In an effort to increase awareness of and proper treatment for GYN conditions, we’re shining a spotlight on an underdiagnosed GYN condition: the coexistence of endometriosis and fibroids. While researchers estimate that about 10-15% of women of childbearing age, and 70% of women with chronic pelvic pain have endometriosis, it remains one of the most difficult conditions for doctors to diagnose.1
Symptoms can vary from person to person, and some women may have no symptoms at all. For others, endometriosis can be debilitating and have a significant impact on quality of life. Symptoms of endometriosis can range from painful periods to back pain, pain during sex, heavy bleeding, nausea and infertility. One of the reasons endometriosis is so difficult to diagnose is because these symptoms are shared with many other conditions, including fibroids.
There is also no definitive way to diagnose endometriosis other than during laparoscopic surgery. To date, there are no blood tests or “biomarkers” that can detect endometriosis, and the condition is often not seen on ultrasounds or MRIs. But imaging can detect fibroids. This often leads to the conclusion that painful symptoms are due solely to fibroids, a condition that can be treated surgically through a laparoscopic or abdominal myomectomy or hysterectomy. Unfortunately, failure to detect and treat coexisting endometriosis during a myomectomy or hysterectomy often results in continued pain, infertility and eventual reoperation.
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The coexistence rate of fibroids and endometriosis is not well understood. Previous literature reports the existence of endometriosis during laparoscopic myomectomy is between 12% and 26%.2-4 But our surgeons at CIGC found endometriosis in nearly 50% of patients undergoing laparoscopic myomectomy for symptomatic fibroids.
When fibroids are suspected, most OBGYNs perform an abdominal myomectomy, which involves a 6-inch incision. While this surgery provides easier access to the pelvic area, it is an invasive approach requiring a long recovery time. With this procedure, surgeons may not be able to completely visualize smaller endometriosis lesions with the naked eye, especially when they are in difficult to reach locations, such as an area tucked behind the uterus known as the cul-de-sac.5 This often results in endometriosis being overlooked.
For fertility patients with symptomatic fibroids, the GYN surgical specialists at CIGC use an innovative and minimally invasive approach known as Laparoscopic Assisted Abdominal Myomectomy (LAAM). During this procedure, our surgeons conduct a comprehensive and methodical review of the abdomen and pelvis for any coexisting endometriosis. The camera typically used during laparoscopic procedures provides a magnified view of potential endometriosis lesions. All suspected endometriosis is surgically removed (excised) and biopsied, as it has been well established that superficial burning techniques (such as ablation) can leave underlying disease behind and do not allow for a definitive diagnosis of coexistent fibroids and endometriosis.
If existing endometriosis is not removed at the same time fibroids are removed, patients may still have symptoms. This is especially important for patients who are trying to get pregnant. Fibroids are rarely the only cause of infertility, and some studies suggest that up to half of unexplained infertility could be attributed to endometriosis.3,6 Failing to remove coexisting endometriosis likely leads to ineffective treatment of infertility — including potentially wasted time and money on IVF treatments — and eventual painful and costly reoperation.
For patients who opt for a hysterectomy as a definitive fibroid cure, failing to treat endometriosis during the same surgery may also fail to alleviate painful symptoms. Endometriosis occurs outside the uterus, so removal of the uterus alone will not fully treat the condition. A total hysterectomy with removal of the ovaries may be successful in cutting off future endometriosis growth due to decreased estrogen production, but if existing endometriosis lesions are left even after the uterus is removed, symptoms will likely continue. Any existing lesions on other organs like the bladder or bowel need to be excised for the best chance of long-term relief.
Even when the main purpose of surgery is to remove fibroids, the GYN surgical specialists at CIGC are highly skilled in recognizing and removing endometriosis during the same procedure. It’s routine for them to inspect the entire pelvis during a hysterectomy or myomectomy and effectively excise any endometriosis that is present at the time. Using innovative laparoscopic techniques that involve only a few small incisions, low complication rates and virtually invisible scarring, our patients can have outpatient surgery at a freestanding surgery center and go home the same day to start their recovery.
No matter what your ultimate goals are — symptom relief, fertility or both — CIGC’s specialists can help you reach them.
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CIGC is dedicated to providing resources and materials for women to better understand the symptoms and best treatment options for gynecological conditions that frequently coexist, like fibroids, endometriosis and adenomyosis. The CIGC founders, minimally invasive GYN surgical specialists Paul MacKoul, MD, and Natalya Danilyants, MD, developed their advanced GYN surgical techniques using only a few incisions with patients’ well-being in mind.
Their personalized approach to care helps patients gain a better understanding of their condition and the recommended treatment so they can have confidence from the very start. Our specialists have performed more than 25,000 minimally invasive GYN procedures, and women come from all over the world to receive their expert care.
References:
1. Carter JE. Combined hysteroscopic and laparoscopic findings in patients with chronic pelvic pain. J Am Assoc Gynecol Laparosc. 1994;2(1):43-47. doi:10.1016/s1074-3804(05)80830-8
2. Isono W, Wada-Hiraike O, Osuga Y, Yano T, Taketani Y. Diameter of dominant leiomyoma is a possible determinant to predict coexistent endometriosis. Eur J Obstet Gynecol Reprod Biol. 2012;162(1):87-90. doi:10.1016/j.ejogrb.2012.01.018
3. Maclaran K, Agarwal N, Odejinmi F. Co-existence of uterine myomas and endometriosis in women undergoing laparoscopic myomectomy: risk factors and surgical implications. J Minim Invasive Gynecol. 2014;21(6):1086-1090. doi:10.1016/j.jmig.2014.05.013
4. Nicolaus K, Bräuer D, Sczesny R, Lehmann T, Diebolder H, Runnebaum IB. Unexpected coexistent endometriosis in women with symptomatic uterine leiomyomas is independently associated with infertility, nulliparity and minor myoma size. Arch Gynecol Obstet. 2019;300(1):103-108. doi:10.1007/s00404-019-05153-5
5. Walter AJ, Hentz JG, Magtibay PM, Cornella JL, Magrina JF. Endometriosis: correlation between histologic and visual findings at laparoscopy. Am J Obstet Gynecol. 2001;184(7):1407-1413. doi:10.1067/mob.2001.115747
6. Nezhat C, Li A, Abed S, et al. Strong Association Between Endometriosis and Symptomatic Leiomyomas. JSLS. 2016;20(3):e2016.00053. doi:10.4293/JSLS.2016.00053
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