"Ask Dr. Cook" is a series of questions and answers regarding endometriosis. The current subject and answer can be found on Current Ask Dr. Cook web page. The questions may represent a summary of questions I have been asked by several different patients. I hope you find this information helpful. If you have a question you would like answered, please Submit A Question.

Question:
I had a hysterectomy January 1997. A few months later, the pain returned. My original doctor told me it was "in my head" and I was fine. Just last month, I went to another doctor and she did a laparoscopy and found I had adhesions and recurrent endometriosis (because they put me on estrogen replacement and it made it grow back). She said she got what she could and now has me on Prometrium. She has suggested I take depo provera to "kill" the remaining endo (if there is any). Will Depo take care of this? I have read that as soon as you stop taking Depo, it comes back. I don't know what step to take. Any suggestions? Thank you.

Answer:
I have the following observations. First, there is no medical treatment currently available that will kill or eliminate endometriosis, including Depo-provera. Both Prometrium and Depo-provera are progestational agents which may suppress the activity and thus the symptoms of endometriosis. I personally have not had very good results with this type of medical treatment. The long term concern, if you were to remain on Depo-provera and off of estrogen replacement, is the potential for developing osteoporosis.

I don't personally believe that the estrogen made the endometriosis return. It may have facilitated the rate at which it returned but I do not believe that it caused new endometriosis to grow. If you have all of the endometriosis removed surgically you would be at a very low risk of recurrence. There is no know cure for endometriosis. There is always a chance of recurrence.

I believe a specific surgical approach offers the best chance of eliminating endometriosis from the body and thus minimizing the chance of recurrence of endometriosis and its symptoms from your life. I have had good results using this approach, which is based on the reasoning as follows. If you have looked at pictures of endometriosis, it is evident that the disease is usually multifocal. By this I mean that there are numerous individual sites of endometriosis. Similar to the appearance of freckles. There can be a wide variety in both the appearance and size of the individual endometriotic lesions. Some are very small and can be missed if the peritoneum is not examined close-up with "near contact" laparoscopy, which provides maximal laparoscopic magnification. Several studies have shown a fairly high incidence of microscopic endometriosis in "normal" appearing peritoneum. This microscopic endometriosis will be missed even if the surgeon uses "near contact" laparoscopy or for that fact an operating microscope. Part if the key to successfully treating endometriosis patients and minimizing the rate of recurrence is ablation or resection of these microscopic lesions. This is accomplished by ablating or resecting all of the pelvic peritoneum. Second, patients which have undergone a hysterectomy for the treatment of endometriosis have by definition been through at least one surgery and often many more. If the endometriosis is not removed prior to the hysterectomy she is at an increased risk of having endometriosis buried as the tissue is clamped, cut and tied during the removal of the uterus. These areas need to be "undone", explored and removed during surgical treatment of post-hysterectomy endometriosis patients. The last critical point in the surgical treatment of this type of situation is careful evaluation and possible removal of the vaginal cuff. Nodularity and tenderness on pre-operative vaginal exam is indicative of vaginal cuff endometriosis. Once again the surgeon (even myself) cannot always see or even fell endometriosis in the vaginal cuff at the time of surgery. I have had cases which by preoperative assessment indicated vaginal cuff endometriosis, felt normal at the time of surgery and when removed, revealed the presence of endometriosis when examined by the pathologist under the microscope. I believe that aggressive and through treatment of post-hysterectomy "recurrent" endometriosis can and usually does result in resolution of symptoms without recurrence of endometriosis.

It is important to mention the team approach in treatment of this type of situation. All too often endometriosis is but just one of several conditions contributing to the patients symptoms. A careful history and physical examination will help lead the physician to a complete understanding of the patients situation. Examples of these other conditions include nerve damage and/or entrapment, bladder or bowel problems and even subluxation of the spine (misalignment of the spine).

Updatede October 29, 2005