Eileen left a comment last week asking me to write about adhesions.
This is an interesting subject, and there are some vigorous debates within the academic community about whether or not adhesions cause pain. Throughout the years it has become almost a running joke that the general surgeons don't think adhesions cause pain and gynecologists think they do cause pain. In reality, I think there are some adhesions that are dense, attached to something sensitive like an ovary, or definitely pull on structures like the bowel or abdominal wall that can definitely cause pain, and I've operated on these ladies and their pain resolves after cutting and/or removing the adhesion. There are some adhesions that are more filmy with less density to them that often run from small bowel to other structures, and these adhesions rarely cause pain.
Within the context of endo, I have read many, many operative reports from other GYNs who dictate "findings of adhesions in the culdesac". Most of the time this represents stage IV endo, and the adhesions aren't from prior surgery, they're from endo. The simplistic explanation is that endometriosis lesions are like glue, and they will cause other surfaces to stick together, ie bowel to uterus, bowel to ovary, rectum to cervix, and on and on. What really happens is that the lesion secretes metabolically active substances that cause pain and inflammation. The body's response to the inflammation is that of scarring and formation of fibrosis. Just as a scar on the skin contracts with time as it matures, so do scars and fibrosis in the pelvis, causing tension on adjacent structures. Sometimes the tension adds to the basic endo pain and causes (for example) worse than normal ovulation pain because as the ovary enlarges with the cyst that contains the egg, it can pull on whatever it's attached to (usually bowel or pelvic sidewall) and cause pain.
We don't know what the #1 gynecologic cause of adhesions is, because the only way to reliably find them is to operate, and who do we operate on? Women with pain. In one study, 75% of women with endo had adhesions, and 80% of women without endo had adhesions (essentially no difference). They can be caused from prior surgery (especially when there is post operative bleeding), infections like PID, appendicitis (especially if it ruptures), diverticulitis, cancer, or anything that causes inflammation in the abdomen. Some will say that excising endometriosis causes more adhesions than lasering endo, but I'm not aware of a good quality study comparing that. What I am aware of is the dozen or so women that we have operated on since I've been in Bend who have had surgery by Dr. Redwine in the past. These women on average have a few filmy adhesions mostly in the cul-de-sac (and most of these women have had bowel resections), and not too much else. It is remarkable how often we can see where the peritoneum and endometriosis was removed at the previous surgery and healed in perfectly with no adhesions, no endometriosis, nothin'! The patients who had bowel resections usually have some filmy adhesions around their anastamosis, but compared to patients with active endo that hasn't been excised, the number and quality of adhesions is usually less for both, especially the quality (meaning the adhesions are filmy instead of dense and fibrotic).
While there are still many unanswered questions about adhesions, it is the opinion of both myself and Dr. Redwine that simple filmy adhesions don't usually cause a lot of pain, that endo hides in dense adhesions. If doctors don't know what to look for, or don't have a lot of experience with stage IV endo, they may not realize that the pain in those patients is coming not from the adhesions but from the endo at the cause of the adhesions. For stage IV endo (obliterated cul-de-sac) and bowel disease, the only way to relieve pain and cure the endo is to excise it, remove it and the associated fibrosis. Many studies have looked at Lupron and other medical therapies for this most severe type of endo, and the meds failed miserably. Unfortunately, these are the patients who are most challenging surgically and require a surgeon who is familiar with the patterns of endometriosis, and has a lot of experience with this variety of the disease. These endo specialists are few and far between, but if you are a patient with this particular flavor of endo, I guarantee you that it will be worth your while to seek out one of the handful of us who do this kind of surgery every day.
To those of you who are in pain, I wish you the very best and hope you find relief. If I can do anything for you, please don't hesitate to let me know. Either leave a comment on the blog, or email me at info@endometriosissurgeon.com, and I'll do my best.
Take care, and have a great week enjoying the beautiful spring weather.
Dr. Mos