Is treatment needed?

The finding of endometriosis does not mean that patients require treatment.  Patients are often have endometriosis that appears to cause no problems.  This happens in patients with  myomata (fibroids),  patients undergoing sterilization and patients having tubal sterilization reversal.  Most postmenopausal patients with endometriosis have few symptoms and only 29% have endometriosis that appears to be significant.

Some patients become worse over time.  This can happen in women who have tubal sterilization.  This implies that endometriosis may be the result of infertility, whether voluntary or involuntary. 

Is excision superior to coagulation?  

Excision appears to be superior to coagulation with deep endometriosis, endometriosis close to vital organs, and appearances of uncertain pathology. The ability to see what is cut is helpful for deep lesions.  Small (less than or equal to 2mm) lesions are adequately destroyed by coagulation (electrosurgical, thermal or laser), vaporization or excision. 

However excision  is associated with increased risk compared to superficial coagulation or non-surgical treatment.  This risk must be weighed against any anticipated advantages.  These patients may benefit by laparotomy.

Is “atypical” a reasonable term?

The term “atypical”  creates confusion about whether we are talking about malignancy or about endometriosis.  “Subtle” may be a more appropriate term for the gross appearance of some endometriosis.   On the other hand, subtle appearances can also be confused with endosalpingiosis, psammoma bodies and cancer. 

Does rectovaginal endometriosis invade the rectovaginal septum?

The rectovaginal (RV) pouch covers part of the vagina and rectum and its base is the upper limit of the RV septum.  The RV pouch is not the RV septum.  Retroperitoneal endometriosis and posterior vaginal fornix endometriosis are behind the RV pouch and not within it.

The depth of the RV pouch extends to the middle one third of the vagina in 93% of women.  Shortening of the RV pouch and elongation of the RV septum with RV pouch involvement appears related to contraction of the pouch. 

Do research studies need a golden standard for recognition?

Recognition of endometriosis is difficult due to the different sizes and colors.  Small lesions can be missed due to their size while larger lesions may be missed due to  adhesions or deep position. 

Although visualization is said to be the golden standard, gynecologists may see and note only 41% to 70% of the endometriosis that they remove.  This wide range leads to the conclusion that confirmation of lesions in a general practice is not essential.  In a general clinical practice, biopsies and histology may be more valuable to rule out cancer and other pathology than it is to confirm endometriosis.  This appears particularly true with clear and opaque vesicles. 

Will RBRVS and DRG impact on surgical endometriosis research?

RBRVS is an acronym for resources based relative value scale.  Surgical procedures are assigned a value that represents average cases.  When a case is simpler than average, reimbursement is increased per hour.  When cases are difficult, reimbursement is decreased per hour.  This concept works very well for primary care gynecologists who can do basic cases and refer the more difficult cases to tertiary care.  This works poorest for tertiary care who sees higher than the average number of difficult cases which pay less per hour.

In a similar fashion, DRGs (diagnostic related groups) have a similar effect on surgical facilities.  Simple quick cases in the same DRG pay more than complex cases per hour.  Although surgeons performing complex operations may have been encouraged by the hospital 15 years ago, they may be discouraged by the same hospitals today.

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