Easing endometriosis...Is surgery the answer?

From: Helen Dynda (olddad66@runestone.net)
Mon Jan 29 21:48:34 2001


Easing endometriosis: Is surgery the answer?

May 30 - Not too long ago I read an Internet post from a woman who was looking forward to having her thirteenth surgery to remove endometriosis and, hopefully, to quiet her agonizing pelvic pain. Thirteen sounded like a pretty big number to me. But experts on endometriosis say this isn't uncommon, even though no one has ever proven that surgery is the best way to ease pelvic pain.

WHILE STUDIES have linked endometriosis - a condition affecting women of reproductive age in which endometrial tissue migrates from the uterus to other parts of the body - with pelvic pain and infertility, plenty of women with the condition experience neither of these symptoms.

"We know endometriosis is associated with infertility and pelvic pain," says Dr. Barbara Levy, a clinical assistant professor of obstetrics and gynecology at the University of Washington in Seattle and at Yale University in New Haven, Conn. "But that doesn't mean it's the cause of either of these conditions."

Still, for years surgery has been hailed as a permanent fix for women with both endometriosis and pelvic pain. Procedures to cut or laser off endometrial lesions are now common.

Doctors see desperate women and want to help, explains Dr. Dan Martin, a reproductive surgeon and a clinical associate professor at the University of Tennessee in Memphis. It's difficult to tell a woman that there is no simple way to heal her pain, he adds.

Another common endometriosis treatment, hormone therapy to shrink the tissue, must be taken indefinitely and it doesn't work for all women. Plus, hormones, which are often given in the form of oral contraceptives, aren't an option for women trying to get pregnant. A hysterectomy also may help, but it too is not an option for a women wishing to conceive.

Ibuprofen and other pain relievers can ease symptoms but don't treat the disease. Non-drug approaches such as biofeedback and physical therapy also may alleviate pain.

MAKING MATTERS WORSE?

But with many women undergoing so many repeat operations, some specialists are now questioning the value of surgery. Some, like Levy, wonder whether surgeons aren't just making matters worse in many cases.

Every time a doctor operates - whether it's a big incision or a little one - scar tissue forms inside the pelvis, Levy says. This scar tissue - known as adhesions - can cause pain. And then there's the issue of nerve damage, Martin says. Multiple surgeries seem to be linked with pain from injured nerves.

Many women undergo surgery over and over again. If you peruse the endometriosis discussion groups and bulletin boards on the Internet, it is not unusual to read accounts of women who've had multiple surgeries - 12, 13, 14, even more - and still suffer from pelvic pain.

These women believe that they need more surgery because their trusted physicians have told them that the endometriosis has grown back and another operation is the only solution.

So why would women keep coming back for a treatment that seems so ineffective?

Well, first and foremost, it's because their pain is so unbearable, Martin says.

It's also because, for a short time, they feel better. And this may simply be the result of something called the placebo effect, Levy says. Basically, when the doctor and patient both believe in a treatment, it can turn out to be perplexingly potent.

A particularly clear example of the power of the placebo effect came several decades ago when researchers tested a popular surgery to correct angina - chest pain caused by an inadequate supply of oxygen to the heart muscle.

The surgery, which involved tying off an artery in the chest, was eventually tested by having one group of patients treated with the real operation, while another received only a chest incision. Ultimately, 76 percent of the patients who received the real procedure improved. But 100 percent of those who received the sham surgery got better.

MANY OPERATIONS, NO RELIEF

It was the failure of endometriosis surgery to provide long-term benefits that made Levy start to wonder.

"My interest in this subject was tweaked by seeing patients with all these operations still in pain," Levy says. "This is not acceptable."

Some women undergo surgery every two years, some as often as every six months, Levy says. "How many is enough?" she asks. "Do you wait till you have a major complication till you stop operating?"

Levy isn't alone in concluding that an effective treatment should offer lasting relief.

If the condition truly is the cause of the pain, "medical or surgical treatment of endometriosis should result in prolonged pain relief," Dr. William W. Hurd wrote in an article in the journal Obstetrics and Gynecology. Hurd is a researcher in the department of obstetrics and gynecology at the Indiana University School of Medicine in Indianapolis.

Martin agrees that multiple surgeries are not the answer. If one surgery doesn't do the trick, then the doctor needs to try other, noninvasive approaches, he says.

Levy wouldn't even do a first surgery on most women. But, she allows, there is a small subset of women with endometriosis who can be helped with surgery. If the doctor prods a spot on the woman's abdomen during the physical examination and this causes pain each and every time the area is touched, then there is a good likelihood that surgery will help. Levy also will operate if a woman is trying to get pregnant and her reproductive organs are distorted by endometrial tissue growth, she says.

It can be tough saying no to a desperate patient, Martin says. "But as I've gotten older and seen how few times you help someone with surgery, I've done less of it. I've learned to say no more often."

http://www.msnbc.com/news/402412.asp#BODY


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