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Endometriosis and Pain Endometriosis is Not Generally Progressive aka What I think I have learned about endometriosis an

Endometriosis and Pain Endometriosis is Not Generally Progressive aka What I think I have learned about endometriosis and pain. Dan C. Martin, M.D. Clinical Professor University of Tennessee Health Science Center Martin Center for Women's Health & Fertility Memphis, Tennessee

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Endometriosis and Pain Endometriosis is Not Generally Progressive aka What I think I have learned about endometriosis an

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  1. Endometriosis and PainEndometriosis is Not Generally ProgressiveakaWhat I think I have learned about endometriosis and pain. Dan C. Martin, M.D. Clinical Professor University of Tennessee Health Science Center Martin Center for Women's Health & Fertility Memphis, Tennessee Monday, October 24, 2005

  2. Learning Objectives Following the presentation “Endometriosis and Pain,” participants should be able to: • Discuss the concepts of progressive, stable and regressive endometriosis. • Identify the risks of surgery associated with increasing depth of endometriotic disease.

  3. Pain Therapy • This talk will concentrate on the diagnosis, appearance, changes and histology of endometriosis. • But success in pain therapy is having the patient refocus her life away from pain and effectively resume her roles as wife, mother, and/or career woman!

  4. Pain 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 2005

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

  6. Addiction vs. Dependence • Addicts don’t hoard. • Dependents store medicine everywhere for when the pain hits. • Some of the medicine may be 5 years old. They are like mothers who keeps all left over medication for when it is needed.

  7. Quality of Life • The addict's quality of life is severely impaired by the use of narcotics. • The quality of life of the dependent patient is improved through the use of the drug. • Sidney Schnoll

  8. Progression / Regression Sutton JG. Fertil Steril 68: 1070-1074, 1997 Harrison RF. Fertil Steril 74: 24-30, 2000 Murphy AA. ANYAS 995: 1-10, 2002

  9. Degree of Involvement • Asymptomatic in 70% to 100% of women. • Pimple Model • Symptomatic in 0.1% to 8% of women. • 0.1% if definition requires: • Cyclic Pain • Focal Tenderness • Response to Surgical Removal • 8% if definition is surgical visualization. • Increases if definition is based on exam and lab.

  10. Rectovaginal Endometriosis • Adamyan RetrocervicalStaging - 1991 • Netter’s AnatomicError - 1954

  11. Rectovaginal Endometriosis • RV Pouch is tothe middle thirdof the vagina in 93% of women. • Kuhn 1982

  12. Rectovaginal Endometriosis • Rectovaginalendometriosisis morerectocervicalthanrectovaginal. • Martin 2001, 2005

  13. Rectovaginal Endometriosis Futh 1903 Sampson 1918

  14. Rectovaginal Endometriosis • Involvement of the mid-vaginais rare. • 1 in 80 to1 in 300 bowel cases. • Martin 2005

  15. Rectovaginal Endometriosis • Fistulas aftersurgery are inthe lower thirdof the vagina. • Martin 2004

  16. Degree of Involvement Referral Practice Minimum Maximum Endometriosis 5% 70% Deep Endometriosis 5% 53% Bowel Endometriosis 6% 12% Mid-Vaginal Endometriosis 0.1% 0.2% Martin 1997, 2005

  17. Degree of Involvement Referral Practice Minimum Maximum Asymptomatic endometriosis 76% 100% Symptomatic endometriosis 0.1% 8% Deep endometriosis 0.03% 0.6% Bowel endometriosis 0.01% 0.2% Mid-Vaginal endometriosis 0.0002% 0.003% Martin 1997, 2005

  18. Endometriosis and Pain • “There is no correlation between the stage of endometriosis and the degree of pain.” • Treatment of endometriosis in a location that correlates with pain mapping is more successful than treating endometriosis that does not correlate. • There is a correlation between depth and volume with tenderness and fibrosis. • Ripps 1991 and Ripps 1992

  19. Indications for Surgery • Generally Accepted Indications • Bowel Stenosis • Ureteral Obstruction • Mass of Uncertain Nature • Relative Indications • Pain • Infertility • Vercellini, ASRM 2005

  20. Endometriosis after Hysterectomy Conflicting Concepts • Symptoms are the reason for surgery. • Anatomy / Anatomic Pathology is the main concern and requires surgery. Other concepts that may be important: • Immunology • Stress Response • Progression / Regression • Primary / Coexistent / Coincidental

  21. Endometriosis after Hysterectomy 2001 2005 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. She returned in 2005 with abdominal pain and bloating.

  22. 2001

  23. 2005

  24. Response to Surgery • 25 patients had surgery for bowel involvement after hysterectomy. • Pain Relief • 96% in patients with no bowel involvement. • 82% in patients with bowel involvement. • Redwine, David B (1994)  Endometriosis persisting after castration: clinical characteristics and results of surgical management. Obstetrics and Gynecology  83: 405-413

  25. Response to Surgery • Dr. Redwine found significant relief for all symptoms evaluated. • But there was no symptom that was completely eliminated. • Redwine, David B (1994)  Endometriosis persisting after castration: clinical characteristics and results of surgical management. Obstetrics and Gynecology  83: 405-413

  26. Endometriosis after Hysterectomy Treat Symptoms with Hysterectomy • Hysterectomy controls symptoms for some. • But it does not work for all.  Treat Anatomy by Removing Endometriosis • But removal does not work for all. • Does all endometriosis require removal?

  27. Endometriosis after Hysterectomy Is this adequate? 2001 2005 Not in this woman. But will she have surgery?

  28. Endometriosis after Hysterectomy Does this require surgery? 2001 2005 The bowel looks better than it did in 2001. She still plans to avoid bowel surgery by treating this medically.

  29. Medical-Legal Reviewer • Complications are more common than reported. • 4 recent cases with 4 or more surgeries. • Bowel damage with resection of endometriosis. • Bowel damage with lysis of adhesions.

  30. Medical-Legal Reviewer • More complications are seen as legal cases in the United States than are found in the medical literature. • Most complications don't get published. • Some are established in the literature. • But, the literature may be surgical. • Some may not be reported for other reasons. • Lethargy and lack of enthusiasm • Legal

  31. Legal Case 1 • Age 21 - G6 P2 A4 L2 Laparoscopy for endometriosis and pain. (#1) • Age 21 - G7 P3 A4 L3 Post-partum tubal ligation. (#2) • Age 22 - TAH-BS (ovaries saved) for severe endometriosis. (#3)

  32. Legal Case 1 • Age 25 - Hospitalized for possible bowel obstruction. • Age 25 - Laparotomy with lysis of adhesions and resection of the left ovary and appendectomy. (#4) • Age 25 - Laparoscopy and laparotomy with ligation of the ovarian vein and lysis of ureteral adhesions for ongoing pain diagnosed as right ovarian pain syndrome. (#5 and #6) • Age 26 - Hospitalized for possible bowel obstruction.

  33. Legal Case 1 • Age 30 - Laparoscopy, right oophorectomy (cyst), lysis of adhesions. Right ovary densely adherent to the sidewall. Ureters not initially identified. Ovary adherent to the bowel. Bowel also adherent to the left sidewall. (#7) • Age 30 - Day 1 - Readmitted for pain, bloating, urinary retention. • Age 30 - Day 2. - Distention, nausea, free air on flat and upright. Intermittent bowel sounds post-op. Initially did better on hydration and Foley catheter.

  34. Legal Case 1 • Age 30 - Day 5 - General surgery consult. • Age 30 - Day 7 -Laparotomy with repair of small bowel entero-cutaneous fistula. (#8) • Day 11 - Perforation with fistula #2 treated with total parenteral nutrition (TPN). • Age 30 - Day 43 - Home on TPN. • Age 30 - Month 5 - Off TPN

  35. Legal Case 1 • Age 35 - Day 1 - Laparoscopy with lysis of adhesions and repair of bowel perforation. (#9) • Age 35 - Day 2 - Laparoscopy for distention with no perforation seen. (#10) • Age 35 - Day 9 - Perforation and abscess. • Age 35 - Day 10 - Laparotomy with incision and drainage of abscess, lysis of adhesions and repair of fistula. (#11) • Age 35 - Day 15 - CT guided aspiration of abscess.

  36. Legal Case 1 • Age 35 - Day 17 - Upper GI and small bowel follow through with no fistula. • Age 35 - Day 20 - Discharged. • Age 36 - TMJ, weight gain, hypoglycemia, adhesions, depression, pain. • Age 37 - Weakness, dizziness, nausea, constipation, pain, bloating, headaches, myalgias, arthritis, swelling, depression, fatigue, anxiety disorder, gastritis, GE reflux, adhesions, insomnia and pain.

  37. Rectovaginal Endometriosis 1997 - 2004 • 43 of 115 bowel cases had RV involvement. • 28 of 43 patients had intentional resection of bowel endometriosis. • 2 had perforation, diverting colostomy and revision. Those two and one earlier colostomy patient (T=3) had pain relief. None lost to follow-up and no lawsuits. One mother had no pain relief. • 15 of 43 patients decided to limit surgery and avoid bowel surgery. (Schweppe - 24 patients)

  38. Tissue Diagnosis • Diagnostic Standard • Uncertain Appearance • Clear Vesicles • Polypoid Vesicles • Research Standard

  39. Confirmation

  40. Confirmation Cases +/+ -/+ Scott 1952 516 64% 31% Martin 1990 489 70% 29% Pardanani 1988 91 59% - Walters 2001 44 45% -

  41. Range of Confirmation Cases per Physician ≤ 5 6-11 12-26 127 Scott 1952 - - - - Martin 1990 48% 57% 76% 99% Pardanani 1988 - 65% 55% - Walters 2001 45% - - -

  42. Year 1982 1983 1984 1985 1986 Endo Patients 97 91 91 97 119 Patients with 13 34 65 88 119 Tissue Excised 13% 37% 71% 91% 97% Positive for Endo 8 17 59 84 116 All Patients 8% 19% 65% 87% 97% If Excised 62% 50% 91% 93% 97% Martin, 1987 Progressive Confirmation

  43. Year 1982 1983 1984 1985 1986 Endo Patients 97 91 91 97 119 Patients with 13 34 65 88 119 Tissue Excised 13% 37% 71% 91% 97% Positive for Endo 8 17 59 84 116 All Patients 8% 19% 65% 87% 97% If Excised 62% 50% 91% 93% 97% Martin, 1987 Progressive Confirmation

  44. Conclusions • Endometriosis exists as a transient anatomic abnormality in up to 100% of women. • Pimple Model. • Endometriosis progresses to mid-vagina involvement in no more than 0.003% • Endometriosis is a disease if there is: • Pain • Infertility • Mass • Organ Obstruction

  45. Conclusions • Surgical Decisions • Response to Medication • Chance of Progression • Symptoms • Complications • Research • Immunologic Markers • Tissue Diagnosis or other Validated Diagnosis • Pain Mapping • Tenderness Mapping

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