– PainPain– InfertilityInfertility

•Vercellini, ASRM 2005Vercellini, ASRM 2005

Endometriosis after Endometriosis after Hysterectomy Hysterectomy

Conflicting ConceptsConflicting Concepts• SymptomsSymptoms are the reason for surgery. are the reason for surgery.• Anatomy / Anatomic PathologyAnatomy / Anatomic Pathology is the is the

main concern and requires surgery.main concern and requires surgery.

Other concepts that may be important:Other concepts that may be important:• ImmunologyImmunology• Stress ResponseStress Response• Progression / RegressionProgression / Regression• Primary / Coexistent / CoincidentalPrimary / Coexistent / Coincidental

Endometriosis after Endometriosis after HysterectomyHysterectomy

20012001 20052005

I said she needed bowel surgery in 2001 and she went for a second opinion. I said she needed bowel surgery in 2001 and she went for a second opinion. The second opinion physician did a complete hysterectomy (TAH-BSO) in 2003.The second opinion physician did a complete hysterectomy (TAH-BSO) in 2003.She returned in 2005 with abdominal pain and bloating.She returned in 2005 with abdominal pain and bloating.

20012001

20020055

Response to SurgeryResponse to Surgery

• 25 patients had surgery for bowel 25 patients had surgery for bowel involvement after hysterectomy. involvement after hysterectomy.

• Pain ReliefPain Relief– 96% in patients with no bowel 96% in patients with no bowel

involvement.involvement.– 82% in patients with bowel involvement.82% in patients with bowel involvement.

• Redwine, David B (1994) Endometriosis persisting after castration: clinical characteristics Redwine, David B (1994) Endometriosis persisting after castration: clinical characteristics

and results of surgical management. Obstetrics and Gynecology 83: 405-413and results of surgical management. Obstetrics and Gynecology 83: 405-413

Response to SurgeryResponse to Surgery

• Dr. Redwine found significant relief Dr. Redwine found significant relief for all symptoms evaluated.for all symptoms evaluated.

• But there was no symptom that was But there was no symptom that was completely eliminated. completely eliminated.

– Redwine, David B (1994) Endometriosis persisting after castration: clinical Redwine, David B (1994) Endometriosis persisting after castration: clinical characteristics characteristics and results of surgical management. Obstetrics and Gynecology 83: 405-413and results of surgical management. Obstetrics and Gynecology 83: 405-413

Endometriosis after Endometriosis after Hysterectomy Hysterectomy

Treat Symptoms with HysterectomyTreat Symptoms with Hysterectomy

• Hysterectomy controls symptoms for some. Hysterectomy controls symptoms for some.

• But it does not work for all. But it does not work for all.

Treat Anatomy by Removing Treat Anatomy by Removing EndometriosisEndometriosis

• But removal does not work for all. But removal does not work for all.

• Does all endometriosis require removal?Does all endometriosis require removal?


Is this adequate?Is this adequate?

20012001 20052005

Not in this woman. But will she have surgery?Not in this woman. But will she have surgery?


Does this require surgery?Does this require surgery?

20012001 20052005

The bowel looks better than it did in 2001. She still plans to avoid bowel surgery by The bowel looks better than it did in 2001. She still plans to avoid bowel surgery by treating this medically.treating this medically.

Medical-Legal ReviewerMedical-Legal Reviewer

• Complications are more common than Complications are more common than reported.reported.

• 4 recent cases with 4 or more 4 recent cases with 4 or more surgeries.surgeries.

• Bowel damage with resection of Bowel damage with resection of endometriosis.endometriosis.

• Bowel damage with lysis of adhesions.Bowel damage with lysis of adhesions.

Medical-Legal ReviewerMedical-Legal Reviewer

• More complications are seen as legal More complications are seen as legal cases in the United States than are found cases in the United States than are found in the medical literature.in the medical literature.

• Most complications don't get published.Most complications don't get published.– Some are established in the literature.Some are established in the literature.– But, the literature may be surgical.But, the literature may be surgical.– Some may not be reported for other reasons.Some may not be reported for other reasons.

• Lethargy and lack of enthusiasmLethargy and lack of enthusiasm

• LegalLegal

Legal Case 1Legal Case 1

• Age 21 - G6 P2 A4 L2 Laparoscopy Age 21 - G6 P2 A4 L2 Laparoscopy for endometriosis and pain. (#1for endometriosis and pain. (#1))

• Age 21 - G7 P3 A4 L3 Post-partum Age 21 - G7 P3 A4 L3 Post-partum tubal ligation. (#2tubal ligation. (#2))

• Age 22 - TAH-BS (ovaries saved) for Age 22 - TAH-BS (ovaries saved) for severe endometriosis. (#3severe endometriosis. (#3))


• Age 25 - Hospitalized for possible bowel Age 25 - Hospitalized for possible bowel obstruction.obstruction.

• Age 25 - Laparotomy with lysis of adhesions Age 25 - Laparotomy with lysis of adhesions and resection of the left ovary and and resection of the left ovary and appendectomy. (#4appendectomy. (#4))

• Age 25 - Laparoscopy and laparotomy with Age 25 - Laparoscopy and laparotomy with ligation of the ovarian vein and lysis of ligation of the ovarian vein and lysis of ureteral adhesions for ongoing pain ureteral adhesions for ongoing pain diagnosed as right ovarian pain syndrome. diagnosed as right ovarian pain syndrome. (#5 and #6(#5 and #6))

• Age 26 - Hospitalized for possible bowel Age 26 - Hospitalized for possible bowel obstruction.obstruction.


• Age 30 - Laparoscopy, right oophorectomy Age 30 - Laparoscopy, right oophorectomy (cyst), lysis of adhesions. Right ovary (cyst), lysis of adhesions. Right ovary densely adherent to the sidewall. Ureters densely adherent to the sidewall. Ureters not initially identified. Ovary adherent to not initially identified. Ovary adherent to the bowel. Bowel also adherent to the left the bowel. Bowel also adherent to the left sidewall. (#7sidewall. (#7))

• Age 30 - Day 1 - Readmitted for pain, Age 30 - Day 1 - Readmitted for pain, bloating, urinary retention. bloating, urinary retention.

• Age 30 - Day 2. - Distention, nausea, free Age 30 - Day 2. - Distention, nausea, free air on flat and upright. Intermittent bowel air on flat and upright. Intermittent bowel sounds post-op. Initially did better on sounds post-op. Initially did better on hydration and Foley catheter.hydration and Foley catheter.


• Age 30 - Day 5 - General surgery consult.Age 30 - Day 5 - General surgery consult.

• Age 30 - Day 7 -Laparotomy with repair of Age 30 - Day 7 -Laparotomy with repair of small bowel entero-cutaneous fistula. (#8small bowel entero-cutaneous fistula. (#8))

• Day 11 - Perforation with fistula #2 treated Day 11 - Perforation with fistula #2 treated with total parenteral nutrition (TPN).with total parenteral nutrition (TPN).

• Age 30 - Day 43 - Home on TPN.Age 30 - Day 43 - Home on TPN.

• Age 30 - Month 5 - Off TPNAge 30 - Month 5 - Off TPN


• Age 35 - Day 1 - Laparoscopy with lysis of Age 35 - Day 1 - Laparoscopy with lysis of adhesions and repair of bowel perforation. adhesions and repair of bowel perforation. (#9(#9))

• Age 35 - Day 2 - Laparoscopy for Age 35 - Day 2 - Laparoscopy for distention with no perforation seen. (#10distention with no perforation seen. (#10))

• Age 35 - Day 9 - Perforation and abscess. Age 35 - Day 9 - Perforation and abscess. • Age 35 - Day 10 - Laparotomy with incision Age 35 - Day 10 - Laparotomy with incision

and drainage of abscess, lysis of adhesions and drainage of abscess, lysis of adhesions and repair of fistula. (#11and repair of fistula. (#11))

• Age 35 - Day 15 - CT guided aspiration of Age 35 - Day 15 - CT guided aspiration of abscess. abscess.


• Age 35 - Day 17 - Upper GI and small Age 35 - Day 17 - Upper GI and small bowel follow through with no fistula. bowel follow through with no fistula.

• Age 35 - Day 20 - Discharged. Age 35 - Day 20 - Discharged. • Age 36 - TMJ, weight gain, hypoglycemia, Age 36 - TMJ, weight gain, hypoglycemia,

adhesions, depression, pain. adhesions, depression, pain. • Age 37 - Weakness, dizziness, nausea, Age 37 - Weakness, dizziness, nausea,

constipation, pain, bloating, headaches, constipation, pain, bloating, headaches, myalgias, arthritis, swelling, depression, myalgias, arthritis, swelling, depression, fatigue, anxiety disorder, gastritis, GE fatigue, anxiety disorder, gastritis, GE reflux, adhesions, insomnia and pain.reflux, adhesions, insomnia and pain.

Rectovaginal Endometriosis 1997 - Rectovaginal Endometriosis 1997 - 20042004

• 43 of 115 bowel cases had RV involvement.43 of 115 bowel cases had RV involvement.• 28 of 43 patients had intentional resection 28 of 43 patients had intentional resection

of bowel endometriosis. of bowel endometriosis. • 2 had perforation, diverting colostomy and 2 had perforation, diverting colostomy and

revision. Those two and one earlier revision. Those two and one earlier colostomy patient (T=3) had pain relief. colostomy patient (T=3) had pain relief. None lost to follow-up and no lawsuits. One None lost to follow-up and no lawsuits. One mother had no pain relief.mother had no pain relief.

• 15 of 43 patients decided to limit surgery 15 of 43 patients decided to limit surgery and avoid bowel surgery. and avoid bowel surgery. (Schweppe - 24 patients)(Schweppe - 24 patients)

Tissue DiagnosisTissue Diagnosis

• Diagnostic StandardDiagnostic Standard

• Uncertain AppearanceUncertain Appearance– Clear VesiclesClear Vesicles– Polypoid VesiclesPolypoid Vesicles

• Research StandardResearch Standard

ConfirmationConfirmation

ConfirmationConfirmation

CasesCases +/++/+ -/+-/+

Scott 1952Scott 1952 516516 64%64% 31%31%

Martin 1990Martin 1990 489489 70%70% 29%29%

Pardanani 1988Pardanani 1988 91 91 59%59% --

Walters 2001Walters 2001 44 44 45%45% --

Range of ConfirmationRange of Confirmation

Cases per PhysicianCases per Physician≤ 5≤ 5 6-116-11 12-2612-26 127127

Scott 1952Scott 1952 -- -- -- --

Martin 1990Martin 1990 48%48% 57%57% 76%76% 99%99%

Pardanani 1988Pardanani 1988 - - 65%65% 55%55% --

Walters 2001Walters 2001 45% 45% -- -- --

Progressive ConfirmationProgressive Confirmation

YearYear 19821982 19831983 19841984 1985198519861986

Endo PatientsEndo Patients 9797 9191 9191 9797 119119

Patients withPatients with 1313 3434 6565 8888 119119Tissue ExcisedTissue Excised 13%13% 37%37% 71%71% 91%91% 97%97%

Positive for EndoPositive for Endo 88 1717 5959 8484 116116All PatientsAll Patients 8%8% 19%19% 65%65% 87%87% 97%97% If ExcisedIf Excised 62%62% 50%50% 91%91% 93%93% 97%97%

Martin, 1987Martin, 1987

ConclusionsConclusions

• Endometriosis exists as a transient Endometriosis exists as a transient anatomic abnormality in up to 100% of anatomic abnormality in up to 100% of women.women.– Pimple Model.Pimple Model.

• Endometriosis progresses to mid-vagina Endometriosis progresses to mid-vagina involvement in no more than 0.003%involvement in no more than 0.003%

• Endometriosis is a disease if there is:Endometriosis is a disease if there is:– PainPain– InfertilityInfertility– MassMass– Organ ObstructionOrgan Obstruction

ConclusionsConclusions

• Surgical DecisionsSurgical Decisions– Response to MedicationResponse to Medication– Chance of ProgressionChance of Progression– SymptomsSymptoms– ComplicationsComplications

• ResearchResearch– Immunologic MarkersImmunologic Markers– Tissue Diagnosis or other Validated DiagnosisTissue Diagnosis or other Validated Diagnosis– Pain MappingPain Mapping– Tenderness MappingTenderness Mapping

Endometriosis and Pain Endometriosis is Not Generally Progressive aka What I think I have learned...

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