Image © by Pavel Klimenko provided through licensed usage.
By Dr Jeff Arrington
“Two roads diverged in a yellow wood,
And sorry I could not travel both
And be one traveler, long I stood
And looked down one as far as I could
To where it bent in the undergrowth;
Then took the other, as just as fair,
And having perhaps the better claim,
Because it was grassy and wanted wear…”
—Robert Frost
As I was reviewing some articles regarding the use of hysterectomy (removal of the uterus) for treatment of endometriosis, I reflected on why. Why and how did hysterectomy become promoted as the “definitive” treatment for a disease that rarely involves the uterus itself? My thoughts caught hold of the poem by Robert Frost and upon ‘the Easy Path.’
Promotion of hysterectomy, in the shadow of Sampson’s Theory of retrograde menstruation, makes complete sense as a method of preventing new disease. Although very flawed, it has been the prevailing theory that has guided treatment (although I don’t know why hysterectomy was promoted, instead of just tying the tubes).
For years, without any evidence to support it, hysterectomy has been considered the “definitive” treatment for endometriosis. Doctors noted, however, that there was a high rate of recurrent pain; pain always being the marker while avoiding other aspects such as infertility, adhesions and organ invasion. As OB/Gyns stood at the paths ahead, there were likely two that were very evident:
1. Difficult and advanced surgery directed at the disease tissue that would take years of training and understanding to master; and
2. Trying to find another approach that all OB/Gyn’s should be able to master.
In a 1995 study published in the journal of Fertility & Sterility by Namnoum et al., the authors noted the high rate of recurrence of pain after total abdominal hysterectomy. In the study, all hysterectomies were done by an open laparotomy incision (this is similar to a cesarean section incision). Through this incision, there is no hope that a surgeon could adequately see into the pelvis from a normal standing height, looking through an incision in the abdomen and trying to see around the uterus into the sides and back of the pelvis. This approach was a straightforward surgery for completing a hysterectomy, but leaves no hope for an attempt at full recognition and removal of endometriosis.
Instead of focusing on the disease itself and trying to find a way to actually treat the endometriosis, the authors placed focus on another routine and standard surgery that every OB/Gyn could perform - removing the ovaries (oophorectomy). If removing the uterus didn’t solve the problem thought to be caused by Sampson’s Theory, certainly removing ovarian estrogen would take care of the issue. In fact, they did see a lower rate of pain recurrence.
A later small study by Fedele et al. looked at the benefits of regular laparoscopic hysterectomy versus a radical hysterectomy (radical hysterectomy is the type of surgery used for uterine or cervical cancer; by definition, it includes removal of the broad ligament, round ligaments, much of the uterosacral ligaments and partial removal of the upper vagina). This study found that radical hysterectomy had a lower rate of pain recurrence as well. It was proposed that the wider and more aggressive removal of deep endometriosis as part of the radical hysterectomy contributed to the improvement seen. In essence: the method of hysterectomy actually removed much of the deeply infiltrating endometriosis that is usually ignored and left during a standard hysterectomy.
Once again, there was a choice to be made:
1. Teach difficult surgery with advanced dissection techniques that would allow improvement in pain and address adhesions and organ involvement; or
2. Take the easy path by just removing the ovaries which, like the uterus, may not even be involved with endometriosis.
OB/Gyns took the easy path. Advanced surgery is just too difficult to master and everyone can remove the uterus and ovaries.
To establish the pattern of the OB/Gyn profession choosing the easy way to the detriment of patient care, I’d like to briefly discuss treatment of vaginal prolapse and pelvic floor support. For years, the gold standard treatment has been a procedure known as sacrocolpopexy. This procedure requires suturing a new mesh ligament between the upper vagina and the presacral ligament. In the past, this was done very successfully through an open incision. As laparoscopic suturing became more prevalent, many surgeons began offering laparoscopic sacrocolpopexies. This was an extremely hard surgery to master for most OB/Gyns. It required very advanced laparoscopic skills that most do not have. Instead of trying to push the training programs and increase the surgical skill to benefit the patient, doctors and medical device companies invented vaginal mesh kits. These kits employed sheets of mesh fixed by ‘arms’ passed through various muscles and ligaments of the pelvic floor to support or encase the vagina in a new supportive structure. No advanced skill needed. Just a simple training course or two, and any OB/Gyn would be able to fix vaginal prolapse just like those “advanced laparoscopic” docs.
As we all know, this did not end well. But, for the OB/Gyns, it was thought to be the easiest path.
With endometriosis, there continues to be a pattern of seeking the easy path. There is very little effort made to take time teaching advanced laparoscopic or robotic dissection; very little time spent teaching the patience needed to meticulously attack this terrible disease. There continues to be promotion of the “definitive” hysterectomy.
This also limits progress in research. More time and money is spent on researching hormones and medications that may help control only the symptoms than there is on understanding the actual disease and looking at tools for better surgical identification of margins, or even medications or therapies that may actually one day help the body truly get rid of endometriosis.
The current standard of care for endometriosis is not sufficient.
Delay of diagnosis with prolonged suffering and progression of destructive disease is far too rampant. We cannot sit back and continue to palliate the symptoms of endometriosis with our fingers crossed that this different birth control pill or that new hormone will keep the patient happy long enough for the doctor to ‘take a break’ from trying to “deal with” the pain patient.
The standard of care is not limited by available treatment - but by the unwillingness of a profession to teach the surgical skills necessary to treat advanced endometriosis, until the day when we do find a true non-invasive cure.
At the Center for Endometriosis Care, founded by Dr. Albee in 1991, Dr Sinervo and I have over 35 years of combined experience. We have chosen the more difficult path. As we continue to walk that difficult path, we do encounter the entanglements of difficult disease - but we also witness the figurative, breathtaking vistas that will never be seen by those surgeons on the easy path. We are able to restore and give hope to many for whom hope has been lost.
As Frost concluded,
”…Two roads diverged in a wood, and I-
I [we] took the one less traveled by,
And that has made all the difference.”
Citations:
Fedele L, Bianchi S, Zanconato G, et al. Tailoring radicality in demolitive surgery for deeply infiltrating endometriosis. Am J Obstet Gynecol. 2005;193:114–117.
Namnoum AB, Hickman TN, Goodman SB, Gehlbach DL, Rock JA. Incidence of symptom recurrence after hysterectomy for endometriosis. Fertil Steril. 1995;64(5):898-902.