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The state of endometriosis diagnosis and treatment in America is nothing short of depressing. During the height of my gynecological career in the 80s and 90s, I am proud to say we were way ahead of the game. Now? We are third world. It would be difficult to list 10 expert endometriosis surgeons in the United States today. (Of that ten, there are few disciples to follow in their footsteps, but, more on that later.)
In the rest of the world, there are exponentially more expert endo surgeons. If we continue like this, I believe, we will make Europe into the major surgical referral center it was 100 years ago, and women will continue to travel to obtain the best treatment.
Many women who undergo multiple endometriosis-related laparoscopies have no disease. The surgeons do an easy diagnostic laparoscopy without biopsy (what I call a look-see laparoscopy) followed by six months of GnRH agonist treatment (as a means of symptom relief) followed by another diagnostic laparoscopy.
I call this method easy money or “cashectomy,” or, the extraction of cash from the patient without any long-term benefit.
The concept that endometriosis comes back after a proper excision surgery is really just a good excuse for poor treatment. What is called recurrent disease is really persistent disease that was not treated in the first place.
The problem starts at the top. There is very little interest in gynecologic laparoscopic surgery for endometriosis in our universities or our ACOG (American College of Obstetricians and Gynecologists). Few department chairmen do advanced laparoscopic surgery. Because of this, two distinct groups doing laparoscopic surgery have evolved: a huge cluster doing it for diagnosis and minimal treatment and a much smaller elitist segment doing it for optimum treatment instead of open abdominal laparotomy.
RELATED VIDEO: Watch Dr. Harry Reich talk about endometriosis at #PatientDay2018
There is also the rise of robotics. But, I’m not a fan. Laparoscopic surgery is very different than robotic surgery, and, in my opinion, the former is the superior method of treatment. In laparoscopy, there are smaller incisions and a faster recovery for the patient. The robot precludes palpitation, which means that doctors don’t feel the endometrial lesions—something that is super necessary for excising it.
There’s also a poor reimbursement for complex endometriosis surgery despite its increased medicolegal risk. (I was able to afford surgically-treating extensive endometriosis only because I did not participate in our managed care insurance system. I took “private pay,” because it paid out much more than insurance.)
The practicing gynecologist is actually penalized financially for spending too much time in the operating room instead of the office. On average, office patient visits and procedures pay much more than what can be made by operating. Therefore, very few gynecologists want to get stuck with a complex endometriosis surgical case involving the rectum, ureters, and, frequently, small bowel. One may have to do 100 cases just to cover the sky-high malpractice insurance.
@Mdcurcio asks: My daughter has had her period for five years now. She is 15. She is showing signs of endo. Late for her period about 10 days now. We went to local OB-GYN, and we were going to put her on birth control pills. But I am concerned she has a cyst. What do you recommend for her as best treatment? I plan to get her back to OB-GYN, (she did not have an exam). I am so devastated she has to do this journey.
Your daughter has no evidence of endometriosis at this time. Late periods are usually associated with sluggish ovulation, i.e., cycles which are anovulatory, or, without the release of an egg. The birth control pill stops ovulation and thus inhibits ovarian cyst formation. Therefore, they may reduce the discomfort from normal ovulation and normal periods. If endometriosis were there, which I do not suspect, it would stop its progression— a win-win proposition.
@Kasey_22 asks: Is going back on the pill the best way to stop endo from growing back after laparoscopic surgery?
My recommendation after endometriosis surgery is to try to get pregnant. If you're not interested in getting pregnant, going back on the pill is fine. The pill will suppress pain from persistent endometriosis.
Editor’s note: The opinions, beliefs, and viewpoints expressed by Dr. Harry Reich in this column are solely his own and based on his experience.