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

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Endometriosis and Pain Endometriosis is Not Generally Progressive aka What I think I have learned about endometriosis and pain. Dan C. Martin, M.D. – PowerPoint PPT presentation

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Title: Endometriosis and Pain Endometriosis is Not Generally Progressive aka What I think I have learned about endometriosis and pain.


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 164787 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 dont 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
  • Netters AnatomicError - 1954

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

12
Rectovaginal Endometriosis
  • Rectovaginalendometriosisis morerectocervicalt
    hanrectovaginal.
  • 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 (T3) 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
Progressive Confirmation
  • 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

43
Progressive Confirmation
  • 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

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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