Dr. Duncan Turner: "We're here today at the 10th Annual ISGE meeting in Chicago. I'm a Clinical Advisor for OBGYN.net, and I have the privilege today of talking to one of the real pioneers of laparoscopic surgery, Dr. Harry Reich. The subject today is going to be endometriosis and Harry is well versed in this problem and has led the way in terms of treatment. It's changed very significantly over the last few years in terms of our ability to diagnose and treat these patients and a lot of this is thanks to Harry. I'm going to give the mike to Harry and see what he has to say about endometriosis."
Dr. Harry Reich: "Thank you, Duncan. I'm Harry Reich, I'm also a Clinical Advisor to OBGYN.net and presently I work in New York City at St. Vincent's Hospital and also in Pennsylvania at both Nesbitt Hospital in Kingston, Pennsylvania and CMC in Scranton, Pennsylvania."
Dr. Duncan Turner: "Harry, we used to think that endometriosis was a disease of thirty and forty year old women. I think we've discovered recently that that's not accurate, that it appears much earlier in a lot of patients' lives. Would you comment on that?"
Dr. Harry Reich: "It's my belief that endometriosis is actually present before birth. I believe that cells very similar to the cells that are inside the uterus actually don't quite make it to the inside of the uterus. They get close; they get to the area of the cul-de-sac especially posteriorly, around the rectum, the top of the vagina, and the back of the cervix in the ligaments that support the uterus. Now this disease doesn't then become manifested until the patient starts to have menstrual periods. At that time it's almost as if the patient were to cut her finger at the same time every month and a chronic inflammatory response occurs. With time that chronic inflammatory response stimulates fibrosis in fibromuscular tissue around it and that's the endometriosis that we see and that's the endometriosis that we could palpate on a physical exam. Now in some people this reaction occurs quite quickly and it could be in their late teens when we'll see the patient with this problem but in most women our patients present with symptoms in their late twenties to early forties and the symptoms become increasingly bad with subsequent periods."
Dr. Duncan Turner: "What about the treatment of endometriosis now? First of all, the diagnosis can't be made except by visual inspection and biopsy because there's no non-invasive method, although we can be very suspicious on examination but once you make that diagnosis how do you believe it should be treated?"
Dr. Harry Reich: "With the type of patients I see, in most cases I can make the diagnosis without the usual examination. I could make it on a simple rectovaginal examination in the office. What I do is I put my finger behind the cervix, I elevate the cervix, then with my rectal finger I can usually feel the back of the cervix, the top of the vagina, and the ligaments that hold the cervix in place, and that's how I diagnose most of my cases. In some situations where the patient's having severe pain, I may have a normal exam. I would think that would be about 25% of cases and those cases I would laparoscope and what I would see that would be suspicious for endometriosis I would remove. The only way we'd know it's endometriosis is by removing it and taking a look at it under the microscope in the pathology lab, otherwise, what we think may be endometriosis often time is products of the last menstrual period from retrograde menstruation. So if we were to biopsy that type of an area, we would get back hemosiderin-laden macrophages as the diagnosis without endometriosis glands. Those people don't have endometriosis and the body in most cases will resorb that process of what the doctor sees and treats as endometriosis without a firm biopsy to prove it."
Dr. Duncan Turner: "There's been a lot of money spent and a lot of time put into the medical treatment in hormonal therapy for endometriosis. Do you feel that that is of any benefit or can cure endometriosis at anytime?"
Dr. Harry Reich: "Another favorite topic - I believe that endometriosis isn't cured at all by medical treatment. I'm not sure that it has any effect on the endometriosis other than preventing the chronic inflammatory response that happens with periods in a woman who's on no suppressive therapy. Actually, most medical treatments stops periods and it also stops the endometriosis from becoming inflamed every month. But as we well know, as soon as the medical treatment is stopped the periods resume and the endometriosis glands and stroma are still present and will in a very short period of time cause symptoms once again. Hopefully in the future we'll be able to develop some type of compounds that could actually treat the endometriosis glands and stroma to make it necrose away but we're far from that at the present time."
Dr. Duncan Turner: "If we go and think of surgery as being the only definitive way to treat endometriosis, even within that there's some controversy as to what sort of surgery - whether vaporization, fulguration with electrocautery, or excision is appropriate. What do you think about each of those methods?"
Dr. Harry Reich: "We all know that endometriosis treated by laser ablation usually just gets the tip of the iceberg unless the surgeon is adept at using the laser to undercut the lesion and remove it totally so in my own practice I remove it using scissors without electricity. I use scissors, I pick up the lesion, and I use scissors to cross underneath the lesion. I then tent up the lesion and continue using scissors to remove it because endometriosis does not have a definitive blood supply, it has a blood supply from what we call neovascularization - new vessel formation. When we cut across it with scissors the bleeding that occurs usually will stop spontaneously. After removing the major pieces of endometriosis, I then try to identify what hasn't stopped bleeding with microbipolar forceps. For that technique, I use fluid through microbipolar forceps to identify the exact bleeder and coagulate just there so I would have much less thermo effect. Can I excise all the endometriosis - probably not. There certainly are microscopic components adjacent to the areas where I've excised, and I believe that given time those could become symptomatic again. Since most patients we operate on are in their thirties, most of the time they've had this lesion developing from a microscopic stage to a symptomatic stage over a twenty year period of time. Most of these people will not need future surgery if the endometriosis is excised well down to the point where you can't see it anymore."
Dr. Duncan Turner: "Traditionally and ultimately, in very bad cases, hysterectomies have been recommended to patients but isn't it true to say that a hysterectomy may not cure their endometriosis or even sometimes if the ovaries are removed?"
Dr. Harry Reich: "Hysterectomy doesn't cure endometriosis. The major problem in the United States and many other countries is that when hysterectomy is done for endometriosis a surgeon avoids the endometriosis with a false belief that taking out the ovaries will cause the disease to go away, just like putting them on long-term medical treatment. The truth of the matter is, that just doesn't make sense. If you have endometriosis lesions, they should be excised. If the patient's still having pain or if the patient has evidence of endometriosis in the muscle or the uterus, which we call adenomyosis, then the uterus in women past childbearing age or not desiring children should be removed but not a normal ovary. You remove the disease to preserve the normal structures but, again, we can't tell if there's endometriosis in the body of the uterus unless we remove it and the pathologist searches for adenomyosis of the muscle in the uterus."
Dr. Duncan Turner: "I've been surprised when operating on patients with fibroids to find endometriosis there as well and at a greater extent than I had ever read in the literature. I believe that people generally don't have pain from fibroids unless they're undergoing some degeneration. Are the patients that have fibroids and have pain quite likely to have endometriosis?"
Dr. Harry Reich: "Definitely, that's been something I've seen over the years also. If a patient complains that the fibroid is causing pain and not bleeding and you're doing surgery, almost always you'll find endometriosis as the cause of the pain, not the fibroids. Fibroids cause heavy bleeding but pain rarely from degeneration, it's possible but we rarely see it especially if it's cyclic and it keeps coming back every month."
Dr. Duncan Turner: "One last question, what about the concerns of development of malignancy within implants of endometriosis that are untreated?"
Dr. Harry Reich: "I've seen one case and that was back when I started practice in 1976. I operated on a patient who was over sixty years old, had a mass in the pelvis, and had a history of having had a hysterectomy with bilateral salpingo-oophorectomy. In that one case we almost did a hysterectomy operation; when we examined the specimen we could see endometriosis and a focus of cancer coming from the endometriosis. Now that was 1976, I haven't seen another case since so I think it must be a very, very rare phenomena."
Dr. Duncan Turner: "Thanks very much. I'd like to thank Dr. Reich for clearing the way and clearing the ideas in a logical and clinically important manner that will enable us to help our patients more. Thanks."
Dr. Harry Reich: "Thank you."
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