Wednesday, July 30, 2014

Common Genetic Influences: Migraine and Endo

"We examined the co-occurrence of migraine and endometriosis within the largest known collection

of families containing multiple women with surgically confirmed endometriosis and in an

independent sample of 815 monozygotic and 457 dizygotic female twin pairs. Within the

endometriosis families, a significantly increased risk of migrainous headache was observed in women

with endometriosis compared to women without endometriosis (odds ratio [OR] 1.57, 95%

confidence interval [CI]: 1.12–2.21, P = 0.009). Bivariate heritability analyses indicated no evidence

for common environmental factors influencing either migraine or endometriosis but significant

genetic components for both traits, with heritability estimates of 69 and 49%, respectively.

Importantly, a significant additive genetic correlation (rG = 0.27, 95% CI: 0.06–0.47) and bivariate

heritability (h2 = 0.17, 95% CI: 0.08–0.27) was observed between migraine and endometriosis.

Controlling for the personality trait neuroticism made little impact on this association. These results

confirm the previously reported comorbidity between migraine and endometriosis and indicate

common genetic influences completely explain their co-occurrence within individuals. Given

pharmacological treatments for endometriosis typically target hormonal pathways and a number of

findings provide support for a relationship between hormonal variations and migraine, hormonerelated

genes and pathways are highly plausible candidates for both migraine and endometriosis.

Therefore, taking into account the status of both migraine and endometriosis may provide a novel

opportunity to identify the genes underlying them. Finally, we propose that the analysis of such

genetically correlated comorbid traits can increase power to detect genetic risk loci through the use

of more specific, homogenous and heritable phenotypes.

In summary, these results confirm the previously reported comorbidity between migraine and

endometriosis and indicate common genetic influences completely underlie their cooccurrence

within individuals. Therefore, to improve the physical health and emotional wellbeing

of many women—via improved treatment and pain relief—we suggest the presence of

migraine be investigated in women with endometriosis and vice versa. Additionally, our data

indicate comorbid migraine and endometriosis represents a subset of individuals with unique

genetic effects and may therefore provide a novel opportunity to identify the genes underlying

them. Consequently, we propose that the analysis of such genetically correlated comorbid traits

can increase power to detect genetic risk loci through the use of more specific, homogenous

and heritable phenotypes. Also, the identification of genetically correlated comorbid traits has

particular relevance to the currently popular genome-wide association (GWA) paradigm by

providing a tangible means to substantially improve the efficient use of both existing and future

GWA data. For example, in addition to the primary association analysis of GWA data to the

phenotype for which it was ascertained, secondary analyses may be performed for genetically

correlated comorbid traits. Furthermore, examination of comorbid/non-comorbid cases (and

controls) provides a unique opportunity to knowingly stratify according to genetic


More on pelvic floor tension

"Most patients undergo myriad tests and studies to uncover the source of their pain—but a targeted pelvic exam may be all that is necessary to identify a prevalent but commonly overlooked cause of pelvic pain. Levator myalgia, myofascial pelvic pain syndrome, and pelvic floor spasm are all terms that describe a condition that may affect as many as 78% of women who are given a diagnosis of chronic pelvic pain.1 This syndrome may be represented by an array of symptoms, including pelvic pressure, dyspareunia, rectal discomfort, and irritative urinary symptoms such as spasms, frequency, and urgency. It is characterized by the presence of tight, band-like pelvic muscles that reproduce the patient’s pain when palpated.2

"Although the concept of a muscle spasm is not foreign, the location is unexpected. Patients and physicians alike may forget that there is a large complex of muscles that completely lines the pelvic girdle....Although a muscle spasm may be the cause of the patient’s pain, it’s important to realize that an underlying process may have triggered the original spasm. To provide effective treatment of pain, therefore, you must identify the fundamental cause, assuming that it is reversible, rather than focus exclusively on symptoms.

"Physical therapy of the pelvic floor—otherwise known as pelvic myofascial therapy—requires a therapist who is highly trained and specialized in this technique. It is more invasive than other forms of rehabilitative therapy because of the need to perform transvaginal maneuvers (FIGURE 1).
This pilot study by the Urological Pelvic Pain Collaborative Research Network evaluated the ability of patients to adhere to pelvic myofascial therapy, the response of their pain to therapy, and adverse events associated with manual therapy. It found that patients were willing to undergo the therapy, despite the invasive nature of the maneuvers, because it was significantly effective.
"Nevertheless, patients who suffer from chronic pelvic pain may take heart that there is a nonpharmaceutical alternative to manage their symptoms, although availability is likely limited in many areas. Given the nature of the physical therapy required for this particular location of myofascial pain, specialized training is necessary for therapists. Despite motivated patients and well-informed providers, it may be difficult to find specialized therapists within local vicinities. Referrals to centers where this type of therapy is offered may be necessary.
Weighing the nonpharmaceutical options for treatment of myofascial pelvic pain
Physical therapyMinimally invasive Moderate long-term successRequires highly specialized therapist
Trigger-point injectionMinimally invasive Performed in clinic Immediate short-term successOptimal injectable agent is unknown Botulinum toxin A lacks FDA approval for this indication Limited information on adverse events and long-term efficacy
Percutaneous tibial nerve stimulationMinimally invasive Performed in clinicRequires numerous office visits for treatment Lacks FDA approval for this indication Limited information on long-term efficacy
Sacral neuromodulationModerately invasive Permanent implantRequires implantation in operating room Lacks FDA approval for this indication Limited information on long-term efficacy
"A plethora of various terms/diagnoses encompass pelvic pain as a symptom, including but not limited to: chronic pelvic pain (CPP), vulvar pain, vulvodynia, vestibulitis/vestibulodynia (localized provoked vestibulodynia or unprovoked vestibulodynia), vaginismus, dyspareunia, interstitial cystitis (IC)/painful bladder syndrome (PBS), proctalgia fugax, levator ani syndrome, pelvic floor dysfunction, vulvodynia, vestibulitis/vestibulodynia dyspareunia, vaginismus, coccygodynia, levator ani syndrome, tension myaglia of the pelvic floor, shortened pelvic floor, and muscular incoordination of the pelvic floor muscles.1
"Vulvodynia is associated with other pain conditions such as: fibromyalgia, irritable bowel syndrome, tempromandibular joint dysfunction, and interstitial cystitis/painful bladder syndrome. Pelvic floor over activity is found in 80-90% of these patients....3
"Interstitial cystitis (IC) or painful bladder syndrome (PBS) is defined as pelvic pain associated with urinary frequency, urgency, and irritable voiding.  It can be associated with vulvodynia, irritable bowel syndrome, endometriosis, fibromyalgia, and chronic fatigue syndrome.  It is estimated that 50-87% of patients with IC/PBS have pelvic floor muscle overactivity.3 The sensation of the need to void is associated with the pressure from the pelvic floor muscle over activity.  Pelvic floor physical therapy is more successful with this population compared to treatment directed at the bladder. 3
"Proctalgia fugax and levator ani syndrome are two anal region pain conditions that are associated with hypertonic pelvic floor musculature.  Proctalgia fugax is a sudden, severe, transient attack of pain in the rectum lasting less than five minutes.  Levator ani syndrome is defined as a near constant pain of a dull ache nature in the anal and rectal region.  Because of the presence of pelvic floor muscle over activity, the failure of the pelvic floor muscles to relax can lend to incomplete defecation and post defecatory pain inside the anus.3
"Varying mechanisms can also contribute to the maintenance and evolution of CPP.  One hypothesis is: neuroplastic changes that occur in the posterior horn of the spinal cord, which can lead to neurologic inflammation and cross-sensitivity of the viscera and muscles, share innervation. Due to these aforementioned mechanisms, an overlap of symptoms including: dyspareunia, dysmenorrhea, gastrointestinal complaints, genitourinary complaints, and musculoskeletal complaints can occur with CPP.5 In particular, irritable bowel syndrome (IBS), fibromyalgia, and interstitial cystitis are common co-morbidities of patients with CPP. 2 Furthermore, there is strong evidence that currently demonstrates the involvement of the musculoskeletal system in CPP.5 Over activity in the pelvic floor musculature is found in up to 80-90% of patients with vulvodynia.3, 6 Dysfunction of the musculoskeletal system can lead to the adoption of abnormal postures which contribute to increased tension, spasm, and adaptive muscle shortening that can exacerbate or perpetuate the pain.5 
"...when treating this population, it is important to address the myofascial component of pain to be successful in treatment. 3 Physical therapists are treating a specific musculoskeletal dysfunction such as muscle spasm, myofascial restriction, muscle incoordination, and impaired activities of daily living in patients with vulvar pain. 2
 Indications for Treatment: 8
  • Increased pain (including vaginal, rectal, suprapubic, vulvar region)
  • Urinary urgency/frequency/incontinence
  • Impaired muscle performance
  • Impaired functional mobility
  • Increased joint mobility
  • Impaired boney alignment
  • Impaired posture
Contraindications / Precautions for Treatment: 8
The following precautions/contraindications refer to the performance of an internal pelvic floor examination:
  • Pregnancy (must receive written consent from patient’s obstetrician)
  • Active pelvic infections of the vagina or bladder
  • Active infectious lesions (i.e.: genital herpes)
  • Current yeast infection
  • Immediately post pelvic radiation treatment (within 6-8 weeks without physician approval)
  • Immediate post pelvic surgery or postpartum (within 6-8 weeks without physician approval)
  • Severe atrophic vaginitis
  • Severe pelvic pain
  • History of sexual abuse
  • Lack of patient consent
  • Pediatric patients
  • Absence of previous pelvic exam
  • Inadequate training on the part of the physical therapist
The following precautions/contraindications refer to patients who are currently pregnant: 9
  • Deep heat modalities (ultrasound) and electrical stimulation
  • Manual therapy techniques that may increase laxity
  • Maintaining supine positions longer than three minutes after the fourth month of pregnancy
" Oral contraceptives have been recently linked as a possible contributor to the development of pelvic pain.14 A lifetime risk of 6.6 of developing localized provoked vestibulodynia when using oral contraceptives has been found.15 Topical medications are often used with vulvar pain.  Topical gabapentin has also been shown to reduce vulvar pain. Topical steroids are another class of medication that are used if the patient has an accompanying inflammatory skin condition, such as lichens sclerosis.16 Lidocaine applied topically to the vulva is a commonly used treatment strategy.  Local estrogen has also been used in cases where there is a specific lack of local estrogen, as in post-menopausal conditions and thyroid disorders.15  Tricyclic antidepressants are typically used as first line treatment for vulvar pain (amitriptyline, desipramine, and nortriptyline are commonly used and used at lower doses that would be used for depression).15,16  Furthermore, anti-epileptic drugs including gabapentin or pregabalin have also been used to decrease pain, especially associated with unprovoked vulvodynia.15
Most pelvic floor exams include a detailed medical history, posture assessment, pelvic floor muscle exam, sensory, coordination, and neurological testing, pelvic girdle and associated structure exam, bowel and bladder function including voiding diaries, digital and surface electromyography, hip, sacroiliac, and spinal mobility, abdominal, and lower extremity strength testing.2
Observation/Visual Inspection:
  • Gait- The patient may present with an abnormal or antalgic gait pattern.5 Decreased or increased pelvic mobility may be observed during gait by observing quantity of movement of the pelvis in both the sagittal and transverse planes.
  • Function- Patients may have difficulty with prolonged sitting, standing, ambulation, activities of daily living, as well as bladder and bowel functioning and intercourse.
  • Posture/Alignment: 
o   AROM of the spine, quadrant tests, passive segmental mobility may reveal specific facet joint dysfunction, facilitated segments, and motion restrictions.2
o   Head alignment, shoulder positioning and symmetry, scoliosis, as well as pelvis and lower extremities should be analyzed for postural deviations.5   
o   Muscle imbalances may occur in and around the pelvic girdle, hips, and trunk because of muscle pain and become chronic once established.
o   Typical pelvic pain posture has been found in 75% of women with CPP which includes: exaggerated lumbar lordosis, increased anterior pelvic tilt, increased thoracic kyphosis.17
o   Abnormal sitting postures may also be found such as increased weight distribution on the sacrum instead of ischial tuberosities.18 Patients may exhibit shifting and frequent changes of position while standing. Patients may favor weight bearing on one side, which may contribute to muscle imbalances between the gluteus medius and the tensor fascia lata.
o    Toileting and intercourse positions should also be reviewed.
  • Pain: Pain location can be in the vagina, vulva, rectum, suprapubic region, or lower abdomen. Pain can also radiate into the back and hips. Pain reports associated with pelvic floor muscle (PFM) over activity are often vague and poorly localized and defined as aching, throbbing, pressure-like or heavy. Pain can be provoked as the day progresses or during activities specifically involving the pelvic floor such as walking, sitting, exercise, intercourse, urinating, and defecating.3
(Please refer to Hand Washing Protocol for details)
  • External Trunk and Abdominal Palpation:
o   The clinician may start with an observation and examination of the pelvic bones and lower extremities to determine the presence of pelvic obliquities, innominate rotation or shear dysfunctions, and sacral positional or movement dysfunctions.2, 8 Please refer to the Pelvic Girdle Pain Standard of Care and the Special Tests Task Force document of preferred tests to examine this area.
§  Testing may include:  sacroiliac joint compression/distraction, FABER, Gaenslen’s test, standing forward bend, spring rests, and stork test (see Special Test Task Force SI Tests for details)
o   A lower quarter screening examination including reflex testing and dermatomal testing for sensation impairment is conducted, assessing for possible adverse neural tension of the lower quarter nerves.  This would be revealed with specific positional testing to help determine if the pain in the pelvis is resulting from pudendal, obturator, sciatic, ilioinguinal, or genitofemoral nerve compression, adherence, or restriction.2
o   External palpation of the abdominal wall, including any scarring or deformities and assessment of any abdominal trigger points or adhesions should be made. 2 Palpation of the bilateral iliacus, psoas, abdominal obliques, rectus abdominis, and quadratus lumborum muscles should also be performed, as these muscles can be commonly involved with those with pelvic pain. 7 Carnett’s test can be conducted to differentially diagnose between visceral and musculoskeletal causes of pain in this region.4,5  Diastasis recti testing should also be conducted to determine any separation and possible reduced stability of the rectus abdominis muscles.4
o   Evaluative findings in this area may include: thoracolumbar and sacroiliac joint dysfunction, pubic bone malalignment, coccyx dysfunction, hip impairments, lower quarter flexibility and strength impairments, pelvic ligamentous tautness or laxity, and dysfunctional muscle firing or movement patterns.2
  • ROM: Assessment of the range of motion of the lumbar spine, hips, and sacroiliac joints, and coccyx is also conducted. 
  • Strength:  Manual muscle testing of the abdominal region and lower extremities is conducted. The pelvic floor muscles are tested for strength as well, using the Modified Oxford Laycock scale for assessment described in a later section.2
Rehabilitative ultrasound imaging (RUSI) can also be used to assess the timing and accuracy of the pelvic floor muscles as well as the transverse abdominis contraction to facilitate its correct timing during functional and strengthening activities (described later).2 
  • Sensation: Lower extremity and perineal sensation should be assessed for any alterations or deficits.
  • External Pelvic Floor Palpation:
o   A physical therapy exam of the pelvic floor starts with observation of the external perineum to assess for swelling, asymmetry, color, and skin changes.  If dermatoses are noted, the patient may be referred back to MD for further evaluation of such conditions.  Also, external examination of the vulva, vestibule, urethra, and external pelvic floor (pelvic clock) should be assessed for injuries, irritation, adhesions, scarring, or trigger points. 
o   External observation of a pelvic floor muscle contraction and relaxation is observed to see recruitment, coordination, and symmetry of the pelvic floor and anal sphincter activity. Neurological exam including reflex testing of the anal wink and bulbocavernosus reflex can occur, along with external palpation of the superficial PFM for pain and trigger points, shortening and spasm.2
o   The cotton swab test can be conducted.  This test helps to determine the patient’s irritability and tolerance to pressure or contact on the vestibular tissue and is considered to be a hallmark of localized provoked vestibulodynia. A cotton swab moistened with water is applied lightly, deflecting the skin 1 mm, around the areas of the vestibule at the following locations: 12:00, 12-3:00 quadrant, 3-6:00 quadrant, 6-9:00 quadrant, and 9-12:00 quadrant. These are tested in random order and the posterior fourchette is tested last as this area has a high probability of provocation.  Pain is rated on the Numerical Rating Pain Scale from 0-10, where 0 is no pain and 10 is the greatest pain one can imagine. The test is repeated during re-evaluation following procedural interventions.2 From this assessment, the therapist can determine where symptoms are perceived versus where they can be provoked.3
o   Pelvic and visceral adhesions may be seen and detected with visceral manipulation techniques, although they lack validity, reliability, and effectiveness, it may prove to be a useful tool in the evaluation and treatment of this population.2
  • Internal Palpation/Exam (vaginal):
o   An examination of the middle and deep pelvic floor muscles should then commence and is best conducted via transvaginal or transrectal palpation. From this exam, the clinician can evaluate the pelvic floor musculature for the presence of trigger points, spasm, vaginal vault size, symmetry, muscle activity, and muscle strength.2  Manual muscle testing, using the modified Oxford scale, is done to determine PFM strength and excursion.2,8
o   A cleaned, well glove, and lubricated finger is used to enter the vaginal (or rectal) vault to assess presence of pain and vaginal/rectal coordination and strength (Please refer to Hand Washing Protocol for more details).
o   Common findings for patients with CPP and PFM tension myalgia include: tenderness of PFM, spasm of the PFM, trigger point presence, shortened muscles, overactive PFM, poor posture, and/or deconditioned pelvic floor muscles. With shortened muscles, pain and weakness may be present and will have a decreased ability to lengthen, elongate, or bulge their PFM downwardly, which is needed to allow voiding or penetration to occur without pain.2 With pelvic floor muscle over activity, the musculature has tension at rest, and these patients are often unable to demonstrate much more of a contraction and will rarely show a release of the muscle between attempts at contraction.  Consequently, the attempt to contract the pelvic floor musculature will often be ineffective.3
§  The aforementioned possible findings of altered muscle activity can be evaluated with palpation, surface electromyography (sEMG), observation, and RUSI.
·         Surface Electromyography (sEMG): For diagnostic studies, objective determination of pelvic floor muscle over activity or under activity can be obtained through various techniques, one of which is sEMG. Either internal vaginal or rectal sensors or external superficial adhesive sensors may be used. The examination will likely reveal at least 3 of the 5 following findings: elevated and unstable resting baseline activity, poor derecruitment after contraction, poor return to baseline after contraction, spasms with sustained contractions, and poor overall recruitment.2,3
·         Rehabilitative Ultrasonic Imaging (RUSI): Overuse of abdominal oblique muscles or valsalva maneuver during the execution of a PFM contraction may be seen on RUSI which may be worsening symptoms2
o   Less likely to be observed is under activity or weakness of PFM, yet still possible and should not be overlooked.2
·         Functional Outcomes:
It is important to recognize that no single measurement can capture the entire scope of pelvic floor symptoms or impairments; therefore, the use of health related quality of life measures as an adjunct to clinical examination and evaluation offers a more accurate means of demonstrating and understanding the impact of pelvic floor dysfunction, including vulvar pain, on a woman’s daily life. 2
o   Health-related quality of life questionnaires refer to a person’s total sense of well-being and consider multiple dimensions including: social, physical, and emotional health.
o   Vulvar Functional Status Questionnaire (VQ): provides a measure of physical function among women with vulvar pathology
o   Pelvic Organ Prolapse and Incontinence Sexual Function Questionnaire (PISQ): assesses the impact of POP or UI on the sexual function of sexually active women.2
Differential Diagnosis:
  • Non-musculoskeletal gynecological and/or urological or colorectal disorders (i.e.: endometriosis) should be considered.19
  • Hip pathology, lumbosacral radiculopathy, plexopathy, or peripheral neuropathy including pudendal neuralgia should also be examined in the differential diagnosis process.19
  • Lumbar source of pain: Current reports of or a history of lumbar pain, pain located above the sacrum, decreased ROM in the lumbar spine, pain with lumbar motion, pain with palpation of erector spinae muscles, and negative PGP special testing should be examined as part of the differential diagnosis.
  • Pelvic girdle pain: Pelvic girdle pain (PGP) is defined by pain experienced between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the sacroiliac joints (SIJ). PGP is a specific form of low back pain (LBP) that can occur separately or concurrently with LBP.  The pain may radiate in the posterior thigh and can occur in conjunction with/or separately in the symphysis, a similar location to that of vulvar region pain. PGP generally arises in relation to pregnancy, trauma, or reactive arthritis. The pain or functional disturbances in relation to PGP must be reproduced by specific clinical tests.20
  • Rupture of the symphysis pubis: A pubic symphysis rupture is characterized by tenderness and swelling over the symphysis pubis. Separations greater than 1 cm are considered to be symptom producing. Palpation of gapping in the joint may occur. Patients may report difficulty with ambulation. Patients may have PGP in addition to rupture.21
  • Vulvar skin condition (such as lichens sclerosis)16
  • Tumor or infectious process
The main goal of physical therapy for pelvic pain is to rehabilitate the PFM by: increasing awareness and proprioception, improving strength, speed, endurance, and muscle discrimination, decreasing over activity and improving voluntary relaxation, increasing elasticity of the tissues at the vaginal opening, and decreasing the fear of penetration.10
Treatment should focus on the cause of the dysfunction, not just the source of pain. The goal of therapy is to address any musculoskeletal imbalances that are causing or perpetuating the pain.19
Patient Education:
Patient education must always occur first and is one of the most important factors in treating this population.3 Specifically, educating the patient about the physical therapy examination findings, the specific nature of their pain, and how treatment strategies correlate with improvement in their condition.2, 3 The role of the pelvic floor muscles in posture, sexual appreciation, bowel, and bladder control, physiology of micturition/defecation, proper bowel and bladder habits/techniques, proper postural techniques, role of hormonal changes, and proper skin care techniques should all be addressed.3  Education regarding proper posture and use of support devices such as lumbar rolls and perineal support cushions may be included. Recommended vulvar care practices such as: avoiding irritants, wearing only cotton underwear, and cleaning the area only with water may be provided to the patient.2  Furthermore, education to avoid provocating activities initially (i.e.: intercourse, tampon usage)  or changing positions with painful activities may also be warranted.12, 22 Finally, a comprehensive program should always include instruction in a home exercise program to promote patient/client independence and continuity of treatment.2
Manual Therapy:
Specific manual soft tissue mobilization techniques to address scar tissue, adhesions, trigger points, and to desensitize the tissue in this area should be utilized. Such techniques would include: scar mobilization, myofascial release, trigger point release, muscle energy techniques, strain-counterstrain, and joint mobilization.19, 22  Passive and resistive stretching techniques are designed to improve blood flow and mobility to the pelvic and vulvar region, and normalize postural imbalances.22  In either cases of over- or under-active PFM dysfunction, correction of spinal, hip, pelvic, sacroiliac joints, and coccyx dysfunction will help to balance the system and may improve some of the function and pain level experienced by the patient.  Correcting dysfunctional movement patterns, resolving neural tension, resolving pelvic visceral adhesions, and increasing abdominal strength are all important in this population.2
External Perineal Treatments: Skin rolling, external trigger point/myofascial release techniques, and scar mobilization to the affected regions around the pelvic and vulvar region can be useful.
Internal Treatments (intra-vaginal): Transvaginal manual techniques of the pelvic floor muscles have been used for the treatment of high-tome dysfunction of pelvic floor patients with CPP and IC, with symptoms remaining significantly improved after four and one half months.5  Trigger point release, myofascial release, stretching, manual scar mobilization, strength and coordination training of the pelvic floor musculature using digital tactile cueing, is also warranted in this population.5 Manual therapy techniques directed at the vaginal introitus can be useful for increasing vaginal entry space and desensitizing areas that are painful to touch.22
Surface Electromyography (sEMG) Biofeedback:
Biofeedback with use of sEMG can be beneficial to facilitate a patient’s awareness of the activity in their pelvic floor muscles and facilitate pelvic floor muscle coordination and relaxation or downtraining as appropriate.3,19  Biofeedback is a conditioning treatment whereby typically unknown information about a bodily function (pelvic floor muscle activity) is converted into simple auditory or visual cues so they can be voluntarily altered to become more efficient.23
·         In the case of a patient with overactive PFM contributing to their pain, sEMG can be used to facilitate a reduction in the patient’s resting level of activity of the PFM. When the PFM improve in their resting level as demonstrated by decreased activity at rest, then PFM weakness may become more apparent.2 This should then be addressed with pelvic floor muscle uptraining as described below. Home biofeedback can also be issued to the patient if needed for further training.
Rehabilitative Ultrasonic Imaging (RUSI):
Incoordination of the PFM, abdominal muscles or both may be observed with RUSI. Therefore, RUSI can be used to facilitate increased patient awareness of the inappropriate muscle activity to promote proper PFM and/or abdominal contraction and synergy.2
Therapeutic Exercise:
If there is imbalance of the muscles of the pelvic floor, trunk, and hips, the following therapeutic exercise strategies can be used: stretching of shortened musculature in and around the pelvis after pelvic obliquity correction and specific trunk stabilization exercises including transverse abdominis, multifidus, and pelvic floor musculature and breathing diaphragm.2, 22
Additional intervention options include modalities such as internal or external electrical stimulation, ultrasound, moist heat, and cryotherapy.2 Heat applied to the lower pelvis and pelvic floor musculature can be facilitory of pelvic floor muscle relaxation.3 Heat and cold modalities can be helpful to promote pain management and relaxation of muscles.19
Transvaginal electrostimulation has been associated with a success rate of 50%, approximately with pain intensity being improved after 4 weeks post-treatment and remained after 30 weeks post-treatment in patients with CPP and interstitial cystitis symptoms.5 Furthermore, the use of pelvic floor electrical stimulation in patients with pelvic pain and pelvic floor muscle over activity has been reported to both reduce pain and increase muscle strength in patients with vulvar vestibulodynia.25
Behavioral Retraining:
Retraining of proper bladder and bowel habits and techniques, as well as proper postural awareness is essential for long term management of pain in this population.3 Proper breathing strategies are also important in patients with pelvic pain. There is a normal synergy between the respiratory diaphragm and the pelvic floor muscles, in that during inhalation, the pelvic floor muscles descend and relax, while during exhalation the pelvic floor muscles return to their resting baseline. Patients should be taught that during rest, the pelvic floor muscles should be relaxed and the patient educated on ways to monitor pelvic floor muscle activity during the day so that the muscle tone in this area is not inadvertently raised at the end of the day.19
Frequency & Duration:
Typically, a patient with pelvic or vulvar pain is seen by the physical therapist for one visit per week for at least 8 to 12 weeks.12
Patient’s Discharge Instructions:
Patient’s instructions at discharge should include: continuation of and independence with home exercise program to promote independent symptom management, as well as independence with activity modification and postures to minimize pain as appropriate. Patients should follow up with their physician if symptoms progress or re-occur."

Saturday, July 26, 2014

Why Excision Is Recommended


What Is Excision?

Excision is the surgical removal of tissue by cutting out. It differs from ablation/laserization/burning/vaporizing which are techniques that use a heat source to destroy tissue. “Excision removes endometrial implants by cutting them away from the surrounding tissue with scissors, a very fine heat gun or a laser beam. The technique does not damage the implants, so the gynaecologist is able to send a biopsy of the excised tissue to the pathologist to confirm that it is endometriosis and not cancer or another condition. Excision allows the gynaecologist to separate the implants from the surrounding tissue, thus ensuring that the entire implant is removed and no endometrial tissue is left.”

There are many ways to remove endometriosis from the body, but excision is considered one of the most effective methods at this time. The term excision refers to using a type of cutting method to try to remove the entire endometriosis implant and leave nothing behind.

Excision can be done with a number of different tools and methods. There are mechanical tools such as scissors or a scalpel and others methods such as laser, vaporization, or electricity; all can be used to remove endometriosis implants from organs and tissues.

In many cases, the specific tool is not the key, but rather having a surgeon who is able to use a tool or tools in a skilled and expert manner to cut away existing implants. Some surgeons even use a combination of tools depending on the location of endometriosis.

Excision is important for a couple reasons. One, it leaves tissue intact so there is something to send to pathology to confirm diagnosis. Having positive proof of your diagnosis can help treatment decisions. Two, excision is less likely to leave remaining endometriosis implants that can continue to cause symptoms and problems.

Unfortunately, there are a limited number of surgeons in the United States, and even the world, with expert excision skills. Instead, many surgeons use an ablation method that burns the surface of the endometriosis implant using heat, laser, or cautery methods, which can cause more scarring and tissue damage. In addition to possible tissue damage, this method is also more likely to leave behind some of the endometriosis because it cannot reach deep implants, nor can it be used on all organs and tissues. Plus, ablating the implants leaves no tissue for pathology to confirm diagnosis.

Finding an endometriosis specialist who has the ability to excise your endometriosis could offer you the most optimal treatment option. It can take some time and effort to find this type of surgeon, but it can be well worth it!”

Why Excision Is Preferable to Ablation?

“Because there is no objective way of knowing how deeply an endometrial lesion might invade by simply looking at it, the laser surgeon may vaporize the surface of a lesion and still leave active disease below. This is particularly true for deeply invasive nodules of the uterosacral ligaments. In addition, the laser surgeon is frequently reluctant to vaporize disease located over the bowel, bladder, ureters, or major vessels for fear of damaging these organs. Again, active disease can remain in the pelvis and continue to cause pain.

Because laser vaporization completely destroys tissue suspected of being endometriosis, there is no way to confirm through a pathology report that the vaporized tissue was in fact endometriosis, not some other type of abnormal tissue. This can lead to problems in the scientific study of the disease, since the "evidence" presented in a medical journal becomes a matter of opinion rather than a matter of fact.

No long term studies have been published giving data on pain and recurrent disease after laser vaporization. Studies published to date reflect pregnancy outcome, which is misleading when one is treating pain.”

Coagulation destroys implants by burning them with a fine heat gun or vaporising them with a laser beam. When coagulating implants, care must be taken to ensure that the entire implant is destroyed, so it cannot regrow.  Care must also be taken to ensure that only the implant is destroyed, and no underlying tissue, such as the bowel, bladder or ureter, is damaged. The possibility of accidentally damaging the underlying tissue means that most gynaecologists are wary of using coagulation on implants that lie over vital organs, such as the bowel and large blood vessels.

Of the two techniques, excision is more effective, requires more skill, and is more time consuming.

The skill and time required means that it is not used by all gynaecologists. If your gynaecologist does not have the skill to excise all your endometriotic implants, ask to be referred to a gynaecologist who specialises in endometriosis surgery and is skilled in excision.

The effectiveness of excising endometriotic implants has been shown in two clinical trials. Women who had their implants excised had fewer symptoms 12 months [6] and 18 months [7, 8] after surgery compared with women who underwent a laparoscopy without excision of their implants.”

The European Society for Human Reproductive Endocrinology guidelines encourage excision, stating that pain due to endometriosis can be reduced by surgical removal of the entire lesion in severe and in deep, infiltrating endometriosis. The guidelines also state that the best approach is to diagnose and remove endometriosis surgically. Despite these recommendations, most surgeons do not excise endometriosis during diagnostic procedures. A recent survey of British gynecologic consultants and surgeons found that only 30% performed surgical removal. In the survey, 95% favored ablative techniques, and 25% used both ablation and excision.7 This reluctance to adopt excision of endometriosis has been judged appropriate by some, due to the lack of good long-term data regarding its effects and the increased potential for surgical complications.


A review of the literature yields 2 randomized controlled trials (RCTs) and 5 cohort studies addressing the effectiveness of laparoscopic excision for the treatment of endometriosis.8-14

A 2003 study involving 39 subjects with histologically confirmed endometriosis randomized

patients to either immediate excisional surgery or diagnostic surgery only.8 All patients underwent second-look laparoscopy, with 80% of women in the excision group reporting improvements in pain symptoms versus 32% in the control group. Women with more advanced disease experienced a greater response to laparoscopic excision. Furthermore, responses on quality-of-life instruments showed significant improvements in both mental and physical scores.8 In the second RCT, 24 women with mild endometriosis (stage 1 or 2) were randomized to either laparoscopic excision or ablation of endometriotic lesions.9 There was no significant difference between groups with respect to pain relief and pelvic tenderness, but there was a significant improvement in the signs of endometriosis (eg, back pain, fatigue, tenderness, adnexal pain) in the excision group. As in the first RCT, severity of symptoms was the strongest indicator of the success of treatment.8,9 The latter study identified no additional morbidity associated with excision, but both trials were limited by small size and short follow-up.8,9


There were 5 cohort studies involving laparoscopic excision of endometriosis, 4 of which directly assessed the effects of excisional surgery on pelvic pain (Table).11,12,14-16 A 1996

investigation reported on a 2-year follow-up of women undergoing excision versus laser

vaporization. At 12 months, 96% of excision patients and 69% of vaporization patients were pain-free, falling to 69% and 23%, respectively, at 24 months.10 Findings from a study of 135 patients with a mean follow-up of 3.2 years revealed reductions in pain scores related to dysmenorrhea, nonmenstrual pelvic pain, dyspareunia, and dyschezia.11 As expressed by survival curves, the likelihood of avoiding further surgery over the subsequent 5 years was 64%, with the strongest predictive factor for reoperation being a revised American Fertility Score of 70 or higher. Interestingly, endometriosis was not identified at the time of subsequent surgery in 32% of subjects.11 A study that followed 62 women for an average of 13 months reported a 71% satisfaction rate with excision, but 40% of subjects still required regular medication and 11%

underwent further surgery.12 Finally, among 107 women treated by laparoscopic excision and followed for a mean of 7.65 years, the 2-, 5-, and 7-year surgery-free rates were 79.2%, 51%, and 41.4%, respectively.14 All of these studies were limited by the lack of a control group, but they consistently showed a 2-year surgery-free rate of more than 70%. Three studies presented data regarding quality of life before and after excision.11,12,17 A 4-month follow-up of 57 consecutive patients undergoing laparoscopic excision of endometriosis reported significant improvement in the physical components of quality-of-life scores, but showed no improvement in the mental components.17 The aforementioned study of 135 patients noted improvement in a quality-of-life scale that persisted through 5 years of follow-up, but these improvements did not reach the quality of life of healthy subjects. 17 Finally, the study that involved 62 patients noted only limited increases in quality-of-life scores, with improvement in social life reported by 32%, in relationships by 24%, and in anxiety levels by 39%.12


Deep dyspareunia is a common complaint among women with endometriosis, affecting 60% to 79% of patients undergoing surgery.13 An observational prospective cohort study addressed the effects of laparoscopic excision on deep dyspareunia and overall sexual function. The study enrolled 68 women, of whom 87% had stage 3 or 4 disease. At 6 and 12 months’ follow-up, patients demonstrated both significant reductions in the intensity of deep dyspareunia and

improvements in the quality of sexual function.13 Two of these studies reported significant improvements in pleasure and comfort.11,13 One RCT comparing laparoscopic endometriosis ablation with diagnostic laparoscopy reported a 62.5% improvement in symptoms at 6 months versus 22% in the control group.15 At a mean followup of 73 months, there was a symptom recurrence rate of 74%, but a 55% rate of satisfactory symptom relief. Whereas the cohort study of 107 patients noted a 2-year reoperation rate of 21.2%, this RCT yielded a median time to symptom recurrence of 19.7 months and a 2-year reoperation of 37%.14,16 Overall, these data have several limitations.


All of the studies were conducted by expert laparoscopic surgeons, whose results are unlikely to be reproduced by the generalist surgeon. Also, the absence of a control group in the cohort studies limits the significance of their findings. Finally, variations in designs, endpoints, and surgical techniques make it difficult to generalize. There is no definitive study as of yet, and a large, well-designed RCT of laparoscopic excision versus ablation of endometriosis remains to be performed. Based on the studies performed to date, it is the author’s opinion that laparoscopic

excision of endometriosis, when technically feasible, should be the standard of care. First, whereas visual diagnosis of endometriosis is correct in only 57% to 72% of cases, excisional

surgery yields specimens for histologic confirmation—and identifies endometriosis in 25% of “atypical” pelvic lesions as well.18 The availability of such specimens would prevent unnecessary treatment and ensure more reproducible research findings. Excision should also reduce the incidence of persistent disease secondary to inadequate “tip of the iceberg” destruction, removing both invasive and microscopic endometriosis to provide the best possible symptom relief.


Finally, the results of excision are comparable to or better than those of ablation. Endometriosis usually recurs, but excision both prolongs the time to reoperation and reduces the severity at second surgery. Excision provides the greatest benefit for patients with extensive disease without increasing complication rates or morbidity Surgical treatment of endometriosis can be difficult due to its tendency to target the uterosacral ligaments adjacent to the ureter and to cause fibrosis and adhesions. However, these complexities need not result in suboptimal debulking of lesions. These studies suggest that converting from ablative to excisional therapy will refine diagnosis,

reduce disease burden and morbidity, lengthen the time to recurrence, and improve outcomes overall..”

Studies on Excision of Endometriosis:

The goal of laparoscopic treatment of extensive endometriosis is to excise all visible and palpable endometriosis and to restore normal anatomic relationships. Benefits to the patient include substantial symptom relief and resolution of infertility in many cases, circumvention of major abdominal surgery with its related morbidity, and avoidance of the hypoestrogenic effects of ovarian suppression therapy, which prohibits fertility during its administration and never eradicates deep infiltrating endometriosis. The laparoscopic approach can be lengthy, and the persistent nature of the disease may dictate more than one application. Therefore, determining factors in achieving the desired outcome are the surgeon's skill and tenacity and the patient's persistence.”

Complete laparoscopic excision of endometriosis in teenagers--including areas of typical and atypical endometriosis--has the potential to eradicate disease. These results do not depend on postoperative hormonal suppression. These data have important implications in the overall care of teenagers, regarding pain management, but also potentially for fertility. Further large comparative trials are needed to verify these results.” “A recent article published by Dr. Yeung in Fertility & Sterility 2011:  (1) demonstrates that complete excision (even in teenagers) by an expert is potentially curative, and can eradicate disease; (2) implies the importance of early excision, to prevent progression and preserve fertility, and (3) indicates that these results do not require long-term hormonal suppression.”

Results: There was a reduction in all pain scores over the five year follow up in both treatment groups. A significantly greater reduction in dyspareunia VAS scores was seen in the excision group at 5 years (univariate p= .031 and multivariate p=.007). More women went on to use medical treatments for endometriosis amongst the ablation group (p= .004) by 5 years.

Conclusions: Surgical treatment of endometriosis provides symptom reduction for up to 5 years. There are some limited areas, such as deep dyspareunia, where excision is more effective than ablation.”


"CONCLUSIONS: Laparoscopic excision of endometriosis significantly reduces pain and improves quality of life for up to 5 years. The probability of requiring further surgery is 36%. Return of pain following laparoscopic excision is not always associated with clinical evidence of recurrence."

Surgical treatment of endometriosis leads to endothelial function improvement, resulting in reduction of cardiovascular risk.”

"A new study shows women who undergo surgical treatment for endometriosis have a lower risk of developing ovarian cancer. The Swedish research also found that hormonal treatments for endometriosis did not lower the risk."

Diagrams detailing appearance, anatomic site, and surgeon's suspicion of endometriosis versus atypical lesions were compared with final histologic diagnosis. The greatest number of patient lesions were excised from cul-de-sac (n = 309). For this site, using visual criteria for diagnosis of endometriosis, positive predictive value was 93.9%, sensitivity was 69.3%, negative predictive value was 41.9%, and specificity was 83.1%. Prevalence was noted to be 79.0% and accuracy was 72.2%. In addition, atypical-appearing tissue not presumed to be endometriosis was confirmed to be endometriosis histologically in 24.3%. In examining tissue specimens from multiple anatomic sites, laparoscopic visual diagnosis of typical endometriosis generally had high positive predictive value. However, both sensitivity and negative predictive value were lower than expected because of atypical lesions subsequently diagnosed as endometriosis.These data suggest that when the surgical objective is complete eradication of endometriosis, the surgeon must be prepared to excise all lesions suggestive of endometriosis and tissue atypical in appearance as in most anatomic sites approximately 25% of atypical specimens proved to be endometriosis."

"Endometriosis could still be regarded as a recurrent disease; nevertheless recurrence could not be ascribed to the retrograde menstruation, but to an incomplete surgical intervention, since it is demonstrated that endometriosis lesions could be also made up of microscopic foci (Redwine, 2003), and or to different timing of growth of the lesions in the same patient, probably due to individual susceptibility that is a typical phenomenon of the diseases inducted by endocrine
disruptors (Mori et al., 2003). Therefore surgery, if complete in exhausted growth disease can be considered curative. Contrarily, exposition to endocrine disruptors such as synthetic estrogens or SERM chemical compounds, though reducing the symptoms, could increase the growth of

"A systematic review found that post-surgical hormonal treatment of endometriosis compared with surgery alone has no benefit for the outcomes of pain or pregnancy rates, but a significant improvement in disease recurrence in terms of decrease in rAFS score (mean = −2.30; 95% CI = −4.02 to −0.58) (Yap et al., 2004). Overall, however, it found that there is insufficient evidence to conclude that hormonal suppression in association with surgery for endometriosis is associated with a significant benefit with regard to any of the outcomes identified (Yap et al., 2004)....Moreover, even if post-operation medication proves to be effective in reducing recurrence risk, it is questionable that ‘all’ patients would require such medication in order to reduce the risk of recurrence. It has been reported that about 9% of women with endometriosis simply do not respond to progestin treatment (Vercellini et al., 1997), which may result from progesterone receptor isoform B (PR-B) down-regulation (Attia et al., 2000). If PR-B is silenced due to promoter methylation, as reported in endometriosis (Wu et al., 2006b), progestin treatment or OC use may be of little value since the action of progestins is mediated mostly through PR-B. Therefore, the use of post-operation medication indiscriminately may cause unnecessary side effects (and an increase in health care costs) in some patients who may intrinsically have a much lower risk than others and in others who may be simply resistant to the therapy. The identification of high-risk patients who may benefit the most from drug intervention would remain a challenge. Finally, whether a single medication represents the optimal interventional option is debatable. The recent finding that PR-B and nuclear factor-κB (NF-κB) immunoreactivity jointly constitute a biomarker for recurrence (Shen et al., 2008) suggests the possibility that perhaps a combination of drugs may be superior to a single drug in reducing the risk of recurrence, especially if PR-B is silenced due to promoter methylation."

"Several clinical studies suggest that the recurring endometriotic lesions arise from residual lesions or cells not completely removed during the primary surgery. Nisolle-Pochet et al. (1988) reported that in women who received microsurgical resection of ovarian endometriosis, a high prevalence of active endometriosis without signs of degeneration is found after hormonal therapy. Compared with women receiving no treatment, the mitotic index was similar in women treated for 6 months either with lynestrenol (a progestin), gestrinone (an androgenic, antiestrogenic and antiprogestogenic agent) or buserelin (a GnRH agonist) (Nisolle-Pochet et al., 1988). This suggests that hormonal treatment does not lead to a complete suppression of endometriotic foci and that recurring lesions appear to grow from the residual loci. Vignali et al. (2005) found that for those patients who underwent a second surgery, the recurrence of deep endometriosis is observed in the ‘same’ area of the pelvis involved in the first operation. Exacoustos et al. (2006) reported that of 62 patients with recurrent endometriomas, 50 (80.6%) had recurrence on the treated ovary, 7 (11.3%) on the contralateral untreated ovary and 5 (8.1%) on both the treated and untreated ovaries. Overall, the majority of recurrent cases (88.7%) have recurrence involving the treated ovary, suggesting that the recurring cysts seem to grow likely from the residual loci."

"Above all, this report is directly at odds with the one reporting that recurrent symptoms still occur in about 10% of women even ‘after’ hysterectomy and bilateral salphingo-oophorectomy are performed (Namnoum et al., 1995). In fact, some earlier reports also found recurrence after hysterectomy. Sheets and Fetzer (1956) and Andrews and Larsen (1974) reported a 1–3% reoperation rate after hysterectomy with some ovarian conservation. Hammond et al. (1976) reported an 85% reoperation rate 1–5 years after hysterectomy surgery with ovarian conservation. Some anecdotal reports also documented the development of endometriosis after hysterectomy (Goumenou et al., 2003)."

"RESULTS: Interval rates of reoperation and recurrence/persistence of disease and extent or invasiveness of disease when found at reoperation did not increase with the passage of time after surgery. The maximum cumulative rate of recurrent or persistent disease was 19%, achieved in the 5th postoperative year.

CONCLUSION: Laparoscopic excision of endometriosis results in a low rate of minimal persistent/recurrent disease. The natural history of endometriosis after surgery suggests a rather static nature of the disease."

"Main outcome measures Effect of laparoscopic excision on pain scores and quality of life, operative findings, type of surgery, length of surgery and incidence of intra- and post-operative complications.

Results Patients with endometriosis were severely ill with significant pain and impairment of quality of life and sexual activity. Four months after radical laparoscopic excision for deep endometriosis there was significant improvement in all the parameters measured including their quality of life based on EuroQOL evaluation: EQ-5D (0.595:0.729, P= 0.002) and EQ thermometer (68.9:77.7, P= 0.008); SF12 physical score (44.8:51.9, P= 0.015); sexual activity (habit P= 0.002, pleasure P= 0.002 and discomfort P≤ 0.001). Only the mental health score of SF12 failed to show any statistical improvement (47 1:48.4, P= 0.84). Symptomatically, there was a significant reduction in dysmenorrhoea (median 8.0:4.0, P≤ 0.001), pelvic pain (median 7.0:2.0, P≤ 0.001), dyspareunia (median 6.0:0.0, P≤ 0.001) and rectal pain scores (median 4.0:0.0, P≤ 0.001). Complications were noted, but were deemed to be acceptable for the extent of the surgery.

Conclusions This is an early analysis of the first 57 cases studied, but structured evaluation suggests that meaningful improvements in clinical symptoms and quality of life can be obtained with this approach with acceptable levels of operative morbidity. Further follow up of this series is required, but early evidence would suggest that the technique should be further evaluated as part of a randomised trial."

"Recent findings: Large, long-term, prospective studies and a placebo-controlled, randomized, controlled trial suggest that laparoscopic excision is an effective treatment approach for patients with all stages of endometriosis. The result of such laparoscopic excision may be improved if affected bowel, bladder and other involved structures are also excised. Adjuvant therapies such as the levonorgestrel intrauterine system and pre-sacral neurectomy may further improve outcomes. Ovarian endometrioma are invaginations of the uterine cortex, and surgical stripping of this cortex removes many primordial follicles. Despite this apparent disadvantage, stripping of the capsule is associated with better subsequent pregnancy rates and lower recurrence rates than the more conservative approach of thermal ablation to the superficial cortex.

Summary: Laparoscopic excision is currently the ‘gold standard’ approach for the management of endometriosis, and results may be improved with careful use of appropriate techniques and suitable adjuvant therapies."

"Surgical excision can be carried out by laparoscopy, laparotomy or vaginally using sharp dissection, electrosurgery or with the use of a CO2 laser. Excision is the treatment of choice because of a high pregnancy rate, a complete cure of pain in most women, and a low recurrence rate....The choice of treatment will therefore depend on the local expertise with minimal invasive surgery, certainly if a first excision has been incomplete and pain symptoms recur."

Which one is better for pelvic pain and recurrence in ovarian endometrioma, excisional surgery versus ablative surgery? recent Cochrane review

A recent Cochrane review evaluated the most effective technique for treating an ovarian endometrioma, either excision of the cyst capsule or drainage followed by electrocoagulation of the cyst wall, measuring the primary outcome as pain symptom improvement [15]. Two randomized studies of the laparoscopic management of ovarian endometrioma, greater than 3 cm were included. Laparoscopic excision of the cyst wall of the endometrioma was associated

with a reduced recurrence rate of dysmenorrhea (OR, 0.15; 95% CI, 0.06 to 0.38), dyspareunia (OR, 0.08; 95% CI, 0.01 to 0.51) and nonmenstrual pelvic pain (OR, 0.10; 95% CI, 0.02 to 0.56). For the secondary outcome measures, laparoscopic excision of the cyst wall was associated

with a reduced rate of recurrence of the endometrioma (OR, 0.41; 95% CI, 0.18 to 0.93) and with a reduced requirement for further surgery (OR, 0.21; 95% CI, 0.05 to 0.79) compared with ablative surgery.”


A particular strength of this study is that it describes outcomes after excision for endometriosis from multiple referral centers; as such, it is the first study known to include data from multiple centers after excision. This shows that a multicenter trial is feasible, even among surgical referral sites. Most studies that have been published on excision for the surgical management of endometriosis have been from a single surgeon or center.5,8,9 Patients were suspected to have endometriosis based on the overall assessment of the surgeon from the clinical history and examination findings. One of the benefits of excision is the histologic confirmation of disease, and more than 7 of 10 patients who underwent surgery in thisstudy for the suspicion of endometriosis had histologically proven disease. Even more noteworthy is that of the patients in whom histologically proven endometriosis wasvfound, a high percentage (84.6%) had received either previous hormonal therapy or surgery by ablation as “treatment” for presumed endometriosis, indicating that these interventions are ineffective at suppressing or preventing

disease. The data from this study further indicate that the addition of hormonal suppression after excision did not further reduce VAS scores for pain or benefit QOL scores, when compared with patients without postoperative hormonal suppression.


In the RCT of excision versus ablation for endometriosis by Healey et al.5 (2010), differences in pelvic pain were not statistically significant, but there were trends for a difference in bowel-related symptoms and dyspareunia. In addition, as mentioned earlier, the results of their study came from a single center and are likely only applicable to generalist gynecologists. In our prospective multicenter study on excision for endometriosis, there were significant reductions in pelvic pain, dysmenorrhea, dyspareunia, and bladder symptoms but not bowel symptoms.

In contrast to the study by Healey et al.,5 where fewer than one-third of patients who underwent surgery previously received either hormonal or surgical treatment, patients in our study received either hormonal or surgical treatment in the vast majority of cases (_80%). One might predict

that patients having previous treatment might respond with less benefit from another surgical intervention, yet the rates of improvement in VAS scores were comparable in both studies. Also of note is the finding that patients did not have symptom improvement in QOL scores when no

endometriosis was found histologically. A strength of this study is the inclusion of a single validated measure of QOL before and after excision surgery. A scale of 0 to 100 for the QOL score is easy to use and has been validated as an assessment tool.7 Most studies on the surgical management of endometriosis use pelvic pain as the primary outcome as measured by VAS scores.1,3,5 A potential problem with using pelvic pain as the primary outcome of a study on endometriosis is that some components of pain may improve after surgically treating endometriosis whereas others may not, at least to the same extent. A QOL assessment may be a better overall measure of the clinical benefit of surgery for treating endometriosis by translating multiple pain symptoms to a single measure of their effect on daily functioning. In fact, published reviews have recommended the inclusion of a QOL assessment in trials that look at pain as an outcome.10,11 Our study showed a statistically significant improvement in QOL scores after excision at multiple centers. It is our recommendation that a QOL measure be

used as the primary symptom outcome measure for future comparative trials on excision versus ablation in the surgical management of endometriosis. This study has produced an estimate of the benefit on QOL after excision to be an increase of 20 points. There are no known studies

that have evaluated QOL after ablation. Weaknesses of this study include the skewed actual numbers of recruitment, with more than 58 of 100 patients coming from a single center and 78 of 100 from 2 centers. Perhaps more important is the lack of quality assurance or some objective way to determine whether adequate or complete excision of all areas of abnormal

peritoneum was achieved at each of the centers. In any subsequent randomized comparative trial comparing excision and ablation, objective or third-party quality assurance will need to be included for both techniques, especially if a particular referral center favors a particular approach over the other. As reported in a recent study on complete excision of endometriosis in teenagers, one of the most important benefits of excision may not be symptom relief but may be eradication of disease.12 Potential eradication of disease by excision might benefit future fertility, and this

benefit might need to be evaluated also in a comparative trial of excision versus ablation in the treatment of endometriosis.


One of the aims of this study was to obtain an estimate of the rate of patients presenting to referral centers for pelvic pain or endometriosis (in particular, centers that specialize in the excision of endometriosis) who would be willing to be randomized to either excision or ablation of endometriosis at the time of surgery. The vast majority of patients (84.0%) were willing to be randomized when asked this question. This bodes well for the feasibility of a randomized comparative trial even at referral centers that specialize in a particular surgical approach to the treatment of endometriosis.


The results of this study indicate that patients were overwhelmingly willing to be randomized to either excision or ablation for endometriosis even at referral centers, that QOL may be a better overall measure as a primary outcome when one is looking at the benefit of surgery for endometriosis, and that a comparative RCT is feasible, as well as needed, among multiple centers that specialize in surgically treating endometriosis.”


Laparoscopic surgical removal of endometriosis (through either excision or ablation of endometriosis or both) is an effective first-line approach for treating pain related to endometriosis (Jacobson et al., 2009). Although RCTs have failed to demonstrate the benefit of excision over ablation (Wright et al., 2005; Healey et al., 2010), there is unanimous consensus over the recommendation to excise lesions where possible, especially deep endometriotic lesions, which is felt by most surgeons to give a more thorough removal of disease (Koninckx et al., 2012). It is also acknowledged that, even after expert removal of endometriosis, there may be a recurrence rate of symptoms and endometriotic lesions that varies from 10 to 55% within 12 months (Vercellini et al., 2009), with recurrence affecting _10% of the remaining women each additional year (Guo, 2009). The risk of requirement for repeat surgery is higher in women

younger than 30 years at the time of surgery (Shakiba et al., 2008). First operations tend to produce a better response than subsequent surgical procedures, with pain improvements at 6 months in the region of 83% for first excisional procedures versus 53% for second procedures (Abbott et al., 2004). Excessive numbers of repeat laparoscopic procedures should therefore be avoided. The role of a purely diagnostic laparoscopy has been questioned and, ideally, there

should always be the option of continuing to surgical removal of endometriosis, within the limitations of the surgeon’s expertise….Laparoscopic surgical removal of endometriosis is recognized as being effective in improving fertility in stage I and II endometriosis (Jacobson et al., 2010)… Laparoscopic excision (cystectomy) whenever possible for endometriomas

.4 cm in diameter improves fertility more than ablation (drainage and coagulation) (Hart et al., 2008).”

What Some Of The Experts Have To Say:
Can endometriosis be eradicated?

For the most optimal results, in our opinion, excision of all visible disease must be achieved, which depends on two important factors:

1.     identifying all forms of the disease – including both its typical and atypical or subtle forms [16], and

2.     completely removing the disease wherever it is found (excision).


We published a study [17] recently, which is the largest prospective study of excision in teenagers.

The majority of the women had received previous hormonal treatments, previous (sometimes multiple) surgeries by ablation, and had an “awful” or “poor” quality of life.

All the teenagers received “complete excision” (defined as above) by an expert and experienced surgeon. They were followed for up to 5 years, the mean interval being 2 years. Overall the pain scores and quality of life (perhaps more importantly) improved significantly. The rate of recurrent or persistent endometriosis on second-look laparoscopy was zero.

This data indicates that complete excision is an important part of the management plan for pain. More importantly perhaps, is the implication that there is a potential for complete eradication of disease.

-- Co-author Assistant Professor Patrick Yeung Jr, Saint Louis University

The potential benefit of early diagnosis and complete excision


The data discussed above indicates that early diagnosis and complete excision is the best way to improve quality of life, and perhaps to prevent progression of endometriosis and thereby benefit long-term fertility.

However, further systematic, multi-centre and longer-term studies are needed to confirm this hypothesis.

---Co-author Dr Robert Albee Jr, Center for Endometriosis Care

Embracing the challenge of complete excision surgery, the gold standard of endometriosis treatment

If you are a gynecologist dealing with endometriosis, you know the trite drill dictated by conventional wisdom: in the office diagnose pelvic pain as a sexually transmitted pelvic inflammatory disease (PID) and treat with antibiotics; diagnose recurrent pelvic pain as recurrent PID in a woman with loose morals and treat again with antibiotics; when the patient (sometimes virginal) re-presents with pain thought to be due to yet another recurrent sexually transmitted disease, perform a laparoscopy and finally diagnose endometriosis; shine a coherent beam of light at the disease or put a metal electrode on the various spots and step on a foot pedal to unleash unseen electrons and pronounce that the disease is treated; after surgery administer powerful and expensive medical agents with multiple side-effects and reassure the patient that this combination of treatment will be the best treatment for her disease since this is what most clinicians use; shuffle the suffering patient to various other practitioners, including psychiatrists and pain clinics; question her about childhood sexual abuse when her pain does not respond well; repeat a laparoscopy; repeat the same therapies which did not seem to work the first time; repeat these a third time to be certain they did not work the second time; perform a total abdominal hysterectomy and bilateral salpingo-oophorectomy; rush off to perform a routine vaginal delivery when the patient returns to the office complaining of pain and vasomotor menopausal symptoms. What is wrong with this picture? Modern therapy of endometriosis has become unimaginative, rigid and dogmatic.

It is universally acknowledged that endometriosis is a confusing, enigmatic, mysterious disease, but this need not be so. Confusion is an opportunity for change if this confusion is recognized for what it is: lack of accurate information. Whereas the debate about the origin of the disease rages confusingly, the debate on treatment has become quite distilled. The word 'treatment' is used here in the same manner as when one talks about treatment of a urinary tract infection: the disease is gone when treatment is concluded, and symptoms once caused by the disease are gone as well. This use of the word 'treatment' is familiar and comforting to patients and physicians and can be used to summarize modern therapy of endometriosis accurately in one sentence - Since no available medicine eradicates endometriosis, surgery is its only treatment. It thus becomes a question simply of which type of surgical treatment most effectively eradicates the disease.

Most of the confusion regarding endometriosis stems from long-held biases that are rooted in misinformation. Our profession must grapple with the probability that Sampson's theory of origin is incorrect because the facts upon which it was based were incorrect. Sampson did not have all the facts we have today when he devised this theory. It seems unlikely that he would have supported reflux menstruation as the origin of endometriosis if he had been aware of the information that we now possess. Continuing support for his theory of origin is not just an intellectual question, because this theory directly affects the treatment of most women today. If the theory is wrong, then it is probable that most women with the disease are being poorly treated.

Continuing support for his theory of origin is not just an intellectual question, because this theory directly affects the treatment of most women today. If the theory is wrong, then it is probable that most women with the disease are being poorly treated.

Misunderstanding about endometriosis is due to a predictable phenomenon which has a name: Berkson's fallacy. This fallacy has operated from the very beginning of our understanding of the disease. Because Berkson's fallacy has operated unidentified and uncorrected for many decades, its deleterious effects on our understanding have been magnified over time and have become huge. This has led to enormous inertia in understanding, treatment and research because we have been unwilling to give up the past, partly because of the fear that we have been so wrong for so long. Things can be made right by leaving our minds open to new thoughts regarding the disease, with the possibility that we must reject much of what we think we know. Understanding clearly the origins of our current confusion will make it easier to face a future which contains the real truth about the disease.

The practice of medicine is sublimely simple because there are only three choices available for almost any ailment: (1) Do nothing. (2) Treat with medicine. (3) Treat with surgery. The patient with endometriosis will already have tried doing nothing, and that did not work because she is now in your office. This simplifies greatly the care of patients with endometriosis, because once the diagnosis is made surgically, there are only two treatment options: medicine or surgery. (Observation of a treatable disease which has led to surgery is not rational by anyone's judgment. If observation seems rational, then surgery should not have been done.) To decide between these two modalities, more information is needed, which you will find here among the pages of this site. It should be apparent after reading through the various articles that endometriosis is a disease which requires surgery for diagnosis and treatment, and this should be a part of the process of informed consent with the patient.

So... how does one treat virtually any manifestation of endometriosis surgically? Since surgery is a visual as well as a tactile and judgmental art, an effort has been made on this site to provide illustrations of surgical strategies with the hope that if a surgeon sees what is supposed to happen, it can be made to happen in that surgeon's hands. The articles on surgical treatment admittedly place a heavy emphasis on excision, which alone is able to treat both superficial and invasive endometriosis completely anywhere in the surgery to be done in gynecology, and some cases will seem to be the most difficult surgery possible anywhere in the human body, maximally taxing the mental and physical strength of the surgeon. For those surgeons who relish challenge, endometriosis is the perfect disease.”

When a patient has deeply invasive endometriosis of the posterior cul de sac or rectovaginal septum, or encapsulated ovaries fixed to the pelvic sidewall by adhesions and possibly retroperitoneal, a tension arises in the young patient who definitely has her childbearing years in front of her. How do we best treat this woman’s pain while preserving as best we can her right to make decisions about future pregnancies?

Many gynecologists are critical of the meticulous excision of endometriosis deep into the rectovaginal septum and pelvic sidewall because they think it will result in a flood of pelvic adhesions. If adhesions do occur, they again believe the relative risk of infertility will increase. Fearing that endometriosis will return no matter what they do, they aren’t likely to support a meticulous pelvic dissection as the best form of treatment. Their approach would be to leave the deep disease untreated and prescribe suppressive medication. They would encourage pregnancy as soon as it becomes feasible for the individuals involved.

I favor excision of deep endometriosis even in the young patient for the following reasons:

Limited surgery followed by medical suppression means the patient undergoes both surgery and the medication treatment. Side effects of the medication are considerable, sometimes incapacitating, and frequently quite expensive. Additionally the patient must still deal with any residual symptoms of the endometriosis left behind. Many times the "limited surgery" results in skimming the top off the area of deep disease, leaving behind the remainder. This allows subsequent adhesion formation to bury deep disease. Deep disease covered by new adhesions actually increases the pain, leaving a very dissatisfied patient.

In contrast, with lapex (laparoscopic excision), all endometriosis is removed. Any adhesions that may form will do so immediately post op, because no disease has been left behind to create new ones on an ongoing basis. Our follow-up surveys dating back to 1991 for hundreds of women demonstrate a recurrence rate of only 10-15%. More than 85 of every 100 women will have no more endometriosis. Of the remaining patients, those who do have endometriosis generally have one or two small foci that were not removed at surgery. This can be by accident or design (as in the case of a woman with very limited tubal endometriosis, where it is felt that deep excision could lead to scarring contraindicated in a woman trying to conceive. Such cases are very infrequent).

Adhesions that result from conservative aggressive lapex actually vary greatly from patient to patient. In my experience patients have as much risk of adhesion formation from the progression of disease that persists or that was untreated as from excisional surgery. If the ultimate risk of adhesions is the same in both cases, why not relieve the pain by getting rid of the disease?

The sooner in a woman’s life the disease can be eradicated, the better her long-term outlook becomes. Drug therapy that can destroy endometriosis has yet to be discovered. The best such drugs can do is (sometimes) suppress endometriosis. So a woman who uses such medications keeps herself at risk that the effects of her endometriosis will worsen.

I believe that the best treatment for young women in this situation is for a surgeon with a great deal of experience with endometriosis to perform aggressive conservative surgery. The surgeon should use the most appropriate surgical techniques to minimize adhesion formation (see Adhesions). As for possible future pregnancies, I always feel that a woman who gets herself healthy first will be in a much better position to be the best possible mother to her child. And, although it is true that some cases of infertility can be traced to endometriosis, most women with endometriosis who want to have babies, have babies. The automatic assumption that a woman with endometriosis will have difficulty conceiving is simply not true. Each case should be evaluated individually, and each woman’s goals, feelings, and attitudes carefully considered.”

But excisionists like Yeung who train at the Center for Endometriosis Care in Atlanta don't accept that. They're taught to recognize subtle forms of the disease, including the slightest of spots, which other OB-GYNs either miss or dismiss as something else. Then they use a CO2 laser to cut out every last bit of it.Most OB-GYNs only cauterize or ablate tissue on the surface of organs.”
"Although excisional biopsy and resection offers a higher success rate in treating the disease, surgical excision also requires a higher level of surgical skill. As a result, many patients receive incomplete treatment, which in turn may lead to persistent symptoms and recurrent disease. It should be noted that many women who have undergone repeated surgeries and had a hysterectomy still suffer.86 The need to improve surgical approach and/or engage in timely referrals is unquestionable.
...Complete excision of endometriosis, including vaginal resection, offers a significant improvement in sexual functioning, quality of life, and pelvic pain, including in those symptomatic patients with deeply infiltrating endometriotic nodules in the posterior fornix of the vagina.94 As well, the technique offers good results in terms of reduced bladder morbidity and bowel symptoms.95,96,97 However, in that this kind of surgery requires advanced skills and anatomical knowledge, again, it should be performed only in selected reference centers.95 "

Other Sources on Excision: