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Endometriosis Endometriosis

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Unread 05-07-2003, 10:41 PM

So... I had a TAH with the removal of one ovary, then years later the lone ovary was removed. Recently had a laporotomy to remove a golf ball sized cyst. Now I went back to the dr because I am having pain on the right side and they found another cyst. -small but there and bothersome. The doctor is now treating me for endometriosis. Instead of just taking estrogen, he now has me on Birth Control pills with estrogen and progesterine. Has this helped anyone else before? Does it realy shrink the cysts?
I don't want to have any more surgeries and the last one I had was 12-26-02-I had a bad reaction to morphine and ended up in ICU for 2 days on a breathing machine. ( i don't remember a thing) So my family is petrified for me to have any more surgeries.
I am only 31 and am very frustrated. Thanks to anyone who has any input.
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Unread 05-08-2003, 06:48 AM

I'm so sorry your having to go thru this Unfortunately, your not alone..several others here have recurring Endo. I'm sure they'll drop by & share their advice/experiences Here is some info I have on Endo & treatments, also on Adhesions as they can become a big source of pain & problems too:

Endometriosis Conquering The Silent Invader:

Recurring Endo at the Center For Endometriosis Care:

Endometriosis-Dr. Stanley West:

Endometriosis Treatment Program @ St. Charles Medical Center-Bend, OR-Dr. David Redwine:

Hysterectomy & Endometriosis Questionnaire:

Post-Op Ovarian Suppression:

Incisional Endometriosis:

Endometriosis Research Center:

Radical Endometriosis Surgery:

Causes of Persistence and Growth of Endometriosis:
There are two basic mysteries surrounding the persistence and growth of endometriosis:
Why do endometrial implants survive the attack by the immune system, which is typically launched against any foreign presence in the body?

How do these endometrial travelers develop new blood vessels and implant themselves in other locations?

Impaired Immune System:
Some research is focused on possible immune disorders in women with endometriosis. One theory proposes that women with endometriosis have fewer natural killer (NK) cells, which are factors in the immune system important for surveillance. In their absence, the immune system is weakened and may allow endometrial tissue to invade and take root.

Growth Factors and Angiogenesis.
Macrophages also produce growth factors, which are of particular interest because they play important roles in angiogenesis, a natural process by which new blood vessels form.

Vascular endothelial growth factor
(VEGF) is secreted by endometrial cells, and so is of special interest. Under normal conditions, VEGF is secreted within the uterus. When oxygen levels drop following menstruation and blood loss, VEGF levels rise and promote the growth of new blood vessels. This process is important for repairing the uterus following menstruation.

When endometrial cells land outside the uterus, however, investigators theorize that this same process occurs with unfortunate results. The cells secrete VEGF when they are deprived of blood and oxygen, which in turn stimulates blood vessel growth. In this case, however, blood vessel growth serves to promote implantation outside the womb.

Other growth factors involved in angiogenesis that may play a role in endometriosis include transforming growth factors (such as TGF-beta), platelet-derived endothelial growth factor (PD-ECGF), and tumor necrosis growth factors.

Inflammatory Response:
The damage, infertility, and pain produced by endometriosis may be due to an over-active response by the immune system to the early presence of endometrial implants. The body, perceiving the implants as hostile launches an attack. Of particular note, levels of large white blood cells called macrophages are elevated in endometriosis. Macrophages produce very potent factors, which include cytokines (particularly those known as interleukins) and prostaglandins. Such factors are known to produce inflammation and damage in tissues and cells.
Pelvic Pain (Dysmenorrhea)
** 47% reported pain in the middle of a cycle. (A sharp pain during ovulation may be due to an endometrial cyst located in the fallopian tube that ruptures as the egg passes through.)

Occasionally, however, pain may also occur in other regions. Implants can also occur in the bladder (although rare) and cause pain and even bleeding during urination. Also rarely, implants form in the intestine and cause painful bowel movements or diarrhea. Large cysts can rupture and cause very severe pain at any time in various locations.

Severity of Pain . The severity of the pain also varies widely and does not appear to be related to the extent of the endometriosis itself. In other words, a woman can have very small or few implants and have severe pain, while those with extensive endometriosis may have very few signs of the disorder except for infertility.

Other Symptoms In addition to pain, patients may experience additional symptoms, which include the following:
Heavy menstrual bleeding
Depression and malaise (feeling generally low)
Sleep problems

Once careful instruction is given for all the risks and benefits of the different surgical options, the physician must then respect any decision a patient makes to retain as much of her reproductive system as she wants, even if she is past menopause. Both the patient and the physician should also be clear about the possibility of changing procedures once the operation has begun, depending on what the surgeon may observe. For example, the surgeon may find abnormalities that require more extensive surgery.

Much of the success of any procedure relies on the experience of the surgeon. A woman should always ask for a doctor's track record, or the number of times he or she has performed the procedure in question. The more, the better. Asking for complication rates may be helpful, but a patient should realize that an experienced surgeon may have a higher number of high-risk patients, and therefore, a higher complication rate than a less experienced surgeon with fewer serious cases.

Studies report that between 11% and 19% of all hysterectomies are performed to treat extensive endometriosis. Having endometriosis plus severe symptoms is, in fact, a major risk factor for eventually requiring a hysterectomy. It should be noted that hysterectomy does not necessarily cure endometriosis. One study reported that endometriosis reappeared in 13% of women within three years of a hysterectomy and in 40% after five years.

Most women are satisfied with the procedure. A major analysis of evidence on hysterectomies reported that symptoms related to menstrual problems decline significantly in most women, although none completely disappear for all women. The majority of women also experience improved quality of life and emotional functioning, although 8% of women who were not depressed and 12% of women who were not anxious before the procedure developed these emotional states afterward.

Still, one study suggested that 70% of recommendations for hysterectomies did not meet the standard of care as determined by expert groups. In such cases, patients were not given alternative choices or adequate diagnostic evaluations. Any woman, even one who has reached menopause, who is uncertain about a recommendation for a hysterectomy for fibroids should certainly seek a second opinion.

Surgical Procedures for Intestinal or Urinary Tract Endometriosis:

Implants affect the urinary tract in up to 20% of patients. If deep endometriosis causes severe symptoms in the intestines or urinary tract, surgical excision of these implants may be necessary. Sometimes the surgeon will need to remove adhesions that have joined pelvic structures, such as the vagina and rectum. If a surgeon is experienced, laparoscopy may be used to remove urinary tract or bowel obstructions caused by endometriosis or adhesions, but conventional laparotomy is often required for complete surgical removal of endometriosis in the intestine or urinary tract. Almost any intestinal surgery is major and requires careful preoperative preparation to avoid infection. The operations take a long time, are technically difficult, and pose a risk for bleeding and infection. The recovery period is often lengthy.

Several medical management options are available for the treatment of Endometriosis. The treatment for Endometriosis and Adenomyosis are virtually identical. However, it must be noted that many women diagnosed with Adenomyosis do not respond to traditional treatment. In the majority of cases, hysterectomy is the only cure for Adenomyosis.

These include:

NO TREATMENT, which can lead to more serious health problems.

Limited use of ANALGESICS and nonsteroidal anti-inflammatory drugs (NSAIDs).

ORAL CONTRACEPTIVES can be given cyclically (the patient has a monthly menses) or continuously (the patient has no menses during treatment).

PROGESTINS (Provera 10 mgm every day) or Depo-Provera injections will incompletely suppress ovarian function, but can be associated with breakthrough bleeding; they may be useful in a few women who cannot tolerate oral contraceptives.

GnRH AGONISTS are synthetic decapeptides. The GnRH agonists initially stimulate the pituitary gland to release follicle stimulating hormone (FSH) and luteinizing hormone (LH). Al a consequence, blood estrogen levels initially rise, then fall to menopausal levels within a few days. After 7 to 10 days, these drugs produce a menopausal state which is fully reversible. This produces amenorrhea (no menses), which permits regression of endometriosis and relief of symptoms. The GnRH agonists do not have any known direct effects on the ovary.

Leuprolide acetate (LUPRON DEPOT) is usually given as a single monthly 3.75 mgm intramuscular injection.

Nafarelin acetate (SYNAREL) 200 Fg nasal spray used twice a day, is a superactive, hydrophobic stimulatory analog of GnRH that is 200 times more potent than naturally occurring GnRH, and is delivered in a metered nasal spray pump.

Note that GnRH Agonists may be used for the Treatment of Adenomyosis, but recent studies have found that the GnRH Agonists do not provide adequate long term relief for the pain and bleeding associated with Adenomyosis.

SURGERY - In the infertile patient, laparoscopic therapy is almost always conservative, consisting of excision, laser vaporization, or electrosurgical desiccation of endometriosis.Every attempt should be made to conserve as much ovarian tissue as possible in these patients.

Patients who have completed childbearing often undergo more radical laparoscopic therapy, including hysterectomy and/or bilateral salpingo-oophorectomy (removal of the ovaries). Simple removal of the uterus and\or ovaries is not necessarily the appropriate operation, however. If the surgeon removes the uterus and ovaries, but leaves implants of endometriosis behind, the patient may continue to have pain very similar to that she experienced prior to the operation. Remember, symptoms may be as much a result of the implants of endometriosis as from the uterus or ovaries.

Adequate laparoscopic treatment of endometriosis requires a surgeon who is familiar with the pathophysiology of endometriosis and its various appearances. They must possess the skills to treat implants on or near vital structures in the pelvis, and have access to the proper laparoscopic equipment necessary to perform these procedures.
November 14, 2002
2002 NOV 14 - (NewsRx.com & NewsRx.net) -- A majority of women who suffer from chronic pelvic pain have been told that their pain is "normal" or even exaggerated despite their own perception of it as severe and debilitating.

Ironically, these comments are coming from the people they rely on most for support - their physicians, families and friends - according to a survey conducted by the Endometriosis Association and released at the 58th Annual Meeting of the American Society for Reproductive Medicine in Seattle.

The survey found that 40% of women who suffer from chronic pelvic pain due to endometriosis or the formation of postsurgical scar tissue have been told they exaggerate their pain. More than half (52%) were told this by their ob/gyn and 43% by a friend or family member. Nearly 60% of these women have been told that their pain is normal. Of these, 56% were told this by their ob/gyn and 29% by family or friends.

"The results of this survey are concerning given the impact pelvic pain can have on a woman's life," said Mary Lou Ballweg, president and executive director of the Endometriosis Association, who announced the data. "On a regular basis, we see women completely alter their lives because of the debilitating effects of pelvic pain. The frustrating part is that it often takes years for women to receive a diagnosis, and by then, many are unable to work or fully participate in normal activities."

In fact, 43% of women surveyed describe their pain as constant. More than half describe the intensity of pain as severe to unbearable (26% say it's severe, 18% say very severe, and 9% say unbearable). At this level of pain, it's not surprising that more than 80% say they have been unable to work at times due to pelvic pain, and 45% say they have been debilitated for 2-3 days or longer each month.

"Chronic pelvic pain accounts for 12% of hysterectomies and 40% of laparoscopic surgeries. The total costs of treating chronic pelvic pain are more than $2 billion each year," said Dr. Charles Miller, reproductive endocrinologist, gynecological surgeon and medical director of Specialists in Reproductive Health in Arlington Heights and Naperville, Illinois. "As I've seen with many patients and with this survey, chronic pelvic pain also exacts a significant emotional toll, which makes it even more important that women speak to a doctor at the first signs of pelvic pain."

The survey of 968 women ages 15 through 59 with endometriosis and/or postsurgical scar tissue was designed to uncover specific information about women's experiences with chronic pelvic pain. The survey, conducted by The Endometriosis Association, was cosponsored through a restricted educational grant by Gynecare, the women's health division of Ethicon, a Johnson & Johnson company, and Purdue Pharma L.P.

Two of the leading causes of chronic pelvic pain are endometriosis and the formation of post surgical scar tissue, also called adhesions. Of the women surveyed, 89% had endometriosis, and nearly 40% had been diagnosed with adhesions.

Endometriosis is an immune and hormonal disease that affects 5 million women and girls in the U.S. It occurs when tissue similar to the lining of the uterus (called the endometrium) is found outside the uterus, usually in the abdomen, on the ovaries, or on fallopian tubes.

Postsurgical adhesions are abnormal bands of scar tissue that form inside the pelvis after gynecologic surgery. Endometriosis can also cause adhesions.

As many as 90% of the 3 million women who undergo gynecological surgery each year to treat common female health problems such as ovarian cysts, fibroids and endometriosis, will develop adhesions.

Ironically, women who undergo pelvic surgery to correct endometriosis or to remove adhesions (a procedure called adhesiolysis) are at risk for developing pelvic pain from new formations of pelvic adhesions.

However, new treatments are available to help stop the recurring cycle of pelvic pain. A variety of treatments can help treat pain due to endometriosis, and doctors now have tools to help reduce the risk of adhesion development after surgery to treat endometriosis or remove adhesions. Women should proactively talk with their physicians about chronic pelvic pain, its underlying causes and how it can be treated, or even prevented, in some cases.
Conscious Pain Mapping:

What You Don’t Know Can Hurt You: Knowledge Is Power In A Doctor/Patient Relationship:

Resection of Endometriosis*video*-warning graphic:

The Price of Pain on the Economy:

Disorders More Common in Women:

Endometriosis Angels:

eMedicine - Endometriosis : Article by Manuel Hernandez, MD http://www.emedicine.com/aaem/topic181.htm

Radical Endometriosis Surgery:

Jenny's Endo page:

Endo Association family program:

Theories of origin:

There may be no significant symptoms of implants on the surface of your ovary unless there is the formation of adhesions. You may, however, experience pain on the side of the pelvis where the implants are present. The pain might be a continuous ache or burning, usually worse during menstruation. Additionally, you may feel pain deep in the pelvis or inside the vagina during sexual intercourse, this pain also will intensify during menstruation. During pelvic examination, your physician can likely reproduce some of the pain when he or she palpatesand move the affected ovary.
Treatment: Laparoscopic CO2 laser vaporization or harmonic scalpel destruction of the implants is the optimal surgical treatment for you because neither of these causes significant damage to the ovary itself.If you do have adhesions between the ovaries and the surrounding organs, they should be resected by use of CO2 laser, harmonic scalpel, or laparoscopic scissors with only minimal use of electrocautery. In some cases Lupron Depot suppression for six to nine months may be effective, but you should be aware that it will not affect already formed adhesions. As an additional option you may want to consider suppression using Danazol vaginal suppositories.

Endometriosis inside the ovary:
Description: Endometriosis inside your ovary is usually transformed into the cystic structure within your ovary called endometrioma (chocolate cyst).The endometriotic implant within your ovary or the surface implants burrowing into your ovary are surrounded by ovarian tissue. A small amount of fluid and blood produced by the implant during each menstrual cycle cannot escape that enclosure and it will accumulate within your ovary, forming a cyst (fluid filled space) called endometrioma.The inside of the cyst provides the surface for the endometriosis to spread and grow. This in turn makes the volume of fluid produced with each menstrual cycle greater and makes the cyst grow larger.There are occasional breaches of the wall of the cyst, which allows some of the bloody fluid to escape into your abdomen and pelvis. This in turn causes an inflammatory reaction (irritation) within your abdomen and the formation of scar tissue around the leak as your body tries to prevent wider spread of this irritating material.
You should note that endometriosis of the ovary is almost always a benign condition, and only very small number of endometriomas will show malignant changes.

Symptoms: Pain in your lower abdomen is a common symptom of endometrioma. It is usually chronic and more pronounced on the side of the cyst, sometimes it will radiate to your lower back. You will find that the pain is usually worse around the time of menstruation and on occasion it will become quite severe.There also may be deep pain during sexual intercourse.If you have this condition pelvic examination will usually reveal an enlarged ovary, which may be quite tender and often times is immobile.

Diagnosis: While the combination of your symptoms and a pelvic examination, are often enough to make a diagnosis, you should likely also get an ultrasound in order to identify the cyst within the ovary.Vaginal ultrasound usually provides significant detail as to the appearance of the cyst and aids toward fuller diagnosis of endometrioma. Ultimately, only Laparoscopy and surgical removal of the cyst wall provide a definite diagnosis as to the kind of cyst. Note that CT scan and MRI scan can usually identify cystic masses in your pelvis but they are not as helpful as ultrasound in providing details of its internal appearance.

Treatment: Aspiration of the bloody or chocolate fluid from the cyst is not an effective treatment because the entire lining of the cyst, including all of its endometrial implants, is left behind and ready to form a new cyst.

Laparoscopic resection of the endometrioma is the most effective minimally invasive method of treatment.Because most of your ovary and its function, including all of its eggs, is located on the surface of your ovary, your physician safely proceed to the inside of the cavity of the cyst and remove the entire wall of the cyst, leaving your ovary and its function preserved. Laparotomy alternately and resection of the endometrioma does remove the entire lining of the cyst, but it adds the element of an open abdominal procedure that may be associated with increased formation of new postoperative adhesions and longer recovery.

There are other methods of treatment; these include destruction of the lining of the cyst with CO2 laser, argon laser, YAG laser, electrocauthery, harmonic scalpel and heat probes.It is also possible that a combination of aspiration of the endometrioma followed by Lupron Depot suppression of the endometriosis can be effective in treating endometriomas.

Endometriosis of the pelvic sidewall:

Description:Your pelvic sidewall is covered by a peritoneal layer and faces the front and sides of your ovaries. It contains large blood vessels, nerves and your ureter.This is one of the most common locations for endometrial implants and adhesions.

Symptoms: Pain (burning and aching) in the right or left lower quadrant of your abdomen and on the right or left side of your pelvis is a common symptom.The pain usually worsens before and during menstruation. The pain may also increase with walking or physical activity, especially if there are lateral pelvic wall adhesions between the enlarged endometriotic ovary and peritoneum of your pelvic sidewall.
Treatment: Reestablishment of your normal pelvic anatomy and removal of all endometrial implants is the goal of the treatment.If adhesions are present between your ovary and your pelvic sidewall, the adhesions will need to be divided before your entire pelvic sidewall can be evaluated for the presence and extent ofendometriosis.Your physician may use one of many methods to divide the adhesions between your ovary and pelvic sidewall, including dissection with scissors, CO2 laser dissection and harmonic scalpel dissection.

With your ovary freed up, your peritoneum is exposed such that the extent of endometriotic lesions can be assessed.The most effective method of treatment in this area is to resect endometriotic lesions together with the area of your peritoneum through which they are growing.The key to successful treatment is for your surgeon to identify the course of your ureter (the tube that carries urine from each kidney to the bladder) that traverses just below the peritoneum of your pelvic sidewall. The other important structures that your surgeon needs to identifiy include large blood vessels and nerves that are located in your pelvic sidewall.

Once these structures are identified, your surgeon will inject normal saline solution below your peritoneal layer, which elevates your peritoneum and endometrial lesions away from these vital structures. This produces a safe buffer zone where the laser, harmonic scalpel, or scissors dissection can be carried out.In dissection I try to avoid using unipolar electrocauthery which, although it provides for bloodless resection, it uses high-density electrical current. The surge of electricity can theoretically damage sub-peritoneal mesothelial cells, which are essential for reconstruction of a normal peritoneum within seven to ten days after surgery.To control bleeding points, your surgeon may use CO2 laser, harmonic scalpel, or bipolar electrocauthery.Note that resection of the lesions of the pelvic sidewall is greatly preferred over their destruction by laser, harmonic scalpel, or electrocauthery, due to the fact that destruction is often incomplete (it does notdestroy the lesion deeply enough).

Additional postoperative therapy with GnRH agonists (Lupron Depot, Synarel, etc) or Danazol may improve the effectiveness of the surgical treatment. As an additional option, you may want to consider using Danazol vaginal suppositories.

B]Endometriosis of the posterior cul-de-sac: [/b]
Description:The posterior cul-de-sacis the space behind your uterus. It is surrounded by your uterus in the front, pelvic sidewall and ovaries on the side, and your sigmoid colon in the back. The floor of your cul-de-sac contains your uterosacral ligaments, your rectum and the upper portion of your vagina.The posterior cul-de-sac is one of the most common locations of endometriosis in the pelvis.Most of the time, the implants are quite superficial, but in a number of women they will invade deeper into the tissues. They may form nodules within your uterosacral ligaments, they may cause attachment of your sigmoid colon and rectum onto the posterior wall of your uterus. This causes the most extreme form of the involvement, cul-de-sac obliteration.

Symptoms: Constant pelvic pain/ache is the most common symptom.The pain is usually more severe during menstruation and is usually located in your lower abdomen and lower back. Pain may extend to your upper thighs and your rectum and there may be deep pain in your vagina during sexual intercourse, many times preventing normal sexual relations.There also may be pain with bowel movements.

Endometriosis can implant itself in any number of locations outside of your pelvis.It might involve your omentum(fatty apron lying loosely in the abdominal cavity), small bowel, umbilicus, surgical scars, diaphragm, lungs, kidneys and many other organs and locations.The symptoms will usually be specific to the site involved and generally will be worse during menstruation.

Adhesions and ARD are conditions that are not clearly recognised nor understood and for those who are suffering it is often a very lonely existence. It affects men, women and children, but women seem to be affected more by abdominal adhesions, due to gynecological problems.
Adhesions usually occur in response to trauma, injury of various kinds and are an almost inevitable outcome of surgery, although this is not always the case._ _Any peritoneal injury can result in fibrous Adhesion formation.
There is a great need to raise the level of awareness among doctors, healthcare providers, government, and the public as a whole, to prompt a more comprehensive and integrated care system for ARD sufferers.
Patients suffering from Adhesions and Adhesion Related Disorders are often sentenced to the frustrating ordeal of having to find experienced and accessible healthcare for their condition. Due to the lack of awareness, most doctors are unable or unwilling to tackle the problem of adhesions,often dismissing sufferers as"psychiatric" cases, hypochondriacs and time wasters, thus_increasing the feelings of isolation_from family and friends.

One of the biggest factors in the rehabilitation of the patient suffering from Adhesions seems to be the removal of feelings of loneliness - being able to share_their story._ Participation in support groups are a big help not only for patients, but also for their partners.

From personal experience, I know that the pain, misery and isolation can be unbearable, and I know that I am by no means unique, and find this totally unacceptable.

Emotional stress plays a major role in the pain that Adhesions can cause. A good support network is essential and "a http://groups.msn.com/StickyMomentsA...Supportproblem shared is a problem halved." Many patients have reported that by sharing their experiences with others, be it by phone, local support group or the Internet, their feelings of loneliness, abandonment and frustration have abated, engendering a healing frame of mind.
Adhesions are an almost inevitable outcome of surgery, and the problems that they cause are widespread and sometimes severe. It has been said by some that adhesions are the single most common and costly problem related to surgery, and yet most people have not even heard the term. This lack of awareness means that, excluding infertility, many doctors are unable or unwilling to tackle the problems of adhesions, many insurance companies are unwilling to pay for treatment and many patients are left in misery.This paper describes adhesions, their treatment and their relationship to pain and bowel obstruction. In addition, stories from patients are featured to illustrate how adhesions (or suspected adhesions) affect their daily lives and how they cope with a sometimes-insurmountable problem.

A key lesson and source of comfort for patients with this problem is that they are not alone and the importance of mutual support among patients cannot be underestimated.

ADHESIONS are believed to cause pelvic pain by tethering down organs and tissues, causing traction (pulling) of nerves. Nerve endings may become entrapped within a developing adhesion. If the bowel becomes obstructed, distention will cause pain. Some patients in whom chronic pelvic pain has lasted more than six months may develop "Chronic Pelvic Pain Syndrome.” In addition to the chronic pain, emotional and behavioral changes appear due to the duration of the pain and its associated stress. According to the International Pelvic Pain Society: www.pelvicpain.com

"We have all been taught from infancy to avoid pain. However, when pain is persistent and there seems to be no remedy, it creates tremendous tension. Most of us think of pain as being a symptom of tissue injury. However, in chronic pelvic pain almost always the tissue injury has ceased but the pain continues. This leads to a very important distinction between chronic pelvic pain and episodes of other pain that we might experience during our life: usually pain is a symptom, but in chronic pelvic pain, pain becomes the disease."

Chronic pelvic pain is estimated to affect nearly 15% of women between 18 and 50 (Mathias et al., 1996). Other estimates arrive at between 200,000 and 2 million women in the United States (Paul, 1998). The economic effects are also quite staggering. In a survey of households, Mathias et al. (1996) estimated that direct medical costs for outpatient visits for chronic pelvic pain for the U.S. population of women aged 18-50 years are $881.5 million per year. Among 548 employed respondents, 15% reported time lost from paid work and 45% reported reduced work productivity. Not all ADHESIONS cause pain, and not all pain is caused by ADHESIONS. Not all surgeons, particularly general surgeons, agree that ADHESIONS cause pain. Part of the problem seems to be that it is not easy to observe ADHESIONS non-invasively, for example with MRI or CT scans. However, several studies do describe the relationship between pain and adhesions. According to an early study (Rosenthal et al., 1984) of patients reporting CPP, about 40% have adhesions only, and another 17% have endometriosis (with or without adhesions). Kresch et al., (1984) also studied 100 women and found ADHESIONS in 38% of the cases and endometriosis in another 32%. Overall estimates (Howard, 1993) of the percentage of patients with CPP and ADHESIONS is about 25%, with endometriosis accounting for another 28%. These figures must be understood in their context, and I recommend highly Howard's article.It is important to recognize that emotional stress contributes greatly to the patient’s perception of pain and her/his ability to deal with the pain. Rosenthal et al. (1984) found that of the patients in whom a possible physical cause of pain (including ADHESIONS) could be identified, 75% had evidence of psychological influences on the pain.

The problem with adhesiolysis is that ADHESIONS almost always reform, and so the procedure is sometimes self-defeating. This is one of the main reasons why surgeons are reluctant to perform adhesiolysis, particularly in severe cases. In addition, the presence of adhesions makes surgery more hazardous, because of the risk of injury to the bowel, bladder, blood vessels and ureters. As we have seen, some patients may have periods of relief from and/or bowel obstruction for several months, only to have the problem recur

Adhesions are a common occurrence after pelvic or abdominal surgery. Adhesions are also common in women who suffer from pelvic inflammatory disease (PID), endometriosis, or sexually transmitted diseases.

The likelihood of adhesion formation and the seriousness of their consequences vary based on multiple factors (e.g., type of surgery, number of previous surgeries, surgical technique, and the predisposition of individual patients). However, studies have consistently shown that a majority of women who have gynecologic surgery will experience some degree of adhesion formation.
All of the abdominal and pelvic organs except the ovaries are at least partially wrapped in a clear membrane called the peritoneum. When this membrane is traumatized during surgery, the site of the trauma becomes inflamed. Inflammation is normal and in fact is part of the healing process, but it also contributes to adhesion formation by encouraging the development of fibrous bands of scar tissue.

Normally, these fibrin bands eventually dissolve through a biochemical process called “fibrinolysis,” and the traumatized site continues to heal. But sometimes the nature of the surgery results in decreased blood flow to these areas (ischemia). This ischemic condition can suppress the fibrinolysis. If the fibrin bands do not dissolve, they may develop into adhesions that connect pelvic organs or tissues that normally are separate.

Pelvic Pain: Adhesions are commonly associated with pelvic pain. Adhesions cause pelvic pain because they bind normally separate organs and tissues together - essentially “tying them down” - so that the stretching and pulling of everyday movements can irritate the nerves involved. Adhesions can also cause pain during intercourse.

Bowel Obstruction: Adhesion formation involving the bowel is particularly common following a hysterectomy. While these adhesions don’t normally result in any problems, there is one serious problem that can develop. It is called intestinal or bowel obstruction, and it can occur a few days or many years after surgery. Symptoms of bowel obstruction may include pain, nausea, and vomiting.

Ovarian Surgery: The ovaries are one of the most common sites where adhesions form. Adhesion formation after ovarian surgery can lead to pelvic pain and infertility.

Surgical Treatment of Endometriosis: Endometriosis is a condition in which patches of cells similar to the ones in the uterine lining become implanted outside the uterus – usually on the ovaries, bladder or fallopian tubes. This condition can be associated with severe inflammation and dense adhesions, and can potentially contribute to infertility. Endometriosis itself can lead to adhesions, and when those adhesions are surgically removed, new adhesions can re-form.

Myomectomy: Myomectomy is surgery to remove fibroid tumors from the uterus. Adhesions may form at the incision line on the uterus. These adhesions can also involve the ovaries and fallopian tubes, potentially causing infertility and pelvic pain.

Reconstructive Tubal Surgery: The repair of blocked fallopian tubes is a delicate procedure that often includes the removal of existing adhesions. Unfortunately, the surgery itself can also lead to the formation of new adhesions and associated complications such as pelvic pain and infertility.

Hysterectomy: Hysterectomy is a procedure in which the uterus is removed. Removal of one or both ovaries (oophorectomy) is sometimes performed at the same time. Adhesions that form after this procedure may attach to the small intestine, causing pelvic pain, constipation, and sometimes a more serious complication –bowel obstruction (blockage of the intestine). Bowel obstruction may occur shortly after surgery or may may occur years after surgery.

Cesarean Section: These adhesions typically do not cause pain. They can sometimes make subsequent cesarean sections more difficult, however, because the physician must cut through these adhesions to reach the uterus and the baby. This can increase the length of the procedure and the amount of time the mother and baby are under anesthesia. There is also a risk of damaging surrounding organs such as the bladder.

To determine whether adhesions are the cause of pelvic pain or fertility problems, your doctor may perform a laparoscopy, an exploratory procedure using a laparoscope (a narrow lighted telescope inserted through a small incision in the “belly button”) to inspect the abdominal cavity and pelvic structures.

The only way to treat adhesions is to remove or separate them surgically. This procedure is called adhesiolysis. Studies have shown that patients with pelvic pain and severe adhesions can experience a marked reduction in symptoms after adhesiolysis.

However, even following adhesiolysis, adhesions reform more than 70 percent of the time. That’s why adhesion prevention is so important.
Meticulous surgical technique – Careful surgical technique can help minimize trauma, minimize the interference with the blood supply, prevent the introduction of foreign bodies, minimize bleeding, lessen the incidence of raw surfaces and decrease the incidence of infection - all of which help reduce adhesion formation.
Barriers – Fabric or liquid barriers create a physical separation between raw tissue surfaces while they heal. Thin tissue-like fabric barriers may be used to try to reduce adhesion formation at specific sites, while liquid solution barriers can help prevent adhesions over broad areas of the abdominal and pelvic region
Treatment is aimed at reducing the symptoms of endometriosis, usually either pain or infertility. Treatment is divided into three paths - observation, medication, or surgery.

Women who have minimal or mild endometriosis and do not have pain may not require any treatment other than careful follow-up. In practice, however, if the diagnosis of endometriosis is made during laparoscopy, most gynecologists will burn or cut away these cells. However, a few studies have demonstrated that this treatment of mild endometriosis does not enhance fertility. For women with mild endometriosis, fertility rates are good even if no treatment is performed._

It is known that estrogen causes endometriosis to grow. Endometriosis is extremely rare before a young woman begins to produce estrogen and starts to have periods and the disease usually disappears after menopause, when estrogen production stops. Therefore, one goal of treatment with medication is to lower, or stop, the production of estrogen. Reducing the levels of estrogen "starves" the endometriosis and causes it to shrink and sometimes even disappear. Two classes of drugs have been developed which lower the amount of estrogen in a woman's body - Danocrine and GnRH agonist (see details in our book). Progesterone can also be used to treat endometriosis._

Conservative surgery may provide a cure, but it may also provide only temporary relief of symptoms. A woman may elect to have conservative surgery in order to complete her family, and then, at a later time, she may elect to undergoing radical surgery. And, some women may require more than one conservative surgical procedure before they need to have, or are willing to consider, a more extensive operation. Yet, for some women, multiple conservative operations may provide relief of symptoms._
HRT and special situations: Endometriosis and post-hyst HRT:
It is now becoming accepted that a hysterectomy/oophorectomy does not “cure” endo, although it may remove some of it. The most realistic expectation of the surgery is that subsequent use of HRT may provide a more stable hormonal environment with less endo stimulation. Because estrogen stimulates endo growth (just as it stimulates proliferation of the uterine endometrium) and progesterone inhibits it, current post-hyst endo management theory calls for the addition of progesterone to estrogen HRT. This is to avoid the stimulation of endo proliferation and the risk of converting that endo to a cancerous state. Many endo specialists also call for a post-op period (varying from 6 weeks to 6 months to “as long as you can stand it”) without HRT, in order to encourage any remaining bits of endo not removed during surgery to shrink away. Some take that a step further and prescribe the use of progesterone alone to directly squelch that endo growth. This has the additional benefit of helping ease some of the transitional menopause symptoms experienced during the wait for estrogen.

Not all doctors espouse this theory, of course. Some surgeons are highly indignant at any suggestion that they might not have cleared all traces of endo; others freely admit that microscopic bits of endo are virtually guaranteed to remain and require other treatment. We're not going to argue with your doctor's take on the situation, other than to suggest that if your doctor insists that all endo is gone and you continue to experience post-op endo-like pains, you might want to research this part of the question further. Endo is a long, grim battle, and it's sadly not one that seems to be over after a hyst.

What are Adhesions?
Adhesions: Fibrous Bands that Connect Tissue Surfaces that are Normally Separated

Adhesion formation is a natural consequence of surgery, resulting when tissue repairs itself following incision, cauterization, suturing or other means of trauma. Even the most careful and skilled surgeon will inevitably effect tissues inside the abdomen during a surgical procedure. At the places where a surgeon has had to cut, handle, or otherwise manage parts inside the body, tissues which normally should remain separate will sometimes become "stuck" together by scar tissue, defined as adhesions. This process begins immediately and continues for up to 7 days following surgery. _

The Problem of Adhesions:

The incidence of adhesions is overwhelming. Adhesions develop in 93% of patients following abdominal and pelvic surgery.2

Following surgery, adhesions may form, for example, between the incision in the abdominal wall and the small bowel, often causing small bowel obstruction. This obstruction can lead to vomiting and debilitating pain. In extreme cases, the bowel may rupture, necessitating emergency surgery for the patient.

How Adhesions Effect a Patient:

Adhesions can lead to serious complications including small bowel obstruction, female infertility, chronic debilitating pain and difficulty with future operations.

The consequences of adhesions can be substantial. Postsurgical adhesions cause up to 74% of bowel obstructions.3 Postsurgical adhesions are responsible for 20-50% of chronic pelvic pain cases.3 Adhesions also are a leading cause for female infertility, causing 15-20% of cases.3 Quality of life is also potentially impaired.

Quite often a patient will undergo surgery to lyse (cut) adhesions, only to have them re-form. Once a patient has undergone a colorectal procedure, the incidence of re-operation within two years is high - up to 20% of patients will have a subsequent colorectal procedure in that time.4 Many of these surgeries are to remove adhesions. Between 2.3 and 5% of patients will have to undergo adhesiolysis for bowel obstruction within two years of colorectal surgery.

Re-operations are also complicated by adhesions. Surgeons have to spend a considerable amount of time, anywhere from 10 minutes to several hours, lysing adhesions before the new procedure can begin. This can prolong the patient's recovery time and increase the risk, cost and complexity of the surgery.

Seprafilm Adhesion Barrier: Proven Adhesion Prevention:

Adhesions can range from filmy to dense, with dense adhesions proving to be the most difficult for a surgeon to treat. The use of a physical barrier to separate the traumatized tissue from other tissues will decrease the risk of all adhesion formation.

Seprafilm Bioresorbable Membrane from Genzyme Biosurgery is an absorbable adhesion barrier that separates the traumatized tissue surfaces while the body's normal tissue repair process takes place. In a randomized, double-blinded, multi-center clinical study, Seprafilm prevented adhesions in 51% of patients. In the same clinical trial, only 15% of Seprafilm patients had dense adhesions.

What is the Medical Treatment for Endometriosis?

The progression of endometriosis is estrogen dependent. Treatment with continuous progesterone can shrink endometriotic implants. Overall, the treatment that causes significant decrease in estrogen levels (pseudomenopausal state) is more effective than measures involving prolonged progesterone effect. Agents with prolonged progesterone effect such as provera may be given by mouth or by injections. Prolonged progesterone effect can also be achieved with birth control pills which contain estrogen and progesterone, taken continuously for six to eight months. Such treatment may relieve pain; some endometriotic implants may resolve and/or decrease in size. Agents that suppress ovarian estrogen production include Danazol, a weak androgenic (male) hormone, and GnRH agonists such as Lupron. These agents are more effective than progestins in suppressing symptoms and reducing implants. However, their use is limited by side effects which resemble those of menopause. The low estrogen state leads to hot-flashes, bone demineralization, increase in "bad" cholesterol (LDL) and decrease in "good" cholesterol (HDL). The latter changes increase the risk of cardiovascular disease. Therefore, these agents are rarely prescribed for more than six months. Usually, the beneficial effects do not last very long after the cessation of treatment. At times a course of a GnRH agonist is prescribed in preparation for surgery or as adjuvant treatment after surgery. The role of surgery, via laparoscopy or laparotomy, is to resect or destroy endometriotic implants, remove an endometrioma, remove pelvic adhesions and repair obstructed fallopian tubes (tuboplasty.)
Removal of the uterus, alone or with the ovaries and fallopian tubes, should be considered only when it has been established that the ovaries or uterus are the source of the symptoms and that all other treatment modalities have failed. The last requirement is critical. "Failed treatment" is a relative term and depends to a large extent on the dedication, expertise, surgical skills and motivation of the treating physician to spare the involved organs. Meticulous surgery including microsurgical technique in resecting endometriotic implants, lysis of adhesions and pelvic reconstruction may achieve better and more lasting results than less sophisticated surgical techniques. Combining medical and surgical treatment may also be helpful.
A special procedure to relieve pain caused by endometriosis is LUNA (laparoscopic uterosacral nerve ablation.) It involves the destruction of many nerve fibers that provide sensation to the cervix and lower uterine segment. The effectiveness of this procedure in relieving menstrual pain is variable (50-75%). Another procedure known as presacral neurectomy involves severing the nerve fibers which convey pain sensation from the uterus and pelvic floor and is more effective in relieving pain. If presacral neurectomy is performed meticulously it may give long term relief from pelvic pain even if the endometriosis progresses. In my experience hysterectomy with or without ovarian resection is necessary in only a very small percent of patients with endometriosis. [u]It should be emphasized that hysterectomy is not a foolproof treatment for the symptoms of endometriosis. The rate of recurrent symptoms is high (up to 63%) after hysterectomy; after hysterectomy and bilateral oophorectomy recurrent symptoms appear in a significant percent of women (10%)[/].
Endo support:

recurring Endo-Q&A:

Chronic Pelvic Pain Diagnosis and Management:
recurring Endo-Q&A:

Painful Signs of Endometriosis Should Be Taken Seriously:

Myths vs. Facts about Hysterectomy:


The Endometriosis Association Houston Support Group:

Endometriosis Symptoms and Treatments: http://womenshealth.about.com/librar.../aa102400a.htm

Understanding & Managing Endometriosis:
When is hysterectomy a woman's only option for treating endometriosis?

Hysterectomy used to be a much more common treatment for endometriosis than it is today. However, it may still be necessary when other avenues of treatment have failed. Many times, physicians will also recommend removal of both ovaries (bilateral oopherectomy) at the time of hysterectomy because some studies suggest this results in greater long- term pain relief.used to be a much more common treatment for endometriosis than it is today. However, it may still be necessary when other avenues of treatment have failed. Many times, physicians will also recommend removal of both ovaries (bilateral oopherectomy) at the time of hysterectomy because some studies suggest this results in greater long- term pain relief.

If you spend any time with women who have this disease, you realize what a difficult decision this is. I've heard positive hysterectomy stories as well as negative ones. At our most recent meeting, one member told me she felt that having a hysterectomy was the only way she could get her life back. Another member had a different opinion and felt she had traded one set of problems for another. Unfortunately, there are no right or wrong answers with endometriosis treatment, only difficult decisions.

Having a hysterectomy is often very emotional because women may view it as a loss -- not only of reproductive organs, but also as loss of control over our bodies and this disease. Even after definitive surgery, many women still have health- related issues to contend with, the most significant of which is hormone replacement decisions. There is a theory among some endometriosis specialists that hormone replacement should be delayed for a time following hysterectomy and removal of ovaries to allow the endometriosis lesions to "die out." (Estrogen is usually thought of as the hormone that influences the growth and development of endometriosis.) But other specialists don't agree, and begin hormone replacement immediately in order to take advantage of estrogen's heart- protective and bone- protective benefits. Women in the support groups have discussed the merits of natural hormone replacement for endometriosis, but little data exists on this topic.

There is also the question of whether hysterectomy is the answer for everyone. In our support group, we have a few members who continue to suffer with continued symptoms and documented existence of the disease even after hysterectomy and bilateral oopherectomy.

Endometriosis Despite Hysterectomy:


Good Luck w/ everything Pls know your ((Sisters)) will be here for support in whatever your decision may be....my prayers will be with you can find some answers & relief to your pain....(((hugs)))
Unread 05-08-2003, 07:03 AM


Hi Dawnee..

I am so sorry you are having pain still. I am 1 week post-op from adhesion removal. I had the same endo symptoms and both me and my Gyn thought it was recurring endo. At this point I am not to sure he !. removed everything and 2. that there is not deep adhesions or even endo that can not be seen as I am still having cramping.

Mine is just a waiting game right now to see if the cramps ore due to the surgery or not, but I will definetly be talking it all over with my Gyn Friday when I go back.

Sheri has given you alot of GREAT info to read over and I pray that you will find what you are on now to help you instead of heading for another surgery.

We are all here for you, so vent and ask away!!

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Unread 05-08-2003, 07:18 AM
BC pills and endo


I have been taking bc pills since 9 weeks post op because my remaining ovary was cystic. I do believe it has helped in that regard. It may have also helped to keep endo at bay....however, since the bc pills contain estrogen they can actaully feed the endo. In the last few months, I have had some symptoms that are "suggetive of reocurring endo" so, my doc has switched me to a pill with less estrogen in it. (Ortho Tri-cyclen Lo) She has also mentioned Lupron as an option or removing the ovary. I don't relish the idea of further surgery either (had a hard enough time with the hyst) so, I will start with the most conservative approach.

I think that as long as you have a good relationship with your doctor ...lots of communication...you will be able to come up with an option that works for you. Good luck.
Unread 05-08-2003, 10:11 PM
Thank you

Thank you for the wealth of information, I have a lot of reading to do this weekend.

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