Doc Talk: Learning About Minimally Invasive Surgery & Treating Endometriosis

We sat down with Dr. Roa Alammari of Mansfield Ob/Gyn Associates, a Women's Health Connecticut practice, to talk about her specialty in minimally invasive gynecologic surgery and management of endometriosis, uterine fibroids, benign ovarian masses, and other conditions.

Tell us a little more about yourself and why you chose to specialize in minimally invasive surgery.
Growing up in Saudi Arabia, where women often struggle for equal rights and access to services, led me to have a natural affinity for women's health. After I graduated medical school, and as I explored my interest in surgery, I found a way to marry both interests in Obstetrics and Gynecology. I moved from my home country to the United States to pursue residency training in ObGyn. I secured a position in an ACGME-accredited residency at Baystate Medical Center, Springfield, MA.

After completing my residency, I was able to gain acceptance to a highly competitive fellowship program that offered additional training in minimally gynecologic invasive surgery. I completed my fellowship at Beth Israel Deaconess, Boston, MA in 2018 and moved to Connecticut where I joined Mansfield Ob/Gyn Associates.

What are the types of procedures that you perform the most?

My fellowship training in minimally invasive surgery was highly focused on the laparoscopic treatment of advanced endometriosis and complex uterine fibroids procedures. Laparoscopic surgery is not limited to these conditions, and is routinely utilized in the treatment of a variety of issues including abnormal uterine bleeding, pelvic pain, and ovarian cysts.

Another procedure I often perform is hysteroscopy, which is a type of minimally invasive surgery that does not require incisions and can be used to treat growths inside the uterine cavity. This is considered an endoscopic procedure that uses a natural orifice (the cervix) to gain access to the uterus.

Is surgery for endometriosis recurring or is it a one-time procedure?

Endometriosis is a chronic condition. I usually counsel my patients that in a way it's like having a chronic illness, such as diabetes, it’s something that patients unfortunately often deal with for most of their reproductive lives. Many patients will need multiple procedures, but usually the treatment process will start with medical treatment. A subset of patients will be adequately treated with hormones or other available medical treatments in conjunction with pelvic physical therapy.

However, a significant number of patients will require surgery, which usually indicated if the patient does not have success with medical treatment or if she desires to conceive and using hormones is not an option. When patients have a recurrence of symptoms, despite ongoing medical therapy, they may require repeat surgery.

The quality of the first surgery is important to achieve longer intervals of disease remission and decrease the number of surgical procedures needed per patient. Therefore, it’s prudent that the patient looks for a surgeon who is able to perform an advanced procedure if necessary and do excision rather than just burning the implants which is the other way of treating it surgically.

Can you share more information on what that surgical treatment of endometriosis entails?

Surgical treatment of endometriosis is done mainly by excision or fulguration. Fulguration involves “burning” of the endometriosis using different sources of energy that may be used to destroy the implant. The issue with this treatment is that it tends to be superficial and may not remove the entire implant. Excision is usually associated with better outcomes.

Other surgical treatments of endometriosis include, removal of scarring, excisions of deep endometriosis nodules, and removal of endometriosis cysts from the ovaries.

Women have talked about their symptoms being minimized, do you hear this from your patients?

Patients with endometriosis can certainly suffer from a delay in diagnosis because the symptoms can be non-specific. More typical presentation includes painful periods and pain with intercourse. This can be associated with painful bowel movements or pain with urination depending on where the implants are located. We would usually start with hormonal treatment which is at the level of birth control for initial treatment. Luckily, most patients will usually receive the appropriate first-line therapy even if the diagnosis is not made because birth control pills are routinely prescribed when a patient first present with any menstrual complaints and as part of contraception management.

If we were not successful at controlling symptoms with one or two hormonal methods then surgery becomes indicated for two reasons: one (1) to confirm the diagnosis and; two (2) to excise endometriosis and “limit the burden of the disease,” so that when we re-start medical therapy after surgery we can achieve better control of the disease.

What are some examples of different types of common medical treatments?

Different classes of medications are used in medical treatment of endometriosis:

• Non-steroidal, anti-inflammatory drugs which limit the synthesis of prostaglandins, a lipid that can mediate pain by activating an inflammatory response.
• Estrogen and progesterone hormone treatments are effective in treating endometriosis pain and offer suppression of the disease. These include the majority of available hormonal contraceptive options such as birth control pills, vaginal rings, Depo Provera injections, Nexplanon contraceptive implants, and hormonal IUDs.
• Gabapentin is an anticonvulsant that is often used to treat endometriosis pain by its effect on neuropathic pain.
• Gonadotropin-releasing hormone agonists: LupronDepot is commonly used for the treatment of endometriosis with great success. This medication places the patient in medical menopause taking away hormonal support of endometriosis. This treatment is limited by the numerous side effects including menopausal symptoms such as hot flushes and vaginal dryness. Treatment should not exceed 6 months due to concern about the adverse effect on bone density and other side effects.
• New treatments are emerging, and research shows promising outcomes. Aromatase inhibitors appear to be effective in treatment of endometriosis pain and in some studies, resulted in regression of implants. The reasoning behind this therapy is that endometriosis is found to have the ability to synthesize its own estrogen using the enzyme aromatase. Blocking this enzyme can further limit hormonal support of endometriosis. Another new treatment is elagolix which is a gonadotropin-releasing hormone blocker and like LupronDepot, leads to a state of medical menopause.

What age do you find that most patients with endometriosis are seeking treatment?

Usually, the patient can have symptoms within her first few periods, as early as age 12 or 13. If a patient has severe pain with her periods that leads to an inability to function and loss of school days, this is highly suggestive of endometriosis.

Patients will often be placed on a birth control pill to control their symptoms. Surgical treatment is indicated for patients who do not have success with medical treatment. It doesn't really matter how old the patient is. Surgeons should not refrain from operating on younger patients just because of their age. It's more based on where the patient is in her treatment algorithm.

Are endometrial implants only identified through surgery or through the exploratory process?

Endometriosis is very challenging because imaging is often unable to visualize the disease. Imaging is most helpful in diagnosing endometriomas (endometriosis cysts in the ovary) usually evaluated by ultrasound and deep infiltrating endometriosis nodules usually evaluated by MRI. Otherwise, it is difficult to visualize endometriosis on imaging.

While performing surgery, some endometriosis implants have a typical appearance and are easily identified. Other implants can have an atypical appearance and careful examination of all the peritoneal surfaces is important to identify the full extent of the disease. Some disease will be invisible. Any residual disease that may be left behind will be controlled with hormonal suppression. This is why I always remind my patients that surgery is not an alternative to medical therapy, it is an adjunct.

Is it less common to treat endometriosis by having a hysterectomy?

A hysterectomy is sometimes considered as a last resort for treatment of severe endometriosis usually after the failure of multiple other treatments. However, it may not definitively treat the disease because endometriosis can sometimes recur even in the absence of the uterus.

So, I don't think that hysterectomy is an appropriate treatment for endometriosis in the absence of other uterine pathology such as adenomyosis. In addition, endometriosis can often be treated without removing the ovaries which can have severe implications on the patient’s long-term bone and cardiovascular health.

What would your advice be for a patient who are suffering from these symptoms and is not sure what treatment options are right for them?

First, patients should have a conversation with their ObGyn about her symptoms. It is important for patients to advocate for themselves and seek a second opinion if they suffer from unresolved menstrual and pelvic pain symptoms. Knowing the constellation of symptoms of endometriosis and mentioning this diagnosis during the visit will help include this condition in the differential diagnoses and facilitate early treatment.

Patients for whom surgical intervention is indicated should have an open discussion with their ObGyn about their comfort level with operating on endometriosis and seek a referral to a more experienced pelvic surgeon if complex surgery is anticipated. The exam is often telling if the procedure will be complicated, but sometimes difficult anatomy is encountered when it was not anticipated preoperatively.

The American Association of Gynecologic Laparoscopists (AAGL) offers a 2-year fellowship program to train gynecologists in advanced pelvic surgery. AAGL has developed the MIS for Women website with information on a variety of gynecologic conditions and a Physician Finder tool for a list of its members. When surgery for endometriosis is planned, it is important to meet with a surgeon, like myself, who has a specific focus in the treatment of endometriosis and is comfortable with treating advanced endometriosis surgically with a minimally invasive approach.