Clinical Review

Minimal to mild endometriosis: 4 treatment options

OBG Manag. 2004 May;16(5):46-58

Since even limited disease can cause infertility or substantial pain, it should be taken as seriously as severe endometriosis. An expert details diagnosis and the pros and cons of 4 management approaches.

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References

1. Wheeler JM. Epidemiology of endometriosis-associated infertility. J Reprod Med. 1989;34:41-46.

2. Olive DL, Blackwell RE, Copperman AB. Endometriosis and pelvic pain. In: Blackwell RE, Olive DL, eds. Chronic Pelvic Pain. New York: Springer-Verlag; 1998;61-83.

3. Witz CA, Shenken RS. Pathogenesis. In: Speroff L, Adamson GD, eds. Seminar in Reproductive Endocrinology: Endometriosis. Vol. 15. New York: Thieme; 1997;199-200.

4. Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril. 1997;67:817-821.

5. Lupron Depot 3.75 mg (leuprolide acetate for depot suspension). Physician’s Desk Reference. Montvale, NJ: Medical Economics; 1992;2311.-

6. Hornstein MD, Yuzpe AA, Burry KA, Heinrichs LR, Buttram VL, Jr, Orwall ES. Prospective randomized double-blind trial of 3 versus 6 months of nafarelin therapy for endometriosis associated pelvic pain. Fertil Steril. 1995;63:955-962.

7. Adamson GD, Heinrichs WC, Henzl MR, et al. Therapeutic efficacy and bone mineral density (BMD) response during and following a 3-month retreatment of endometriosis with nafarelin (Synarel). Am J Obstet Gynecol. 1997;177:1413-1418.

8. Surrey ES. and the Add-Bac, Consensus Working Group. Add-back therapy and gonadotrophin-releasing hormone agonists in the treatment of patients with endometriosis: can a consensus be reached? Fertil Steril. 1999;71:420-424.

9. Adamson GD, Kwei L, Edgren RA. Pain of endometriosis. Effects of nafarelin and danazol therapy. Int J Fertil. 1994;39:215-217.

10. Sutton CJG, Ewen SP, Whitelaw N, Haines P. Prospective, randomized double-blind controls: trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild and moderate endometriosis. Fertil Steril. 1994;62:969-970.

11. Jones KD, Haines F, Sutton CJG. Long-term follow-up of a controlled trial of laser laparoscopy for pelvic pain. JSLS. 2002;5:111-115.

12. Walters MD. Definitive surgery. In: Schenken RS, ed. Endometriosis: Contemporary Concepts in Clinical Management. Philadelphia: JB Lippincott; 1989;267-278.

13. Marcoux S, Maheux R, Berube S, et al. Laparoscopic surgery in infertile women with minimal or mild endometriosis. N Engl J Med. 1997;337:217-222.

14. Adamson GD, Hurd SJ, Pasta DJ, Rodriguez BD. Laparoscopic endometriosis treatment: is it better? Fertil Steril. 1993;59(1):35-44.

15. Adamson GD, Pasta DJ. Surgical treatment of endometriosis associated infertility: meta-analysis compared with survival analysis. Am J Obstet Gynecol. 1994;171:1488-1505.

16. Society for Assisted Reproductive Technology and the American Society for Reproductive Medicine. Assisted reproductive technology in the United States: 1999 results generated from the American Society for Reproductive Medicine/Society for Assisted Reproductive Technology Registry. Fertil Steril. 2002;78:918-931.

17. Kim AH, Adamson GD. Does therapy for minimal/mild endometriosis enhance conception? Inf Reprod Med Clin North Am. 1997;8:632-637.

18. Adamson GD. Laparoscopic treatment of endometriosis. In: Adamson GD, Martin DC, eds. Endoscopic Management of Gynecologic Disease. Philadelphia: Lippincott-Raven; 1995;147-148.

19. Adamson GD. A 36-year-old woman with endometriosis, pelvic pain and infertility. JAMA. 1999;282:2347-2354.

20. Adamson GD, Kwei L, Edgren RA. Pain of endometriosis: effects of nafarelin and danazol therapy. Int J Fertil. 1994;39:215-217.

KEY POINTS

Signs of minimal or mild endometriosis include tenderness or nodularity in the posterior cul-de-sac, especially at the uterosacral ligaments, and anterior cul-de-sac nodularity.
Endometriosis can be associated with infertility at all stages of disease.
Indications for laparoscopy include infertility of more than 1 year without other symptoms or after 6 months if the patient has other symptoms or is more than 35 years of age. Patients with pelvic pain that has not responded after 3 months of nonsteroidal anti-inflammatory drugs and/or oral contraceptives also are candidates.
Following adequate surgical extirpation of disease, no further postoperative medical treatment is necessary for patients with either pain or infertility. However, oral contraceptives have benefits for many patients who are not attempting to conceive.

A 30-year-old woman complains of dysmenorrhea and severe dyspareunia and reports a lingering ache after coitus.When the pain began several months earlier, she was given a presumptive diagnosis of endometriosis and advised to take nonsteroidal anti-inflammatory drugs (NSAIDs). Although the drugs provided relief initially,they are no longer effective.An examination reveals tenderness in the posterior culde-sac.The patient asks about the advisability of surgical treatment to eliminate the pain once and for all.

This case represents 1 of the challenges of treating minimal to mild endometriosis—disease without adhesions, invasive lesions, or endometriomas. Endometriosis is suggested in this patient by tenderness or nodularity in the posterior cul-de-sac, especially at the uterosacral ligaments, and anterior cul-de-sac nodularity. The patient’s complaint of pain does not necessarily indicate severe disease. Rather, the relationship between minimal or mild disease and symptoms is unclear. The patient may report significant pain when only superficial implants and minimal adhesions are present.

Although hysterectomy is the definitive treatment for patients with recurrent or intractable pain associated with endometriosis, I make every effort to avoid this operation in young women with minimal to mild disease. This article describes 4 other options—no treatment, ovarian suppression, surgical treatment, and combined treatment—and points out potential pitfalls associated with each approach.

Diagnosis

The diagnosis of endometriosis often can be difficult, and the extent of disease is thought to be underestimated in as many as 50% of patients.^1-3

Clinical presentation. Endometriosis presents as pelvic pain in about 50% of patients, infertility in about 25%, pain and infertility in about 25%, and as ovarian endometrioma in less than 5% of cases.^1-3 Asymptomatic disease is frequent: from 1% to 40%.^1-3 The disease may occur any time after puberty, including adolescence. For other symptoms and characteristics, see “Endometriosis: A snapshot”.

Physical examination. Pelvic examination should be performed at the time of menses, when disease is more easily identified. The location of tenderness often corresponds to the location of the pain. As in the example case, signs of minimal or mild disease include:

tenderness or nodularity in the posterior culde-sac, especially at the uterosacral ligaments
anterior cul-de-sac nodularity

Diagnostic tests. The only definitive test for pelvic endometriosis is diagnostic laparoscopy. Biopsy of lesions is sometimes necessary and always advisable to confirm the diagnosis. Ultrasonography and cancer antigen 125 levels are not helpful in the diagnosis of minimal or mild disease except to rule in more severe disease.

Indications for laparoscopy include infertility of more than 1 year without other symptoms or after 6 months if the patient has other symptoms or is more than 35 years of age. Evaluation for other female factors and sperm quality should be conducted prior to laparoscopy. Patients with pelvic pain that has not responded after 3 months of NSAIDs and/or oral contraceptives (OCs) also are candidates for laparoscopy. In the case described above, I would recommend at least a 3-month trial of OCs and NSAIDs before performing laparoscopy.

Staging the disease. The American Society for Reproductive Medicine has developed a staging system with scores from 1 to 150. Minimal and mild disease ranges from 1 to 15.⁴

Management options. Depending on the woman’s reproductive goals, 1 of the 4 options discussed below may be recommended.

Endometriosis: A snapshot

Prevalence. Endometriosis affects about 7% of reproductive-aged women—approximately 5 million Americans. Most of these women are unaware that they have the disease, although many may suffer symptoms ranging from pelvic pain to infertility.

Symptoms. Endometriosis is suggested by a variety of symptoms, including dysmenorrhea, dyspareunia (especially with aching following coitus, as in the case described at the opening of this article), dyschezia, dysuria, mittelschmerz, or focal or generalized pelvic pain. Hematuria and hematochezia also may be present. About 30% of patients with endometriosis have no pain.¹

Diagnostic challenges. Deeply invasive endometriosis that is overlooked or develops outside the posterior cul-de-sac can be inappropriately staged as minimal or mild disease.

Causes of pain. Pain symptoms often do not correlate well with disease severity. Pain may be due to secretion of irritating factors (eg, histamine), adhesions that cause scarring or retraction, immunologic reactivity, or other unknown entities.

Infertility can occur at any stage. Not surprisingly, patients who have severe or extensive disease have a poorer prognosis than those with minimal or mild disease.

Endometriosis is a progressive disease, but the rate of progression and nature of lesions vary from patient to patient. Adhesions develop due to the inflammatory process caused by longstanding endometriosis, becoming more extensive and dense over time. Complete cul-de-sac obliteration can result from longstanding invasive and adhesive disease or may stem from abnormal mullerian development.