Dr. Zdravko Minev: Endometriosis over 3 cm must be operated on

Dr. Zdravko Minev: Endometriosis over 3 cm must be operated on
Dr. Zdravko Minev: Endometriosis over 3 cm must be operated on

The goals of his studies abroad are in the direction of laparoscopy, hysteroscopy and in vitro. Clinical obstetrics and gynecology is mastering in Bulgaria.

Together with their colleagues, Dr. Georgiev, biologist Nedeva, Dr. Krushkov, Dr. Stavrev and Dr. Topalova are building and breathing life into the specialized hospital for obstetrics, gynecology and reproductive medicine - USBALAG "Selena".

Dr. Minev, does endometriosis still have secrets? It's a common disease, but it's still talked about as an unknown disease?

- Yes, endometriosis is a common disease that affects women of childbearing age. This sometimes causes permanent damage to the function of the female genital organs and impairs the quality of life. The unfamiliarity comes from the fact that the mechanism by which the disease occurs is not clear. While there are several theories in this direction, not all of them are always correct. Therefore, it is still defined as unknown. In addition, it is possible to view the behavior from a different angle, depending on the specialist who is engaged in the problem - whether it will be a doctor who deals with sterility, only with surgery or conservative medicine. For this reason, it is possible to have different opinions about the behavior of this disease.

What is the favorite place for endometriosis to develop?

- Endometriosis can be located on the ovary, on the peritoneum - this is the inner surface of the abdominal cavity. It can also spread inside the wall, between the vagina and the rectum, and deep in the pelvic wall between the nerves, ureter, and large blood vessels. But wherever it is located, this disease causes aseptic inflammation and changes, which are associated with adhesions and with a change in the structure of the tissues.

When located on the ovary, endometriosis damages the ovarian reserve and reduces the number of eggs. It is considered that endometriosis, with a size of more than 3 cm, should be operated. In other cases, it is subject to monitoring. But, if the endometriosis foci continue to grow and increase in size, it is better to be operated on.

For endometriosis located on the peritoneum, when and what treatment is given?

- When endometriosis is located on the peritoneum, causes pain and disrupts the quality of life of patients, treatment is started, which can be conservative or operative.

This disease creates the biggest problem in women who are of childbearing age. When it is on the ovary and is more than three centimeters, the opinion of those who deal with sterility and with laparoscopic surgery is that it is better for the woman to have an operation

And colleagues who do not deal with either sterility or operative gynecology believe that endometriosis can remain. But it has been shown to damage the structure of the ovaries and destroy the eggs that are in the ovary. Thus, it reduces the ovarian reserve.

For the rest, things are a little better, because there we do not aim to get pregnant - the only goal is to eliminate the pain, which is the main problem and worsens the quality of life. And then measures are taken to change it.

What should be the behavior if a woman suffers from deep endometriosis? How is this species different from the others?

- Deep endometriosis is characterized by the development of endometriosis foci, which are located in the septum between the vagina and the colon or in the ligaments that hold the uterus, and also in the pelvic wall along the nerves that pass through it, along ureters or large blood vessels. They cause tissue changes and deformation, which is associated with severe pain all the time. There are cases where women are so disabled that it directly changes their whole life.

They are willing to undergo surgery, which often involves cutting out part of the colon, to remove this focus of endometriosis. And this kind of treatment is very complicated and difficult. In these cases, according to the requirements of modern medicine, a department should be made where there are both surgeons and obstetrician-gynecologists, because part of the large intestine is also cut during the operation.

Unfortunately, in Bulgaria this type of teamwork is not implemented, except in one clinic. The good thing is that this type of endometriosis is extremely rare in Bulgaria. In the last 25 years, I have had two women who had to have such an operation. I sent them both to be operated on in France, because there are conditions to do this treatment there, and economically it seemed the most profitable.

Unlike Bulgaria, this disease is very common in Africa and the Scandinavian countries. Its distribution is geographically dependent, and there is also a racial connection.


Which type of endometriosis occurs most often in Bulgaria?

- Most often in Bulgaria, endometriosis occurs on the ovaries - i.e.so-called endometriosis cysts or endometriomas. And, when the cyst is over 3 cm, it has to be removed because it damages the ovarian reserve. The other problem with endometriosis is that it causes a lot of tissue adhesions and changes. Very often the tubes become blocked or covered by massive adhesions and the woman cannot become pregnant. In this case, the tubes have to be interrupted so that they do not have communication with the uterus. And this is something that women of childbearing age have a hard time experiencing. What nature has given them to be able to bear a child must be removed in order to conceive. Once we do the procedure, there will be no problem with IVF. But, when the procedure is not done, even with in vitro, there is no success rate.

But the most important thing in these operations is to preserve the ovarian reserve. The problem is that normal endometriosis surgery and treatment is associated with ovarian bleeding. During the operation, we can stop it in several ways. One possibility is with electricity. But in this case, the entire ovary gets very hot and the current literally "burns" it and destroys the few remaining eggs. They are located in the capsule of the ovary, and endometriosis develops on its surface - the capsule. It causes acute inflammation, and the ovary becomes indented and overlaps with this focus. That is, endometriosis does not have its own capsule - its capsule is formed by the wall of the ovary itself. And therefore, when the endometriosis focus is removed, this place bleeds a lot. This type of surgery literally destroys the ovarian reserve.

A slightly better option is laser surgery

The endometriosis pseudocapsule is removed and the tissue underneath is vaporized with a laser. The laser penetrates to a much smaller depth, does not overheat the tissue and the entire ovary. So, with the laser, a better effect is obtained to preserve the ovarian reserve.

There is another technique where the pseudocapsule is infiltrated with a solution to cause vasospasm and then proceeded to remove it. Once the vessels spastically contract, they do not bleed, but unfortunately, only during the operation. Very often after that it happens that blood collects in the abdominal cavity after the operation and a new operation has to be done. Having another surgery definitely worsens the ovarian reserve even more.

And which is the best option?

- There is another way to behave in this case. But there is also a problem. The he alth fund covers the treatment as a type of prevention of this disease for six months, but only after the operation is performed and it is histologically proven that there is endometriosis. The preparation creates an artificial menopause. The goal is, if there are other, microscopic endometriosis foci, they degenerate. A tissue that does not function atrophies. And when these outbreaks are small, the effect is good. This medicine costs BGN 140 per month, but patients pay only BGN 20-30 extra.

If the drug is taken three months in advance before surgical treatment, it leads to atrophy of endometriosis cells. And, if the operation is done in the second half of the third month, the ovary almost does not bleed and does not have to be coalgorized and use current or laser. Maximum preservation of the ovarian reserve is achieved. I have had cases where, with this method of operation, the diseased ovary that was operated on has more eggs than the he althy one.


Why does the He alth Insurance Fund not change the conditions for prescribing the drug, since the effect of preserving the ovarian reserve is so high?

- Because she wants 100% histological proof of the disease

I have no other explanation. This drug is also used by people who have had surgery for breast cancer. They get it every month to suppress ovarian function, prevent estrogen from being released and relapse. It is also used in patients who have endometriosis. The treatment is not cheap for this disease, but it solves many problems regarding the ovarian reserve, and with it - also about getting pregnant.

The best I can see as a result is that with this pre-trimester treatment to continue after the laparoscopy is done, the ovarian reserve is preserved and the recurrences are drastically reduced. Unfortunately, 20% of surgeries are associated with recurrences.

What is the reason for the high relapse rate?

- The reason is the presence of microscopic endometriosis foci that remain and were not noticed during the operation. Or, if the operation was performed without a laser, without vaporizing the bed of the cyst - foci remain somewhere, which then develop again. As far as I know, there are only two operational lasers in Bulgaria. One is in Sofia, but they don't do laparoscopies with him and the other is in our hospital, in Plovdiv.

Why are conflicting results and diagnoses often obtained? One specialist says the woman has endometriosis, another doesn't. That is, is there a problem with the diagnostics?

- Diagnosis when it comes to ovarian endometrioma is not a problem. An endometrioma is an ovarian cyst. Diagnosed with ultrasound, MRI or scanner.

But when it comes to pain in the small pelvis and it starts a week before menstruation and continues during the days of menses - it is localized in this period, then we are talking about endometriosis. These are the most common cases in which it is discussed whether or not this disease exists. Because doctors judge by the clinical picture, only by the pain syndrome.

And which form of endometriosis creates the greatest difficulties in diagnosis?

- As I already mentioned, there are four forms of endometriosis - on the ovaries, on the peritoneal surface of the small pelvis and in the abdominal cavity, deep endometriosis and inside the wall of the uterus. There are also described casuistic cases, but they are extremely rare. With this endometriosis, which is on the lining of the peritoneum, the only way to make a diagnosis is to do a laparoscopy. The problem is that women are not willing to undergo this test just to prove where the pain is coming from, because there is no guarantee that it will be removed laparoscopically. That's why there are conflicting opinions.

Each colleague who interprets the pain syndrome does so based on his experience. And there are colleagues who do not interpret it correctly. Any unexplained pain for them is endometriosis. The patient then goes to another colleague, who can explain this pain with another disease or condition, since there is some regularity in its manifestation in endometriosis. If the woman starts drinking contraceptives, the pain changes. These facts lead the second colleague to conclude that it is not endometriosis.

There is another form of endometriosis that causes a lot of discussion and different opinions.

What shape do you have in mind?

- It is about adenomyosis. This form of endometriosis is found inside the wall of the uterus. The special thing about it is that it can be nodular - when it is in the form of a knot and diffuse - when it is spread over a large area, without a clear border, most often along the back wall of the uterus. The nodular form is often interpreted by colleagues as a fibroid. And they operate on the woman.

But adenomyosis, unlike myoma, does not have its own capsule and cannot be operated on. Glands from the lining of the uterus are found in the normal musculature of the uterus. And this section cannot be removed without trauma, the uterus simply tears. And this very often leads to permanent damage to the organ.

What is the relationship between adenomyosis and problem pregnancy?

- There is a variant in which adenomyosis can deform the uterine cavity and then it prevents pregnancy. When adenomyosis is located directly under the lining of the uterus, it forms small cysts - endometrioma foci that are full of old blood, as are ovarian endometriosis cysts. Adenomyosis secretes interleukins 7 and 11, which cause severe irritation of the uterine lining. Many NK cells are released there, which destroy the embryo and the woman cannot become pregnant.

When there are such foci, they must be removed before pregnancy or the in vitro procedure - otherwise it will be doomed to failure. Adenomyosis also plays a role in infertility. Therefore, it should not be underestimated when a woman has a problem getting pregnant.

You said that if it is less than 3 cm, endometriosis is not operated on. What should be the behavior in this case?

- These are the cases in which it is a three centimeter ovarian cyst. The woman can do nothing. If she doesn't want to get pregnant, it's a good idea for her to take a contraceptive, in order to suppress her growth a little. There are other tablets that are taken for six to nine months. And they are hormonal, prevent menses from occurring, and the expectation is that these foci will atrophy. But the truth is that they do not atrophy completely, but their growth is suppressed.

Popular topic