Diagnosis & Therapy
Article 10 of 10: The pendulum swings
The pendulum swings on hysterectomy
For select women with endometriosis, hysterectomy may provide the best relief from symptoms when combined with other treatments.
TEXT BY KARI OAKES
VIDEO BY M. ALEXANDER OTTO
Hysterectomy, long the mainstay of endometriosis treatment, was relegated to the procedure of last resort as medication and laparoscopic surgery advanced. However, for select patients, the procedure may offer better relief from pain than medication or excision alone.
Ray Garry, MD, shared lessons learned during his career as an endometriosis researcher and gynecologic surgeon in an address at the 13th World Congress on Endometriosis, held in Vancouver.
From gold standard to last resort
Dr. Garry, a recently retired professor of obstetrics and gynecology at the University of Western Australia, Perth, said that recent, high-quality studies that evaluate the role of hysterectomy in endometriosis management are few, and much recent literature gives scant attention to the procedure’s role in treating endometriosis. A review of 69 consensus statements regarding the management of endometriosis only found one reference to hysterectomy, and that one statement noted that the role of hysterectomy was still being debated, with “little evidence to inform practice” (Hum Reprod. 2013 Jun;28:1552-68).
Perspectives on Endometriosis Management
Dr. Garry, whose career has seen trends in endometriosis treatment swing across a wide spectrum, pointed out that he has long advocated a balanced approach to the treatment of endometriosis. In a 1997 editorial, he wrote, “endometriosis is an extrauterine disease and the aim should be to remove all of this … while retaining healthy tissue including the uterus.” He continued, “the early resort to hysterectomy is to be deplored” (Br J Obstet Gynaecol. 1997 May;104:513-5).
The central role of laparoscopic surgery in treating endometriosis was reaffirmed in a 2014 Cochrane review that found laparoscopic excision of endometriosis lesions to be clearly efficacious. Among its findings were that the procedure both increased the live birth rate and reduced pain (Cochrane Database Syst Rev. 2014 Apr 3;:CD011031).
The theory that retrograde menstruation causes endometriosis, which dates back to the 1920s, informed treatment decisions and made hysterectomy a logical choice, Dr. Garry said. However, as time went on and research extended physicians’ understanding of reproductive physiology, a more nuanced theory of the etiology of the disease evolved, and medical approaches offered many patients some relief.
Additionally, attention to individual lesions became a viable option with the advent of laparoscopic surgery, which enabled a less-invasive method to achieve identification and surgical excision of the disease. Finally, in-vitro fertilization improved fertility outcomes for many women with endometriosis, Dr. Garry said.
“So, there were these three groups of treatments which were proposed as effective alternatives for hysterectomy,” Dr. Garry said. Collectively, the treatments have helped many women, he said, “but they took over.”
When to consider hysterectomy
“We’ve looked again at the reasoning behind endometriosis origins and pathogenesis. We’ve found that the endometrium contains many endometrial stem cells … and these can be released during the process of menstruation. In fact, researchers have shown that menstrual flow indeed does contain endometrial stem cells,” he said. “We are now relooking at the more modern concept that the retrograde flow contains endometrial stem cells and that these may indeed be the cause of some or many of the cases of endometriosis.”
Although drugs and excision can produce improvements, Dr. Garry said, combining these treatments with hysterectomy and oophorectomy may result in a better, more sustained result.
Another time hysterectomy should be considered is when symptomatic lesions are located on or in the uterus, Laparoscopic excision alone without hysterectomy may mean that lesions left behind may still cause symptoms. Conversely, performing a hysterectomy alone without excisions done by a meticulous laparoscopic approach may also leave a woman symptomatic.
One recent study examined outcomes for 100 patients with extensive bowel resection. Patients who had excision of endometrial bowel lesions in combination with hysterectomy and bilateral salpingo-oophorectomy had better symptomatic relief and bowel function than those whose surgeries only addressed the extrauterine endometrial tissue (J Minim Invasive Gynecol. 2016 May-Jun;23:526-34).
Another study examined symptom resolution among 176 women who had laparoscopic excision of endometriosis lesions. Though most (67%) improved when followed up for a period ranging from 2 to 5 years, about one-quarter of the women experienced worse symptoms and the remainder reported that their symptoms were unchanged after surgery. Of these women, 20 (15% of the overall group) eventually had a hysterectomy post excision. Six (30%) of these women had adenomyosis (Hum Reprod. 2003 Sep;18:1922-7).
Other studies have also found lower reoperation rates with hysterectomy and even lower ones when ovaries are also removed, especially when patients are tracked for several years postoperatively, Dr. Garry said.
When deciding the optimal approach for a hysterectomy, most patient-centered criteria favor a laparoscopic approach. A multicenter, randomized trial performed by Dr. Garry and his colleagues for the UK’s National Health Service found that, when compared with abdominal hysterectomy, a laparoscopic approach resulted in less operative pain (visual analog scale 3.51 versus 3.88; P = 0.01), a hospital stay of 3 versus 4 days, earlier return to sexual activity, and higher quality of life at 6 weeks after surgery. However, quality of life was comparable between methods by 4 and 12 months, and cost-effectiveness data were equivocal (Health Technol Assess. 2004 Jun;8:1-154).
Another study compared the two approaches when hysterectomy was done specifically for the indication of severe endometriosis. It compared 115 women who had laparoscopic hysterectomy with 388 women who had abdominal hysterectomy. Operative time was shorter with abdominal procedures. However, women who had laparoscopic hysterectomy had less than half the blood loss of those undergoing abdominal hysterectomy. Length of stay was also shorter and complications were fewer for those receiving laparoscopic hysterectomy (Int J Gynaecol Obstet. 2012 Feb;116:109-11).
So, how do you pull all of this information together when counseling a woman with severe, persistent, or recurrent endometriosis symptoms? The discussion, Dr. Garry said, can be informed by the knowledge that the uterus probably has some role in pathogenesis and can sometimes itself be invaded by endometriosis.
This might include women who have disease in the cul-de-sac, on the ovaries, and on the posterior aspect of the uterus.
So, the pendulum, he said, may be swinging back toward recognizing that some endometriosis patients – perhaps around 15% – may benefit from hysterectomy. There are some indications that practice patterns may be shifting toward the recognition of a real role for endometriosis in a limited number of patients.
A recent multicenter French study found that, of 1,135 women who had laparoscopic excision of deep endometriosis that involved the rectum and colon, about 15% had a simultaneous hysterectomy (J Gynecol Obstet Hum Reprod. 2017 Feb;46:159-65).
Dr. Garry reported having no relevant financial disclosures.
Kari Oakes and M. Alexander Otto are writers for Ob.Gyn. News.