A 40 year old primiparous woman suspected to be suffering from endometriosis is subjected to diagnostic laparoscopy. Findings indicate - Uterus normal, both the ovaries show presence of chocolate cysts; endometriotic deposits are seen on the round ligament right side, both the fallopian tubes and the pouch of Douglas; moderately dens adhesions are present between the fallopian tubes and the pouch of Douglas. The treatment of choice in this case is :
Ans. is d i.e. Fulguration of endometriotic deposits The situation given in the question is such that it points towards moderate endometriosis (as chocolate cyst, dense adhesions are present). Dense adhesions and cysts cannot be fully treated by medical therapy and so, some form of surgery is required. Main question is whether we would like to go for conservative surgery or Radical surgery (i.e. TAH with BSO). Conservative surgery : The clinical situations involving conservative surgery include ovarian endometrioma, pelvic adhesions, peritoneal implants and deep infiltrative recto vaginal septum disease. In addition laser laparoscopy can be used in order to perform uterine nerve ablation. .. Radical Surgery : Whilst repeated conservative surgery and medical therapy help many women, only some women fail to find pain relief after recurrence, which is the major drawback of conservative surgery. For these women, radical surgery is the only option and involves Hysterectomy with Bilateral salpingo-oophorectomy. According to "Hysterectomy with bilateral oopherectomy should be reserved for women who have completed childbearing and recognise the risk of premature hypoestrogenism including possible osteoporosis and decrease libido." Note : Hysterectomy without BSO is not done in case of endometriosis due to 6 fold increase risk of recurrent chronic pelvic pain and 8 fold risk of repeat surgery.
Total hysterectomy with bilateral salpingooophorectomy
Danazol therapy
Progesterone therapy
Fulguration of endometriotic deposits