|May 2004 · Vol. 16, No. 5
Minimal to mild endometriosis: 4 treatment options
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.
Dr. Adamson is director, Fertility Physicians of Northern California, Palo Alto and San Jose, Calif. He also is clinical professor, gynecology and obstetrics, Stanford University School of Medicine, and associate clinical professor, obstetrics and gynecology and reproductive medicine, University of California, San Francisco.
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.