International Medical Conference Endometriosis 2025:
Endometriosis 2025: Your Mother Should Know, Your Doctor Should Know Better!
Development of Endometriosis - Dan Martin, MD
So we're going to talk about how endometriosis develops in between ages of eight and 65. This is generally a slow development except for ovarian endometriomas, which can grow up almost overnight. Most peritoneal and infiltrating endometriosis is a very slow developing disease that may take anywhere from three to 20 years to develop if it's progressive with dysmenorrhea, if it starts with dysmenorrhea and progresses, it usually goes from cyclic pain to chronic pain can be almost intense and just every day it can be associated with infertility without having pain. In fact, I've had infertility patients who did not have pain, did not have PMS, never even knew when their period started. So it's a very hold microphone. Little bit this way. Yeah. Is that better? We like that. Okay.
And much of it stabilizers or even regresses. If we look at that, Hans Evers did his study where he had seven different studies that these were all prospective studies with control groups. The control groups were untreated, so these are the untreated control groups. In seven different studies, there was more regression and stability than was progression. If we look at this and if we look at the control groups and polo TUI studies, we see that the majority of patients there it is who had deep dyspareunia bowel pain or non menstrual pain. The majority of patients after surgery had no recurrence of their pain.
Surgery was better than no surgery, but if all they did was just do a laparoscopy, the majority of those three did never return to baseline. This has been seen, and so if it's progressive, this has been seen in other studies. If we look at progressive, if we look at those in progression, we think that the natural progression is there's implantation and that may happen in most women develops clear blisters, red, red polyps. It scars with old trap blood and then we get deep infiltration. If we look at some examples, if we look at those, if you look in here, you can see that there's just multiple little bitty clear lesions, lots of small clear lesions, a little red lesion there, and these are quite small. The little red lesion is about 400 microns. The clear lesions about 200. The red lesion has glands and stroma.
The clear lesions had glands only. We didn't have CD tens at the time. These studies were done, so there may be CD 10 positive in there, but we couldn't see any stromal cells. But the problem with looking at these is that these can be similar to Sonoma bodies and osis, mesothelial and proliferation, inclusions, lymphoid, aggregates, granulomas, and a bunch of other diseases. We look at peritoneal lesions like these. We don't know for sure what we've got until the pathologist tells us pathology on those. For polypoid lesions, they can just be little red lesions like this in the corner that are hypervascular. These will always have glands and stroma, and it's just a different appearance. So we have to be ready for all of those and anticipate that any of those can have different characteristics and they each have to be studied and understood by the time we get to.
This is type one powder burn. These are the ones that are the dark scarred powder burns. They have old blood trapped inside of scar. There's glands, str everything in that one. There's a little bit of everything there, and if you notice it, that is a superficial peritoneal lesion that is not deep. That's only about two to three millimeters. The ureter is sitting right behind it. There's the ureter right there. To get rid of these, it's not very hard. All you do is make an incision up here, relax the peritoneum, push it away from the ureter so you don't even meet the ureter and then amputate it. They're easy to remove. It's easy to teach people to do that. All of this starts very early in age. Mary Lou Baldwick, one of her early studies showed that the earliest things were beginning between ages 15 and 25.
More recent data from Philippe, Conex and Germany and Belgium showed that although we have an average age of around in the thirties when it presents and when it's diagnosed, that the initiation began seven to 10 years earlier, and if you look at when it initiated, it would've been a few years before that. So we have to be ready for when it initiated, when it becomes symptomatic and when we finally diagnose it. All of this interferes with our ability to understand exactly what we're studying. As much as we would like to make early diagnosis, one of the things that early diagnosis is associated with is more surgery. The earliest diagnoses on this thing, if we look at patients who were diagnosed in under age 19, anywhere from 50 to 80% have repeat surgery within two years, as opposed to patients who were over 40, 41 where the repeat surgery rates were between 14 and 24%, depends on how far out you go.
Note that the difference between the two year and seven year recurrence rates are almost twofold. So only half of the recurrent surgery is going to be in the first two years. Now, recurrent surgery is a very gross marker. It doesn't really tell us much of what's going on. It makes it hard to understand what's happened to endometriosis. If all we look at is repeat surgery, we'll come back to repeat surgery in a second. One thing that we have found that is that there are certain things that are associated with a decrease in ongoing problems. If we look at the study from Australia by Noidal, this is a non protocol treatment of disciplinary and tertiary centers where they had 74 patients followed for four to 14 years with the mean of 10.2 years of follow-up, 13 of 70 were finally diagnosed with endometriosis. All cases of endometriosis were mild.
No one in that study developed moderate or severe endometriosis and patients who were proactively treated. There were no moderate or severe endometrioid cases. Now, given the way that research is generally done, and it's generally done in retrospective cases where there's six to 10 years of delay, we're not really sure that this study doesn't just show us. This study either shows us that proactive care helps patients, or it may just show that if you do a prospective study starting real early, this is the natural course of the disease. There's no way to know that difference, and there may be other alternatives. Other things that have been associated with decreased risk of endometriosis include some dietary changes, eating healthy omega fatty acids. All of those are also associated with a decreased risk of being diagnosed. There are a lot of things that we can do that may help in general, if a patient is asymptomatic, then they generally don't get worse.
If we look at federally study from Italy on 86 asymptomatic patients who had recto vaginal endometriosis, this isn't mild endometriosis. These are deep erect vaginal pain in patients who did not wish to proceed to surgery, there were 88 patients that were followed for one to nine years and only six of those or 6.8% had progressive symptomatology or growth. So in patients who were relatively asymptomatic or asymptomatic, if you follow them, they generally don't get worse. Unfortunately, that's not what happens all the time. There are lots of cases of hydros G who occur that occur in patients who are also asymptomatic. So the fact that they're asymptomatic and look like they're doing better doesn't mean that we can accept the fact that they're doing better. We have to continue to treat them and follow them and monitor them for any chance that they're progressing. One of the interesting things is the Ontario database study that was published three years ago now.
So most of the studies we've had up until now have been tertiary care studies. The Ontario database study is a primary care. This is everybody who's out there. So they looked at six surgical groups all the way from diagnostic laparoscopies to hysterectomies. One of the interesting things is if you do a hysterectomy and take out the tubes and ovaries, there's only a 4% oh 0.4% repeat surgery rate. Now, that's repeat surgery. Remember, we're going to come back and talk about pain in a second because it's a different character. So if there's repeat surgery rate of oh 0.4%, interestingly, if you did just a diagnostic laparoscopy, there was only a 24.2% chance that they were going to have repeat surgery. 75% of patients had no repeat surgery after a diagnostic laparoscopy only, so we didn't even need to treat that group surgically. They were all managed later by medical and other treatments.
But if you look at pain and look at emergency room visits, even astro hysterectomy, 10% of patients continue to go to the emergency room and 18% after diagnostic laparoscopy. So the differences are not as great. If you look at for office visits for pain, more than 50% of patients continue to be seen in the office for pain no matter what type of surgery they had. So we have to be ready for these differences and characteristics of how patients respond, not based on whether or not the physicians take them back to surgery, but whether they have other markers and other problems that we can monitor. In conclusion, this thing, the study of endometriosis is like nailing jello to a tree. It hasn't changed. The more we know, the more we have to look and decide exactly what we can do in terms of looking at the various characteristics in conclusions. There's no easy answers to any of this. Everybody in this room knows that. I don't think that surprises anybody. You have to be ready for multiple approaches, not only to clinical care, but also to basic and scientific research, and most of all, go back to the same thing that the first slide we saw one of the early slides we saw this morning from Frank. Listen to your patients. Believe Osler, and those guys, if you listen to 'em, they can tell you what's going on. Thank you.
