Healed Lesions Can Still Cause Pain

OB/GYN News, Dec 15, 1999 by Maureen Donohue

LAS VEGAS -- Healed endometriotic lesions may be a source of chronic pelvic pain in patients with no other apparent cause for their discomfort, said Dr. Samir F. Malek.

Over a 4-year period, 120 patients with unresolved chronic pelvic pain--the majority of whom had at least one healed lesion--underwent wide and complete excision of all suspected endometriotic lesions encountered at laparoscopy. Symptoms were relieved in 94% of cases, reported Dr. Malek, chief of gynecologic laparoscopy at the Lutheran Medical Center in New York.

Because of the high success rate in this series, individuals with chronic pelvic pain should be carefully examined for such lesions, which could be the only cause of their symptoms, he said in a poster session at the annual meeting of the American Association of Gynecologic Laparoscopists.

All lesions found, including healed lesions, should be completely and widely excised to afford the patient the best chance for recovery and should not be discarded as an insignificant finding or perhaps as a negative examination, he recommended.

Pathologic assessment indicated that 115 of the patients (96%) had endometriotic lesions and 5 patients (4%) had no lesions. The majority of patients (79%) had at least one healed lesion.

Twenty-four patients (21%) had only healed endometriotic lesions and 70 (58%) had a combination of healed and active lesions. Active lesions only were found in 21 patients (17%).

Of those who experienced pain relief, 98 patients (83%) reported no pain or markedly improved symptoms within 6 months after surgery, 13 patients (11%) had recurrent pain but experienced complete pain relief after a second laparoscopy was performed, and i patient (0.8%) had some pain after the second laparoscopy

Treatment failed in eight patients (6%). Five of these patients had healed lesions and one had healed and active lesions, Dr. Malek said in an interview.

When they entered the study patients had experienced chronic or cyclic pain of more than 6 months' duration localized in the pelvic area. Healed lesions showed microscopic evidence of healing, such as fibrosis, hypermesotheliosis, inclusion cysts, chronic inflammation, and calcification.

Patients had a mean age of 36 years and a mean parity of 1.75.

The mean number of lesions per patient was three, with a maximum of six lesions. The mean duration of symptoms was 2 years, and the mean number of prior operations was 1.5.

Mean operating time was 120 minutes, mean estimated blood loss was 25 cc, and mean length of stay was 6 hours.

The key to success is complete, wide excision of all lesions and surrounding scarring, without the routine use of electrocautery, Dr. Malek said. The causes of chronic pelvic pain in women are not completely understood.

Previous studies have shown that pain from healed endometriotic lesions may occur as a result of the cascade of spontaneous events induced by the healing process, including increases in the activity of macrophages, interleukin-ib, tumor necrosis factor-a, and autoantibodies.

Dr. Malek's associates in the study were Dr. Nahala Merhi, Dr. Irene Kokossian, and Dr. Haldane Clarke, also of the Lutheran Medical Center.