Observations from the Sixth World Congress on Endometriosis, Quebec City, Canada, June 30 - July 4, 1998

I was honored to be an invited speaker at the Sixth World Congress on Endometriosis held in Quebec City this summer. The interest in surgical treatment of endometriosis was high, especially considering that the major sponsors of the meeting were drug companies marketing medical therapy of endometriosis.

Everywhere I listened or looked, papers were being presented on the surgical treatment of endometriosis. I was especially pleased that most of the surgical papers were on excision of endometriosis, usually at laparoscopy, since that is what I have been doing since 1979. (I'm feeling old here.) Here is a sampling of the surgical papers.

Surgeons from Emory University (Atlanta, GA) found a 76% rate of significant pain relief following aggressive excision of endometriosis at laparotomy in 92 patients. They recommended complete pelvic dissection and removal of all endometriosis in patients with pain.

Surgeons in Stockholm found that aggressive surgery for rectosigmoid endometriosis was difficult, but had a dramatic effect on pain relief.

Chilean surgeons reported that resection of deeply invasive endometriosis improves pregnancy rates and added that some patients with high stage disease in their study had been previously misdiagnosed with lower stage disease because their previous surgery had not included excision.

Italian surgeons reported that laparoscopic excision of ovarian endometrioma cysts in infertile women was followed by a 55% pregnancy rate by two years following surgery, while Japanese surgeons using electrocoagulation of endometriosis found pregnancy rates of 32% to 36% in Stages I - IV by two years following surgery.

French surgeons reported that resection of deep endometriosis took time to learn, but is the only technique valid for deep disease. Their pain relief results with excision of deep endometriosis were better than with laser vaporization.

Belgian surgeons reported excellent and long-lasting pain relief following aggressive laparoscopic excision of deep endometriosis.

The Prize Paper of the Congress was awarded to Ray Garry, MD from Middlesbrough, UK. Dr. Garry visited Bend two years ago to observe laparoscopic excision of endometriosis and to study my computer database on endometriosis. He then returned home and set up an endometriosis treatment center modeled loosely on ours here at St. Charles.

Dr. Garry has become a strong proponent of complete excision of endometriosis as well as keeping track of results to gauge success of treatment. Using the surgical and computer techniques he saw here, he has begun to duplicate the outcomes we have observed here, and won a very important international award for his efforts.

I felt like a proud parent when Dr. Garry stepped forward to accept this award. I was happy, too, that excision of endometriosis is becoming more widespread and that other researchers are able to confirm the results we have been achieving here at St. Charles for the last 20 years.

There were many other papers on many other topics, both theoretical and practical. Researchers are busy trying to pry the secrets of endometriosis out of the pelvis, but there does not seem to be a 'magic bullet' on the medical therapy horizon. While we are all waiting for such a fantasy, the bottom line is that women with endometriosis are continuing to hurt and are sometimes infertile because of their disease. They need effective therapy now, not 10 or 20 years in the future when some new discovery may be made.

No one has found that excision of endometriosis reduces fertility or causes most patients to hurt more. Everyone has found that excision of endometriosis is the only thing that can treat both superficial and deep disease anywhere in the body.

There is general agreement that the surgery can be difficult and is not for every gynecologist. But for surgeons with the necessary skill and experience, there is a great deal of evidence that excision provides significant pain relief for most patients, with many studies finding improvement in fertility as well. Excision does not cause pain or reduce fertility, so there is no rational reason to avoid good surgery for endometriosis.

Old Theories Persist
Sadly, some researchers continue to try to support reflux menstruation as the mechanism of origin of endometriosis, thinking that endometriosis is exactly the same tissue as that which lines the uterus. They don't seem to realize that endometriosis tissue is profoundly different from that which lines the uterus. It has fundamental differences in hormone receptors, hormone response, enzymatic activity, cellular differentiation, chromosome structure, and visual appearance among other things.

There are just too many differences to conclude that endometriosis is simply misplaced normal endometrium which has refluxed out the end of the fallopian tube and become transplanted in the pelvis.

Could all these differences be explained by the theory of reflux menstruation? It is extremely doubtful. Even if the journey through the fallopian tubes and implantation in the pelvis somehow affected the tissue, could its fundamental composition be changed so profoundly? There is no evidence to support this theory of "transformation."

Looking Ahead
The next World Congress on Endometriosis will be held in London, England in the year 2000. I expect there will be increasing evidence of the efficacy of surgery, with emphasis on excision for the best results.