Endometriosis, Helica

Endometriosis is one of the most common causes of pelvic pain. This has an enormous effect on women’s lives. Many women will be told that painful periods are common and so do not seek medical advice. It has been estimated by the Endometriosis Society that it takes 7 years for a woman to be diagnosed with endometriosis. 

What is endometriosis?

Endometriosis is when the endometrium (lining layer of tissue in the uterus) is in the wrong place. There have been many theories as to the cause of endometriosis. The most widely held theory is that endometrial tissue enters the pelvis via the fallopian tubes during a period and then ‘implants’ on the surface layer of the pelvic tissues. This supplies the endometriosis with blood, delivering hormones which stimulate the endometriosis to behave as it does in the uterus, i.e. it mimics the menstrual cycle with internal ‘bleeding’ at the time of menstruation. The result is inflammation causing pelvic pain and tissue damage.

Symptoms and signs

The main symptoms of endometriosis are pelvic pain, particularly related to periods, pain at intercourse, sub-fertility and abnormal uterine bleeding.

Although pelvic pain is said to occur prior to the onset of a period, it is usually very variable in its nature, severity, duration and time of onset. Pain due to endometriosis is not always related to the menstrual cycle and should be considered as a possible cause by any young woman with significant pelvic pain. Painful intercourse is a major problem and many women feel unable to have intercourse by the time they seek medical help. Periods are said to be heavier than normal and the monthly cycle shorter, although many different abnormal bleeding patterns are reported. Endometriosis sufferers may not experience severe pain but the diagnosis is made during investigations for sub-fertility. Fertility is often an issue for endometriosis patients, particularly if the disease is advanced.

Diagnosis

If endometriosis is suspected after taking a thorough medical history and performing an appropriate medical examination then a laparoscopy should be advised. A laparoscopy is a procedure performed under general anaesthesia. A small incision is made in the navel and a needle inserted into the abdominal cavity to introduce carbon dioxide gas. The needle is then withdrawn and a telescope inserted to visualise the pelvic organs and endometriosis is diagnosed if there are any features of the disease visible.

Treatment

When endometriosis is diagnosed there are two main approaches to treatment: hormonal treatment or ablation of the endometriosis with the aid of surgery.

Hormonal treatment is designed to stop production of natural hormones so that the endometriosis is not stimulated and the tissue undergoes regression (the endometriosis cells ‘shrink’ and many undergo natural cell death). The most effective method of hormone treatment is by administration of a GnRH analogue drug, which blocks the signals from the brain, which stimulate the ovaries to produce hormones. This causes the woman to develop menopausal symptoms, which include irreversible osteoporosis if the treatment is prolonged. In order to reduce these side effects, HRT (Hormone Replacement Therapy) is prescribed. The levels of hormones in the system from HRT are not enough to stimulate the endometriosis but are effective in relieving symptoms of the menopause. The usual duration of GnRH therapy is six months.

At the time of diagnosis of endometriosis at laparoscopy, it is feasible, provided the patient has given informed consent, to treat endometriosis by ablation. This involves applying an energy source to the areas affected by endometriosis to destroy the abnormal tissue. There are different sources of energy that can be used. HELICA is a low-power energy source, which utilises a beam of helium gas to direct a small ‘flame’ on to the tissues. The advantage of HELICA is that depth of penetration beneath the surface is only 0.2mm, which means that injury to deeper tissues e.g. the bowel or bladder is extremely unlikely and larger areas can be treated more safely.

When there is deep infiltrative disease then excision (cutting out) of the endometriosis may be necessary. Laparoscopic surgery in this situation requires a high level of expertise and carries a significant risk of major complications, particularly bowel injury.

The methods of treatment described above are not curative and repeated treatment is usually necessary. In very severe cases, or when the patient wishes a permanent solution to the problem, curative treatment involves removing the uterus and ovaries. Surgery for advanced endometriosis is often challenging and carries a higher risk of complications. The advantages of surgery with the Da Vinci robot are particularly relevant when considering hysterectomy and oophorectomy (removal of the ovaries) for advanced endometriosis.