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Comment and Controversy

Additional tips for surgical resection of endometriosis … and more

January 2012 · Vol. 24, No. 1

Strategies and steps for the surgical management of endometriosis

Additional tips for surgical resection of endometriosis

The article on surgical management of endometriosis was informative. May I add several suggestions?

First, infiltration of the broad ligament with 5 to 20 cc of a dilute solution of 20 mg of vasopressin in 200 mL of injectable saline minimizes the need for electrocautery.

Second, CO2 laser ablation is effective when it is performed properly. By drilling a defect in the broad ligament, inserting the irrigator, and backfilling the retroperitoneum, you can separate the disease from the underlying structures. The laser can then be used aggressively in scoring and resection or in full-thickness ablation. The result is the same: complete, full-thickness removal of visible disease.

Third, I find hydrodissection helpful in separating an endometrioma from the ovarian stroma. I almost never close the ovary. If sutures are needed for hemostasis, they are involuted to prevent exposure to the ovarian capsule.

Last, I aggressively “suppress” patients postoperatively using norethindrone 5 mg daily unless conception is desired.

Peter M. Dayton, MD
Stuart, Fla

Dr. Anthony A. Luciano responds Suggestions are appreciated

I very much appreciate Dr. Dayton’s interest in our article and his suggestions regarding the surgical management of endometriosis.

Although I would support his use of CO2 laser ablation if it is effective in his hands, I no longer utilize it, and I find that irrigation of the retroperitoneal space distorts anatomy and makes dissection more difficult.

Nor do I use hydrodissection, although I can see how and why it may help develop better planes of dissection when the cyst capsule separates easily from the underlying stroma. The problem is that, with most endometriomas, the cyst wall is so adherent to the underlying stroma that hydrodissection may be ineffective. Another approach is to inject a diluted solution of vasopressin into the space under the cyst wall using a spina needle, as this will also highlight the dissection plane and the separation.

Like Dr. Dayton, I seldom close the ovary. When I do close the ovary, I bury the knots and the suture under the cortex to minimize the formation of postoperative adhesions.

I am happy that Dr. Dayton suppresses his patients’ ovulation postoperatively. I only wish that all gynecologists were as aggressive. As my coauthors and I pointed out in our article, postoperative suppression with norethindrone acetate, continuous hormonal contraception, or a levonorgestrel intrauterine device is an essential component of long-term management of endometriosis.

Insomnia is a troubling and under-treated problem”

Trazodone may be a cheaper alternative for insomnia

I enjoyed the timely article on insomnia. I have had some success with trazodone 50 mg at bedtime.* Although it is not always effective, it is a less expensive alternative to gabapentin (Neurontin) and eszopiclone (Lunesta).

John Lewis, MD
Waterbury, Conn

*An off-label use.

Micronized progesterone may help with insomnia

For my perimenopausal patients who have insomnia, I’ve had good luck prescribing micronized progesterone (100–200 mg at bedtime).* Not only does it help with sleep, it provides protection against unopposed estrogen in overweight patients and those on hormone therapy (HT). My usual HT regimen is 1 mg oral estradiol (because it is so inexpensive) with micronized progesterone (not so cheap but very effective).

Nancy Miller, MD
Clearwater, Fla

*An off-label use.

Dr. Barbieri responds Trazodone and micronized progesterone are clinically useful

I thank Dr. Lewis and Dr. Miller for their great suggestions about the use of trazodone and micronized progesterone to treat insomnia in women at midlife. In my practice, I have seen many women treated with trazodone to help with insomnia, and they are generally very pleased with the result. When trazodone is used to treat insomnia at a dose of 50 mg administered 30 minutes before bedtime, some women may experience slightly reduced short-term memory, verbal learning, and body equilibrium during the daytime.1

I agree with Dr. Miller that micronized progesterone (100–200 mg before bedtime) is clinically useful in managing insomnia in perimenopausal and menopausal women. There is surprisingly little experimental literature on the value of micronized progesterone for managing insomnia in perimenopausal women.

Trazodone is a low-cost medication (approximately 40 cents per 50-mg tablet). Micronized progesterone is more expensive, approximately $2.30 per 100-mg capsule (pricing from

What is the prevalence of cervical cytologic abnormalities and high-risk HPV in the screened population?

Commentator misstated position of ASCCP

As chairman of the Practice Committee of the American Society for Colposcopy and Cervical Pathology (ASCCP), I would like to clarify some misstatements that were included in Dr. Kupets’ commentary.

First, she stated that the latest guidelines from ASCCP recommend both cytology and testing for human papillomavirus (HPV) “to determine the optimal interval between screening tests and for triage to colposcopy.” She cited an interim guidance document. In fact, ASCCP does not recommend any screening modality. ASCCP has developed guidelines for management of abnormal screening tests,1 but it relies on other organizations, such as ACOG, the American Cancer Society, and the US Preventive Services Task Force to guide clinicians on screening intervals and methods. We recognize that co-testing with a Pap test and a validated HPV DNA test is a viable option, but Pap testing alone using conventional or liquid-based methods remains acceptable.

Second, Dr. Kupets argues that, among issues in cervical cancer screening that “need to be resolved,” is the follow-up protocol for women who test positive for HPV 16 or 18. In fact, ASCCP published guidance on that issue in its 2007 Consensus Guidelines: Such women merit immediate colposcopy, whereas women who test positive for high-risk HPV DNA but who are HPV 16/18 negative should have a Pap and HPV DNA test in 1 year, with colposcopy if either is positive.1

L. Stewart Massad, Jr, MD
Professor of Obstetrics and Gynecology
Division of Gynecologic Oncology
Washington University School of Medicine
St. Louis, Mo

Noninvasive test identifies more than 98% of Down syndrome cases

Even a low false-positive rate for Trisomy 21 is too high

I would like to see the MaterniT21 Down syndrome assay undergo rigorous screening in the low-risk population before I use it. I also have reservations about the fact that other tests continue to be needed to provide information on Trisomy 18 and open neural tube defects.

As long as there is a false-positive rate with the new test—however small—there is concern that a normal pregnancy might be terminated.

Tirun Gopal, MD
Allentown, Pa

End of Down syndrome would be a sad affair

I have never met a child with Down syndrome I did not like. I have never met a child with Down syndrome who didn’t like everyone he or she met. It is no wonder that, in classical literature, children who have Down syndrome are referred to as the Clowns of God, a term of endearment, due to their genuine affection, joy, and love for others, and their desire to please. It is with unbelievable sadness that I continue to see our specialty society on a search-and-destroy mission for these most innocent of children.

Allan T. Sawyer, MD, MS
Glendale, Ariz

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