Long-term hormonal therapy is prescribed as first line. But if the fertility of the patient is threatened, surgery is considered.
“Above all, it is necessary to take care of the painful rules, sometimes even before referring to the diagnosis of endometriosis, recalls Prof. Raffaèle Fauvet (University Hospital of Caen). Anyway, you are prescribed an analgesic and, if that is not enough, a contraceptive that will act on a possible endometriosis “. Taken continuously, the latter will indeed act on endometriosis pain by stabilizing the hormonal cycle to prevent the onset of menstruation. Like the endometrium of the uterus, distant endometriotic lesions are no longer subject to the hormonal cycle and regress with their symptoms.
Most often, the doctor prescribes a hormonal treatment that must be adjusted to the patient, its lifestyle and its pain. This treatment should indeed be taken in the long run: the lesions resume their evolution if it is interrupted. “This is a slow evolution, however, recalls Professor Canis (CHU Clermont-Ferrand). Few data suggest that the disease is getting worse all the time, while many data say that it is stable after diagnosis. “
Surgery to protect fertility
Hormonal therapy can also be applied before a surgical solution, to “calm” the lesions and facilitate the procedure. In fact, at present, surgery is very rarely considered first-line and almost always for deep lesions that call into question the immediate fertility of a patient.
“If we spot an ovarian cyst in a 23-year-old patient, we will put in place a treatment against pain and monitoring to not operate immediately,” said Professor Charles Chapron (Cochin hospital, Paris). Thus, we can plan a single intervention closer to the parental project, by preventing the disease from reappearing – since it occurs with the rules – and being forced to intervene again “.
If the patient discovers her endometriosis when she wants to start a pregnancy, the location of the lesions can guide therapeutic choices to restore fertility: surgery or in vitro fertilization. Indeed, if surgery gives spectacular results – more than 60% of spontaneous pregnancies in the year following the intervention -, it is sometimes heavy to bear. If a portion of the intestine must be removed, sometimes requiring even a colostomy, the patient must be able to choose whether she prefers to submit to the consequences of this intervention – even temporary – or to follow a course of in vitro fertilization first.
In this case, multidisciplinary teams in expert centers could provide a favorable environment for the comprehensive, efficient and informed management of patients. A study carried out in 2016 also established that the majority of patients who have undergone major surgery in connection with endometriosis are already referred to experienced services in this area.
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Endometriosis and infertility: a well-established link
Endometriosis does not always cause infertility but it is found almost in one of two cases of infertility. The lesions are sometimes directly responsible for the infertility: they can form cysts able to obstruct the tubes or to prevent the normal activity of the ovaries. It is more difficult to explain how an endometriotic lesion located in the rectum can have an influence on the genitals.
“The presence of endometrial cells causes an inflammatory reaction throughout the abdominal cavity,” says Professor Charles Chapron, head of the gynecology department at the Cochin hospital in Paris. This inflammation disrupts the composition of the peritoneal fluid in which ovulation and fertilization occur. “In this case, endometriosis is indirectly responsible for infertility, which can be restored by suppressing the origin of the inflammation. which explains the success of surgical procedures for this indication.