Laparoscopy was originally only used as a means of diagnosing endometriosis but over the years it has been used increasingly as a way of surgically treating the condition. It is now common for some laparoscopic surgery to be performed at the time of a diagnostic laparoscopy — assuming the woman agrees and laparoscopic treatment is appropriate.

In the early days of laparoscopic surgery only simple procedures were performed but as experience with the technique has increased surgeons have treated increasingly severe cases and performed more complex procedures. The complexity of the procedures that your gynaecologist will attempt will depend on his or her level of training and experience.

Who is suitable for laparoscopic surgery

Laparoscopic surgery is generally only suitable for women with minimal or mild endometriosis, though in some cases it may also be appropriate for women with moderate disease.

Things to discuss before laparoscopic surgery

Before your operation you should discuss with your gynaecologist what he intends to do during the operation and what should be done if more extensive surgery is necessary.

What happens with laparoscopic surgery

The basic routine for laparoscopic surgery is the same as that described for a diagnostic laparoscopy (see Chapter 3) except that in addition to inspecting the pelvic organs, one or more of the treatment procedures outlined below will be performed.

Procedures that may be performed include the removal or destruction of superficial implants and small cysts, the removal of adhesions, the removal or destruction of endometriomas and the removal of an ovary. Few gynaecologists are able to perform the latter two procedures but it is possible that in the future more surgeons will be able to do so.

Any superficial implants and small cysts on the peritoneum and ovary will usually be destroyed by cauterisation. Cauterisation involves the use of a heat source or electrical current to destroy or ‘burn’ the implants or cysts. As the depth of the burn cannot be precisely controlled cauterisation is not used if there is any danger of damaging any important underlying organs, such as the fallopian tubes, bowel or bladder. It is not always possible to destroy all the implants and cysts present. Larger cysts may be removed by cutting them out.

Adhesions can be removed by cutting or cauterisation but again it may not be possible to remove all the adhesions present.

Effectiveness of laparoscopic surgery

Laparoscopic surgery has several advantages over conservative laparotomy because being minor surgery as opposed to major surgery it is associated with fewer risks and complications, causes less discomfort and has a shorter recovery period. It can also readily be done at the time of diagnosis which means that only one bout of surgery, one hospital stay and one recovery period are needed.

It is not possible to compare the results of laparoscopic surgery with other forms of treatment as there are no reliable figures available at present. The impression of many gynaecologists is that laparoscopic surgery relieves the symptoms in many cases and it restores fertility in some cases.

Risks and complications of laparoscopic surgery

The risks and complications of laparoscopic surgery are the same as those associated with a diagnostic laparoscopy except that there is the additional risk of damaging organs during cauterisation.

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How Gestrinone works

Gestrinone appears to work by suppressing the secretion of oestrogen by the ovaries, causing the endometrial implants to degenerate and waste away.

Dosages of Gestrinone generally used

At the moment clinical trials are still trying to identify the most effective dosage. It appears that dosages of 2.5 to 5.0 milligrams two or three times a week are likely to be effective.

Side effects of Gestrinone

The side effects are reported to be moderate and similar to those of Danazol, and include acne, increased appetite, vaginal discharge, irregular vaginal bleeding, headaches, decreased breast size, nausea, weight gain, excessive hair growth and depression.

How effective is Gestrinone

Early clinical trials have indicated that Gestrinone is an effective treatment for endometriosis and that overall it is as effective as Danazol. Its future role in the treatment of endometriosis is not known at this stage.

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Follicle stimulating hormone-The follicle stimulating hormone (often abbreviated to FSH) is produced by the pituitary gland and stimulates the ovarian follicles to grow and develop.

Luteinising hormone-The luteinising hormone (often abbreviated to LH) is produced by the pituitary gland; it initiates ovulation and stimulates the corpus luteum to produce progesterone.

Oestrogen-Oestrogen is a hormone produced by the ovaries which stimulates the growth and thickening of the endometrium.

Progesterone-Progesterone is a hormone produced by the corpus luteum which prepares the endometrium for implantation of the fertilised ovum.

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Fallopian tubes-The fallopian tubes are two extremely fine tubes about 10 centimetres in length which extend from the upper part of each side of the uterus.

The ‘finger-like’ ends of the fallopian tubes, known as the fimbria, lie close to and curve around the ovaries. When ovulation occurs the fimbria draw the ovum (egg) into the fallopian tube, which then propels it to the uterus.

Ovaries-The two ovaries lie close to the ends of the fallopian tubes. They are about the size and shape of a brazil nut. They are 2.5 to 3.5 centimetres long and approximately 1.2 centimetres thick.

The ovaries contain thousands of tiny sacs called ovarian follicles. Each follicle contains an egg which is known as the ovum (plural ova). Once a month, under the influence of the menstrual hormones, one of these follicles grows and releases its ovum. After it has released the ovum, the remaining part of the follicle becomes the corpus luteum.

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Women going through fertility investigations are often told that they are not conceiving because they have ‘old eggs’. The use of this term has a devastating psychological effect on any woman. And it causes a lot of unnecessary heartache because, although you cannot increase the number of eggs you have left, it is very possible to improve their quality by improving your general health.

So, if you are over the age of 35, rest assured that there is a great deal you can do to increase your fertility. You can also take heart from the story of Sarah, a 42-year-old, who came to me for advice.

Case History

Sarah, a solicitor, was absolutely distraught after her third attempt at IVF treatment. She had been told that the quality of her eggs was no good and that she was now menopausal. She had not responded well to her last course of IVF drugs. But when she asked whether the drugs could perhaps be altered she was told that there was nothing wrong with the technology; she was the problem. You can imagine how devastated she felt. She had emerged from the clinic with the words ‘old eggs’ ringing in her ears.

I told her there was no guarantee but I would aim to get her and her partner in optimum health, which would be of benefit anyway. They followed the plan outlined in Section 6 of this book (taking supplements, and making changes to their diet and lifestyle).

Six months later Sarah was pregnant, and she has since had a healthy baby boy.

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If you continue to use them during a pregnancy, of course, it can have disastrous effects on your developing baby.

The Effects of Some Common Recreational Drugs

•     Marijuana can lower a man’s levels of FSH and LH, two hormones needed to produce sperm. It can also lower his libido. For the woman, marijuana can lead to irregular periods, reducing fertility and sometimes even stopping ovulation.

•     Cocaine users will have a lower sperm count, poorly moving sperm and a high rate of abnormal sperm.

•     Heroin can cause a decrease in testosterone levels.

•     Cocaine and heroin, taken together, will make it harder for a woman to conceive and she is more likely to have a miscarriage, a stillbirth or a baby born with a malformation.

Medicines

If you or your partner are taking medication while you are trying to conceive you should speak to your doctor about which drugs are medically essential and which are not. Some drugs have a direct effect on fertility and you do need to discuss this with your GP.

Many drugs can affect not only the man’s sperm but also his ejaculatory function and libido. Some medicines may even cause impotence. These drugs can include sulphasalazine (used to treat irritable bowel), nitrofurantoin, tetracycline, cimetidine, ketoconazole, tricyclic antidepressants, monoamine oxidase inhibitors and propranol.

In addition, medication given for conditions like gout or high blood pressure can interfere with fertility. And non-steroidal anti-inflammatory drugs (often used for arthritis) can stop ovulation.

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Herpes simplex    

The herpes simplex virus (HSV) causes blistery sores (herpes simplex lesions) that most often occur near where moist lining membranes meet the skin around the mouth, the genitals and the anus.

There are two types of HSV: type I and type II. Type I mainly causes cold sores around the mouth. Most people who get oral herpes have been infected during childhood, mostly before 5 years of age. Type II usually affects the genital region, and is most often sexually transmitted. However, either type of HSV can infect any part of the body covered with stratified squamous epithelium. I have seen it on the skin of the buttocks, thighs and neck, and even on the hand of a laboratory technician who accidently pricked her finger while culturing the virus.

HSV belongs to the herpes virus family, which has over 50 members. Only a few are known to cause disease in humans. Once you pick up any herpes virus, it stays in your body for the rest of your life. Though there are often symptoms soon after you first become infected, after recovery these viruses remain in a latent (inactive) state most of the time. However, in some circumstances they can become reactivated to cause symptoms and possibly make you infectious again.

Cysts are the most common cause of breast lumps for women between the ages of 35 and 55, but rarely occur in younger women. They result from fluid being trapped by a blocked duct. A cyst may develop suddenly or slowly and may reach up to several centimeters in diameter. It will feel smooth and round, soft or tense, and is often tender. Cysts usually can be moved around easily within the breast tissue. Some cysts disappear slowly as the fluid in them is absorbed, but usually they need to be emptied by needle aspiration (drawing out the fluid with a fine needle), which makes them disappear immediately. If the cyst refills or if the fluid withdrawn is bloodstained or if a lump can still be felt after the cyst is emptied, further investigation is needed.

The most common solid breast lump in young women is an overgrowth of fibrous and gland tissue (fibroadenoma). These lumps feel smooth and firm, and move around so easily within breast tissue that when you try to feel them they seem to dart away from your fingers. For this reason they’re often called ‘breast mice’. Fibroadenomas are benign and removal is unnecessary unless you’re worried by the presence of the lump, but examination of a fragment of the lump under the microscope is necessary if you decide not to have it removed.

Other lumps and thickenings, such as those caused by hormonal changes or by scar tissue, are more difficult to identify as benign. These days just about all breast lumps are investigated further to rule out the possibility of cancer. Following are the tests commonly used.

Diagnostic mammography

This is a special X-ray technique for examining abnormalities felt in the breasts, and is usually the first test offered to women aged over 25 years. Most women who think they have a lump can be reassured that they don’t have cancer after negative results from a specialist examination, a mammogram, and often an ultrasound.

Previously it was feared that the dose of radiation from mammography might itself increase the risk of cancer. However, the special equipment and techniques used now give such a small dose of radiation that it is no longer considered any risk.

Ultrasound

This test is generally the first performed for women aged under 25 years. It is also used for any woman who has a lump that can be felt but doesn’t show up on mammography, or to look at a change seen in the mammogram but not felt. It involves passing sound waves into the breast. These waves are reflected back differently by tissues of different density, for example cysts and solid lumps. The reflections are analyzed by a computer screen to give a ‘picture’ of the breast tissue. Ultrasound should be used when there is any doubt about a change found by feeling the breast or by mammogram.

Biopsy

This involves removal of some of the suspicious breast tissue so that it can be examined under the microscope. It is done when there is any uncertainty after mammography or ultrasound. Biopsy may be done in two ways.

Fine-needle aspiration A fine needle is inserted into the tissue and a fragment drawn out. The same procedure is used to empty the fluid from cysts. This can be done in your doctor’s rooms. Surgical biopsy Some tissue is removed through a small incision. This may be done in hospital or a day centre under general anaesthetic. The sample removed by either type of biopsy must be examined by an expert in microscopic examination of breast tissue.

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The canal that runs through the cervix opens into the cavity of the uterus at the internal os and into the vagina at the external os (os is Latin for mouth). It is lined by a single layer of columnar epithelial cells that dips down into its wall to form glands. These cells are influenced by oestrogen and progesterone to form varying amounts and types of the cervical mucus that fills the canal. Where the cervix projects into the vagina, its outer wall (called the ectocervix) is covered by a tough stratified squamous epithelium many cells thick, the same as the vaginal lining. The point where the columnar epithelium that lines the canal meets the squamous epithelium covering the ectocervix is called the squamo-columnar (S-C) junction and is very important in cervical health.

At puberty, ovarian hormones stimulate growth of the cervix to its adult size and mucus production by the lining cells and glands of the cervical canal. From puberty on, the cervix undergoes constant changes with the rise and fall of hormones during each menstrual cycle and with the altered hormonal conditions of pregnancy and lactation. Its wall becomes slightly enlarged and softer at the time of ovulation due to an increase in tissue fluid between its cells, and the external os becomes more lax and open.

Throughout the reproductive years there are changes in the position of the S-C junction. At birth and before puberty the junction may be inside the canal, at the external os or on the ectocervix. Its position is thought not to change much during the first 10 years of life. At puberty, pregnancy and other times during the reproductive years the junction may move further out onto the vaginal surface of the cervix. This is called cervical eversion, because the canal lining appears to be ‘turned out’ onto the ectocervix.

The delicate columnar epithelium that lines the canal cannot survive when it is exposed to the acidity of the vagina, so it becomes transformed into the stratified squamous epithelium that covers the ectocervix. The surface of the cervix over which everted canal epithelium has been or is being transformed is called the transformation zone (TZ). During the transformation process (which can happen more than once during our reproductive years) the cervix seems to be more susceptible to anything that might cause unusual or abnormal cell growth and division.

This outward movement of the canal lining seems to be influenced by hormones and possibly other factors not yet identified. It is considered to be a normal process, but we don’t know why it happens in some women and not others. When this is understood we may find the answers to many puzzling questions about abnormalities of the cervix.

The lining of the cervical canal is transparent. When it is everted onto the ectocervix the blood vessels in the tissue beneath show through, so that the eversion looks red. It also appears rather knobbly compared with the smooth surface of the membrane covering the ectocervix.

In the past doctors called this eversion an ‘erosion’ or ‘ulcer’, because that’s what it looked like with the naked eye. It was thought to be abnormal (we now know that it isn’t) and was treated by burning or freezing the area to transform it to ectocervical epithelium. Most of these treatments were unnecessary: given time almost all eversions will be replaced naturally by a transformation zone.

Occasionally an eversion that is slow to transform may lead to chronic inflammation of the cervix.

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Many of the old fears about the consequences of hysterectomy arose from a widely held but quite incorrect belief that it was the same as castration. As explained, the ovaries are preserved unless it’s impossible to do so. If your ovaries must be removed at the time of hysterectomy, you’ll be told about it and encouraged to use oestrogen replacement to eliminate the effects of lack of oestrogen on health and sexual function.

Another myth about hysterectomy is that it makes women gain weight. There is no physiological reason for weight gain after hysterectomy unless you eat more and exercise less than before. Women who become overweight after any surgery may do so because during convalesce they develop a pattern of overeating underexercising that can be hard to break.

The controversy about hysterectomy

Few subjects in gynaecology have caused
as much debate as hysterectomy. The controversy reached its peak in the 1970s when health authorities became alarm at the high rate of hysterectomy in Australia. The flames of the debate were fanned by the press with such sensational headlines as ‘Shock Survey on Hysterectomy: Convenience a Key Reason’.

A survey of hysterectomy in the late 1970s showed that two out of five Australian women had their uterus removed before the menopause, and nearly half of the female population had hysterectomy by the age of 65 years. This was much higher than the rate of hysterectomy in the UK and European countries.

Why had so many Australian women had hysterectomies? Did almost half of all Australian women have serious disease of the uterus that couldn’t be corrected by non-surgical means? (The answer to this must certainly be ‘No’.) Were hysterectomies being performed unnecessarily? Were women pressuring surgeons into performing hysterectomies for ‘convenience’? Worst of all, were surgeons recommending hysterectomy for their own financial gain?

It’s difficult to answer these questions in retrospect, but it seems likely that in the past some hysterectomies were performed for reasons that would be considered invalid today, including sterilisation, to do away with the inconvenience of menstruation, and to prevent possible future disease.

Most women who’d had hysterectomies didn’t think that they were unnecessary. The majority of a survey of 823 women who had hysterectomies in New South Wales in 1977 were satisfied about the outcome of the operation and believed that it had been done for a good reason. Still, some were unsure whether the operation was necessary and a few regretted it.

The controversy in the late 1970s and early ’80s has resulted in both women and surgeons becoming more careful about the decision for hysterectomy. Less hysterectomies are now performed. Other changes since the 1970s have contributed to the fall in the rate of hysterectomies.

• Women are now better informed about their gynaecological health and are encouraged to take a greater part in decisions about their health care.

• Improved non-surgical treatments have been developed for many bleeding problems, menstrual pain and endometriosis.

There will be even fewer hysterectomies in the future. The new technique of removing or destroying the endometrium through the hysteroscope (endometrial ablation) can eliminate many problems of bleeding without removing the whole uterus. Recent studies on progestogen-releasing IUDs have shown them to be as good or better than endometrial ablation in controlling some bleeding problems caused by progesterone deficiency.

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