At the European Congress for Endometriosis in Vienna, where Asociatia Eu si Endometrioza represented our country in November 2018, we had the opportunity to participate in works/papers from worldwide prestigious names in the treatment and analysis of endometriosis.
One of the well-known names is Moamar Al-Jefout, MD, PhD, who spoke about asymptomatic endometriosis.
It is known that about 50% of endometriosis patients don’t have visible symptoms associated with chronic pelvic pain or other symptoms that bring significant changes of physiological functions. Moreover, we already know that the stages of endometriosis don’t relate to the symptomatology. While a patient with an advanced endometriosis stage can have no pain or other symptoms, another patient with first stages may accuse chronic pelvic pain even associated with 9-10 on the V.A.S. scale, as well as other symptoms.
In his paper: “Is subtle endometriosis a disease or a natural phenomenon?”, Prof. Al-Jefout reminds us that the medical world hasn’t yet reached a consensus regarding a clear definition of endometriosis and states that this pathology should have a well-defined mechanism unanimously accepted, which guarantees it. Also, the delay in offering an accurate endometriosis diagnosis is unacceptable in the modern world, declares Prof. Al-Jefout. If we are dealing, in fact, with three distinct diseases, considering the three endometriosis phenotypes that have different origins and, even if there are different surgical approaches to endometriosis, he questions how, in 20 years, there was no clear discovery that could offer an ideal treatment. Moreover, according to M. Hirsh (2018), there is a large variation between the good practice guides and the recommendations of the medical staff about endometriosis. The clinical classification of endometriosis is now based only on the pathology itself, without taking into consideration the symptomatology. Prof. Al-Jefout proposes, rather than a surgical classification of endometriosis, a clinical one.
In his recommendation, endometriosis classification could target:
- Only pain endometriosis
- Pain and infertility endometriosis
- Infertility endometriosis
- Asymptomatic endometriosis.
Although asymptomatic endometriosis is found in 5-25% of cases with laparoscopy made for other reasons than this affection, there is still a big confusion among health services providers in finding the best way of managing the asymptomatic patients.
In a study by Hugh S. Taylor, 2018, asymptomatic endometriosis is defined by the presence of ectopic endometrial lesions without associated pain, infertility, ovarian cysts, bladder, or colon modifications. For asymptomatic endometriosis to be considered a psycho-social phenomenon, it should record a significant spread through the population.
As this is not happening, its approaches are different.
As recommendations regarding the surgical approach to asymptomatic endometriosis, Prof. Al-Jefout mentions the ESHRE references: excision or ablation (with its inherent risks of colon, bladder, ureters, or blood vessels harming) are not recommended. Moreover, considering the lack of chronic pain or infertility, it is difficult to justify the necessity of a performant surgery, and the risks of complications intra and post-surgery (the colon harming, bladder resection anastomosis problems) outweigh any benefit.
In conclusion, the specialists are still researching the best way of managing this patient subgroup. Prof. Moamar Al-Jefout ended his pleading with an appeal to his colleagues in sustaining endometriosis patients, highlighting at the same time the necessity of more detailed research and new studies that target the best management options for the asymptomatic endometriosis patients. Prof. Moamar Al-Jefout is an MD of obstetrics-gynecology in Karak, Jordan, an associated professor at the Department of Obstetrics and Gynecology of Sidney University, Australia, a representative member of WES (World Endometriosis Society), and one of the passionate endometriosis study researchers, having by now numerous specific studies published.
Photo credit: Me and Endometriosis Association (Asociația Eu și Endometrioza)