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endo and hrt question endo and hrt question

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Unread 04-01-2003, 04:45 PM
endo and hrt question

In my quest to figure out if being on estrogen after oopherectomy is a smart idea (as some of you know my gyn is as much use as a chocolate teapot in this area) I started wondering so am hoping my dear sisters can explain to me...

if this is correct.... (from endo assoc website)

Endometriosis... blah blah blah.....this misplaced tissue develops into growths or lesions which respond to the menstrual cycle in the same way that the tissue of the uterine lining does: each month the tissue builds up, breaks down, and sheds.

When we have no ovaries we have no menstrual cycle, right? So, wouldn't that mean the endo would just sit there being benign????

I KNOW this is not the case as I know many of you (us!) are suffering with endo even without ovaries. And I know some say wait 6 months or so to go on HRT, But why and how does it hurt us???

Waiting for you darling experts to respond

Steph xxxx
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Unread 04-01-2003, 05:52 PM
endo and hrt question

Hi Steph,

My humble understanding, for what it is worth, is that the estrogen, in too high a dose, can stimulate the old endo left behind in our abdominal cavities. I also believe from what I have read that the endo itself produces a certain level of estrogen when it is active. Each lady is different in how much estrogen she needs and how much she produces. My understanding is that the endo can feed on itself if enough estrogen is hanging around in our systems, even if we don't have our ovaries any more! The wait period is suggested to allow the remaining endo to "burn itself out" so there is less of a chance of it reactivating.

From my own experience, doctors disagree on what that waiting period should be, and they also disagree on putting endo ladies on hrt at all! I am reluctant to do any hrt but my surgeon insists I maintain some dose of estrogen because of my age and bone density issues, and I am currently taking 1 mg Estrace pills (1 a day). I am having some low estrogen symptoms and had blood tests done. I get the results on Friday and he may up my dosage. I have told hiim I am really concerned about the endo coming back, but he feels I will be fine. I expect he should know as he is the only person to ever take a look at my insides, twice. I hope it works out for me.

Best of luck in your quest for info. It is a tough decision because of the fear of the endo returning.

Unread 04-01-2003, 06:53 PM
endo and hrt question

thanks Sandra

I guess what I was hoping was that if we have no cycle the endo does not "bleed' and can't cause pain.

Hopefully if, as you say,

the estrogen, in too high a dose, can stimulate the old endo left behind in our abdominal cavities

if we get the dose just perfect all will be well!

Optimistic aren't I!

I am currently on estradiol 2mg and get blood tests for levels in 3 weeks.

thanks again
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Unread 04-01-2003, 08:49 PM
endo and hrt question


To add a bit more confusion....my doc said if my ovaries had been removed he would have put me on opposed estrogen therapy. Opposed estrogen means estrogen + progesterone. The progesterone is supposed to block the estrogen from worsening the endo. Something like that....

Anyway, would have been on the opposed estrogen therapy for six months to a year and then switched to estrogen only. Hey, it's a guessing game if you ask me.

Still glad I kept my ovaries. Glad to have missed surgical menopause, for now.

Best of luck in sorting this all out.
Unread 04-01-2003, 10:25 PM
endo and hrt question

Hi again my sweet sister!!

I will speak from MY own experience and what I have researched in the past 2 years.

Endo can produce its own estrogen ( I have heard this many times and some disagree, so it is a 50/50 shot here) and estrogen feeds it.

When they take out the ovaries, most Gyn's (not all, I think they are still confused on this one) will hold off HRT for 6 months so the remaining endo can "Die off". With no estrogen to feed it, even though it can produce its own (again 50/50), it will MOST of the time stop growing. BUT... when you leave the ovaries, they produce estrogen and can feed the endo still left. That is why some Dr's give the Lupron shots to cause a temporary menopause and shut off the estrogen produced by the ovaries.

When we are put on HRT right after a hysterectomy w/BSO, the HRT is taking over the ovaries job by producing estrogen. Therefore it is feeding the endo and it can still grow.

Michelle is RIGHT ON with the estrogen/progesterone mix, I wish I had heard of it long ago.. ANYTHING to keep it from coming back. Of course it has been 2 years with a high dose of estrogen for me and it is no wonder it is probably back!!

I dont think ANYONE knows the PERFECT dose or combination. Like Michelle said, it is a guessing game. Endo is the most misunderstood disease there is as far as womens health goes. I would even go so far as to be a guinea pig for research if I could help just 1 woman conquor this horrible MONSTER!!

As far as the endo still bleeding after removing the ovaries and uterus, endo is caused from the uterine lining not sluffing off outside through the vagina, but backing up into the abdominal cavity causing the lesions, with every period it bleeds because it is active uterine tissue. So even after the organs are gone the endo is still there. It really depends on how much is left and what your Gyn does to try to make it die. I personally think every Gyn has a different outlook on this disease.

Not enough research is done and it is, to me at least, like cancer that spreads throughout the abdominal cavity and can even go up to the upper organs; lungs, breasts, etc,,

I hope I did not confuse you and helped a little. I know how frusterating it is!! If you have anymore questions, I will do my best to help in any way I can and try not to write a book next time!!

Take care!!

Unread 04-02-2003, 05:50 AM
endo and hrt question

Here is some info I found I thot might be of some more help for you

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. We aren't endo specialists, but we have a few links on our links page that may be useful in your researches. Endo is a long, grim battle, and it's sadly not one that seems to be over after a hyst.

In addition to progesterone, you may want to look into other measures to help with your estrogen deficit. You will need to work very hard on maintaining your bone density and keep an eye on your overall cardiac measures such as cholesterol and blood lipids. Both of these profiles see their most rapid rate of change in the year after ovarian hormones decline. Many of the symptomatic relief measures may also be helpful. In particular, use of an SSRI or St. John's Wort may be required if depression and hot flashes become debilitating. It's important to bear in mind that some of the herbal estrogen-alternatives are fine to use and some can totally undermine the point of going without estrogen. As a rule, black cohosh is considered effective in relieving symptoms without having effects similar to estrogen. Red clover's picture is not as clear, and it is also not as clearly demonstrated to be effective. Soy, which is often used as an estrogen supplement or alternative, should be avoided in endo suppression just because it has some of the same capacity for endometrial stimulation as estrogen. Taking the adrenal precursors (DHEA, pregnenolone) is a little questionable as they can ultimately be converted to estrogen; testosterone supplementation during this period will probably also be hijacked for estrogen production, so may not be wise. Even caffeine, as noted at WebMD, stimulates elevations of circulating estrone, an estrogen, and may be implicated in the exacerbation of endo. Check all this with your doctor, of course—but remember the bottom line: if any of these do stimulate further endo, you are the one who suffers. And you know what that's like. Since it only has to go on for about 6 months, our feeling would be to be as conservative as possible rather than risk more endo. But you have to decide this for yourself.
There is no question that endometriosis can be present in a woman who has undergone a hysterectomy and removal of both ovaries (even more likely if the ovaries remain). Performing a hysterectomy does not in itself treat endometriosis. It may reduce the chance of future recurrence of endometriosis, reduce non-endometriosis related cramps, bleeding etc. The key point is that endometriosis, for the most part, does not grow on the uterus, it grows behind the uterus, on the bowel, in the rectovaginal septum, in the pararectal spaces, under the ovaries, around the ureters, on the bladder, etc. If a hysterectomy is part of the agreed upon treatment plan between you and your physician that is fine, but ONLY AFTER the endometriosis has been completely removed from all of the areas which will not be taken out with the uterus. If you have undergone a hysterectomy alone for the treatment of endometriosis (the endometriosis was not treated just prior to the hysterectomy) there is a good chance you will have persistent or recurrent symptoms. The most common symptoms include constant pain, pain with bowel movements, pain with intercourse (usually deep penetration, like he is hitting something inside) and occasionally mid back pain (secondary to ureteral involvement). You can also experience the emotional changes we have seen with endometriosis including moodiness, depression, etc.

Now, assume for a minute that everyone understands your situation (your doctor, significant other, employer etc.) and your gynecologist surgeon is standing there ready to go after the endometriosis. What are the pitfalls? In my experience, by the time a patient has gotten to this point she has undergone so many surgical procedures that is impossible to tell what is and what is not endometriosis. The anatomy is distorted, fairly extensive scar tissue and fibrosis (tough leathery tissue) is present, and often endometriosis is buried out of sight in a patient who has had a hysterectomy performed. The endometriosis gets buried when the surgeon clamps, cuts and ties the tissue during the hysterectomy. The endometriosis that is present get wadded up and buried in this process. After this area heals following the surgery it can be impossible to see endometriosis without dissecting the areas in which endometriosis is known to grow. Another common area for residual endometriosis is the vaginal cuff. Unless all of the endometriosis is removed from the rectovaginal septum prior to the hysterectomy, it can be easily sewn into the vaginal cuff.

We have seen and treated more than 200 women with residual endometriosis after undergoing a hysterectomy. If you are experiencing this situation, you are not alone. In my experience there are several key factors in successfully treating this type of case. First, this is probably the most technically challenging surgery a gynecologist will face. It is important to seek out a surgeon who is technically good and has experience in dealing with this situation. Second, since it can be impossible to determine what is and what is not endometriosis, all abnormal tissue must be removed and the areas in the pelvis where endometriosis is know to grow must be dissected out. It is not uncommon for an area to look normal on the surface, but to have deep endometriosis when opened up. In my experience, all areas need to be dissected down to normal tissue (endometriosis until proven normal). Depending on the specific situation a small portion of the vaginal cuff may need to be resected.

In summary, you can have endometriosis and the associated symptoms and pain even if you have had a hysterectomy. Treatment of this condition is technically challenging and requires the ability, expertise, and equipment to dissect and laser all of the pelvic areas deep down to normal tissue. In my opinion, a surgeon can not get all of the endometriosis and scar tissue by just spot treating or selectively excising lesions. In my experience, once all of the pelvic area is explored and all the abnormal tissue is laser out, the patient feels better.

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:

New and Emerging Treatments for Endo:

Danazol Vaginal:

This appears to be a new and very promising method of suppressing pelvic endometriosis. The treatment plan I use is based on data from studies by a Japanese research group lead by Dr Masao Igarashi.

Danazol was one of the first drugs used to suppress endometriosis. Although it provided good suppression, its side effects: weight gain, acne, hot flushes, increased hair growth and decrease in breast size caused us to abandon it in favor of GnRH agonists. Vaginal Danazol suppresses endometriosis without causing any of the above-mentioned side effects. It gets absorbed directly to the pelvic tissues through the wall of the vagina. The only side effects experienced by my patients using Vaginal Danazol include some vaginal irritation and occasional constipation and those effects are easily corrected. I use Vaginal Danazol after removal of endometriomas and laparoscopic resection of fibrotic endometriosis to suppress any residual and microscopic endometriosis. I am also evaluating the use of vaginal Danazol prior to operative laparoscopy, especially in women with endometriosis involving their bowels. The hope is that pretreatment will decrease size of the fibrotic lesions, making less extensive surgery possible.

Progestagen Releasing Intrauterine Device:

European centers are evaluating intrauterine device containing a slowly released progesterone like, drug. Patients using these devices seemed to have less painful periods and less menstrual flow.

Antiprogesterone Drugs:

GnRH Antagonists:

These drugs are used in Europe to treat endometriosis. They are comparable in their effectiveness to GnRH Agonists.

Vessel Growth Factor Agents:

Agents that affect the growth of new vessels in our body are being tested in cancer therapy. I am not presently aware of the results of any studies in US in patients suffering from endometriosis.


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.

Removal of the ovary containing endometrioma is quite a radical approach and you should consider this if you are not contemplatingfuture pregnancy, if you have massive adhesions around the ovaries that failed previous attempts of conservative surgical treatment or if there is a possibility of ovarian malignancy.

Endometriosis of the fallopian tube:

Endometriosis implants can be present on the surface of your fallopian tube, your mesosalphinx(connection between the fallopian tube ovary and the pelvic side wall) or within the wall of your fallopian tube. Endometriosis of the fallopian tube can play a role in infertility.
Symptoms: Your symptoms will be the same as those of endometriosis of the ovary.

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.

Endometriosis of the bladder area:

Your bladder occupies the space in the front of your uterus and is loosely covered by peritoneum, allowing it to expand as it fills with urine.This expansion process should be totally painless. Endometriosis of the bladder area usually begins with superficial implants; many of them remain as such, causing local irritation and superficial scarring.On occasion, the implants will start growing into the deeper layers of your bladder wall, creating artificial attachment of your superficial peritoneal lining to your bladder wall.

Symptoms: Low abdominal and pelvic pain, usually in the middle, is the most common symptom. Your pain may be aggravated by bladder distention and by sexual intercourse.In the case where your bladder wall is actually penetrated by endometriosis, your symptoms may include pain with urination and the presence of blood in your urine, especially during menstruation.
Endometriosis of the posterior cul-de-sac

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 of the bowel:
Description:Your sigmoid colon (lower portion of the large bowel) and your rectum are pelvic organs which are anatomically associated with areas that are common sites of endometriosis.In some patients, especially those with severe endometriosis, there is extensive involvement of the bowel wall.Most commonly, the endometriotic bowel implants will be restricted to the surface of you bowel and adhesions around your bowel. In more severe cases, the implants may involve the entire thickness of your bowel wall.Your appendix is part of your bowel and on occasion it will become a pelvic organ. The appendix is involved in approximately one percent of patients with endometriosis.

Themost common symptom associated with endometriosis of the bowel is cramping and diarrhea during menstruation (many patients will be incorrectly diagnosed as having irritable bowel syndrome).Minimal and superficial endometriosis of your bowel does not have any specific symptoms different from those of the endometriosis of the cul-de-sac.But severe endometriosis infiltrating deep into your bowel wall is usually associated with chronic pelvic and back pain and painful bowel movements, generally worse before and during menstruation. In endometriosis that has penetrated your bowel wall completely, you may note rectal bleeding or some blood covering the stool during menstruation. In such case, you will likely suffer from extreme pain during bowel movement.

Endometriosis in remote locations:
Description: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.

I have to leave for work Steph but I will do some more looking around when I get home...(((hugs)))
Unread 04-02-2003, 04:25 PM
endo and hrt question

Wow! You guys are incredible. thankyou thankyou thankyou.

Pam I'll certainly be asking about progesterone when I have my next HRT appt. If I get no joy from the chocolate teapot gyn I'll let my GP take over as he is very willing and I trust him to work with me.

Sheri - amazing info! Makes me really wonder even more abt him not looking at certain bits during the lap. Particularly as I had said over and over that I had pain (and still do!) in the rectovag area. Reading what you found about posterior cul-de-sac endo is like reading about me. Grrrr.

Am grumpy and cranky today as I am more and more sure daily that adhesions are happening from this last op. And now I got a cold *sniffle* So getting your messages is a bright spot

I have made contact with a specialist endo clinic attached to a highly respected hospital here, asked if they also look after adhesions. They told me to get a referral if my gyn is not helpful when I ask abt these new adhesions.

But for now I feel I should wait a few weeks so that its certain it is not healing pains- though I just know it is not.

Wish I had known to go to them way back before i had the hyst!!

love you all to bits

Steph xx
Unread 04-02-2003, 04:57 PM
endo and hrt question

Wish I had known to go to them way back before i had the hyst!!
Ditto ((Steph))

Adhesions are a scourge that can create pain and reduce the normal functioning of affected areas. Adhesions are tissues that join two surfaces that normally have no permanent contact with each other. They may be seen in two forms:

* As dense adhesions where two surfaces, usually over an area of one square centimetre or more, are directly and densely stuck to each other so that it is difficult to separate them without breaking into the tissue that underlies either of the surfaces.

* As filmy or cobweb adhesions which in the extreme may envelope organs as though they were wrapped in Gladwrap so that they are still able to move in relation to each other.


The development of adhesions involves damage to one or both of the surfaces that become adherent to each other. Alternatively, a process that involves blood clots may occur on the surface of the peritoneum (ie the membranous tissue that covers the abdominal and pelvic organs). This process creates a mesh on which adhesions develop.


Any process designed to reduce the development of adhesions does so by reducing damage to the peritoneum and the surfaces of the abdominal and pelvic organs. Alternatively, it may work by reducing the likelihood of blood clots forming on the peritoneum.

The main aims of surgery to reduce the development of adhesions are to minimise damage by gently handling the organs and tissues and keeping them moist, and minimising the amount of blood left lying on the peritoneum covering the internal organs.

Minimising damage to the peritoneum invloves using micro-surgical techniques when operating. For example, using special non abrasive instruments to move the organs around in the pelvis. The finer the instruments used the less damage is caused to the tissue and fine instruments are preferred as a result. Ensuring the tissues are kept moist throughout the operation is vital to prevent them from drying out and becoming damaged. It is very important that the fluid used to keep them moist is of a similar composition to the normal body fluids so that the fluid itself does not cause damage. The fluid should also be at body temperature when used.

Not leaving blood in the abdomen is vital as blood clots when formed will stick to the surrounding tissues. By keeping the tissues moist the blood does not stick as readily to the peritoneum covering the organs. In addition, the fluid used to keep the tissue moist dilutes the blood making it less likely to form clots. The fluid can also have a substance known as heparin added to it which further reduces the likelihood of blood clots forming.

In some women it is impossible to prevent adhesions developing as their body has an unusual reaction to injury and adhesions form readily even when all these measures are used.

Infection is another cause of adhesions, as are chemical irritants such as bile, a substance produced by the gall bladder. Infectious organisms may penetrate through the bowel wall causing adhesions. They may also enter the pelvic cavity through the cervix, uterus and tubes and cause adhesions in the pelvic area.


At the end of an operation placing fluid in the pelvic cavity and encouraging the woman to move amy be enough to keep the internal tissues and organs moving around and reduce the likelihood of them sticking together. Chemicals have been tried but thay have not been effective.

Interceed is a product that is used to reduce the likelihood of adhesions developing. It is a cloth-like material that can be wrapped over areas of damaged peritoneum and the underlying organs to reduce the risk of adhesions in the area. The Interceed is laid over the raw areas when surgery has been finished and it is absorbed over the next 10-14 days, during which time the peritoneum has the opportunity to heal itself, thus reducing the risk of adhesions.

Interceed has been shown to be effective, particularly for surgery on the ovary. Three studies with a total of 363 patients showed that there were nearly 50% fewer adhesions when Interceed was used. Another study that involved 483 patients found that there were 25% less adhesions when Interceed was used.

Certainly Interceed is not a guarantee but it is better than not using it. The situations under which it can be used and the way it is applied vary. However, any bleeding whatsoever will prevent its effective use.

Intergel is a new product that is being developed. It is an adhesion prevention solution used in conjunction with a second-look laparoscopy 6-12 weeks after a laparotomy. Early studies suggest that it is effective. It will not be available in Australia until further tests are conducted and it is approved by the government.

A third method of preventing adhesions is to permanently sew a silastic sheet in the area where adhesions are likely to develop. However, in the pelvic cavity the sheet is difficult to use without getting irregularities in its surface because the organs are so small.


Once adhesions are formed they are best left alone unless they are disturbing the normal function of any organs or they are causing pain. Many adhesions can remain without causing any problems, particularly around the bowel.

When adhesions over a larger area are separated they leave a large raw area which predisposes the woman to developing further adhesions. Tissues that have been stuck in an abnormal place are less likely to reform adhesions as they will usually return to their normal position when the adhesions have been removed.

Fine filmy adhesions are more common and they are more easily removed as they usually have only a very small area of contact with the underlying organ or tissue. It is best to remove the adhesion so that it does not continue to move around the pelvic cavity like seaweed and possibly re-attach at another location leading to further problems.

Although a surgeon will do their best to remove all existing adhesions there is no guarantee that all the adhesions will be removed. Removing adhesions is best dealt with laparoscopically as the incisions into the pelvic cavity are small and therefore there is less chance of new adhesions developing. Whenever adhesions are being removed - unless they have been caused by an infection - there is a risk of developing further adhesions as that woman's chemistry may be different to that of people who do not develop adhesions. Therefore, sometimes surgery is not recommended for these women.


Adhesions are one of the biggest problems associated with surgery and every precaution should be taken to minimise their likelihood of developing.

Dr. Bruce G Downing

Royal Australian College of Obstetrics and Gynaecology. / C.R.E.I
Unread 04-03-2003, 05:48 PM
endo and hrt question

thanks yet again Sheri for your research

Maybe I should look for this Dr Bruce G Downing who wrote the article as he is an Aussie! I could ask him if I can be used as a guinea pig for his research

interesting they often mention blood clots and infection as contributing to adhesions.. had that afer both surgeries... hmmm.

Steph xx
Unread 04-03-2003, 05:58 PM
Thanks for the info


Thank you for sharing all the info, and Sheri - the great research!

I see my doc tomorrow about my estrogen level and will ask about the progesterone - if I should be taking it because of my endo.


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