**1.1.3 Surgical treatment**

Typically surgery becomes a choice after expectant management and hormonal therapy failed to reduce the patient symptoms (Olive et al., 2001; Winkel et al., 2001). Likewise, when anatomic distortions due to endometrial growths are present, surgery would also be the primary choice for treatment (Surrey *et al.*, 2003). There are mainly two types of surgery associated with endometriosis: conservative and definitive.

#### **1.1.3.1 Conservative surgery**

This type of surgery is employed in cases of mild to moderate endometriosis, and for women who would like to retain fertility, as this surgery saves as much ovarian tissue and uterus as possible (Camanni *et al.*). The most common conservative surgical approach is the use of laparoscopy for treating endometriosis (Brosens *et al.*, 1981). The aim of this type of surgery is restoration of the normal anatomy of the pelvis. Clinically, it has been shown that most patients, who undergone conservative surgery, realize a relief of pain symptoms associated with endometriosis. Women who had their implants excised had fewer symptoms 12 months (Abbott *et al.*, 2004) and 18 months (Sutton *et al.*, 1994; Sutton *et al.*, 1997) after surgery compared with women who underwent a laparoscopy without excision of their implants, respectively. However, this type of surgery has a high reoccurrence rate of up to 40% at 10 years post surgery.

#### **1.1.3.2 Definitive surgery**

On the other hand, patients suffering from painful symptoms resulted from severe endometriosis, and when fertility does not need to be retained, may require definitive surgery. This can involves the removal of the uterus (hysterectomy), fallopian tubes (salpingectomy), deep endometrial implants (debulking) and scar tissue (fibrinolysis). The ovaries may also be removed (oophorectomy) to prevent fluctuation of estrogen levels, which may cause any remaining endometrial implants to continue to grow. In such cases,

headache, nausea, dizziness and bloating. These side effects are not usually serious and longlasting (Winkel *et al.*, 2001), however many patients still feel unpleasant and difficult to cope

Danazol is an effective androgen for treating endometriosis. It works by suppressing the growth and development of the endometriotic lesion temporarily, hence continuous medication is required. Clinical trials have shown that danazol is effective in relieving the pain symptoms of endometriosis (Kennedy *et al.*, 2005) for approximately 90% of women (Biberoglu *et al.*, 1981). However, common side effects from these treatments include acne, oily skin, increased hair growth, and weight gain. Its unpleasant side effects and its risk of developing cardiovascular disease mean it is not the first choice of treatment for

Gonadotropin releasing hormone (GnRH) agonists are a group of drugs that have been used to treat women with endometriosis for many years (Schweppe, 2005). They work by stopping the production of estrogen by a series of inhibition on the estrogen-related pathway mechanisms. Although this treatment can reduce 50% in symptoms, but in longterm, pain recurrence can be observed in up to 75% of the cases (Surrey *et al.*, 2002). Likewise, affecting the estrogen hormonal cycle can result in major side effects like bone

Typically surgery becomes a choice after expectant management and hormonal therapy failed to reduce the patient symptoms (Olive et al., 2001; Winkel et al., 2001). Likewise, when anatomic distortions due to endometrial growths are present, surgery would also be the primary choice for treatment (Surrey *et al.*, 2003). There are mainly two types of surgery

This type of surgery is employed in cases of mild to moderate endometriosis, and for women who would like to retain fertility, as this surgery saves as much ovarian tissue and uterus as possible (Camanni *et al.*). The most common conservative surgical approach is the use of laparoscopy for treating endometriosis (Brosens *et al.*, 1981). The aim of this type of surgery is restoration of the normal anatomy of the pelvis. Clinically, it has been shown that most patients, who undergone conservative surgery, realize a relief of pain symptoms associated with endometriosis. Women who had their implants excised had fewer symptoms 12 months (Abbott *et al.*, 2004) and 18 months (Sutton *et al.*, 1994; Sutton *et al.*, 1997) after surgery compared with women who underwent a laparoscopy without excision of their implants, respectively. However, this type of surgery has a high reoccurrence rate of

On the other hand, patients suffering from painful symptoms resulted from severe endometriosis, and when fertility does not need to be retained, may require definitive surgery. This can involves the removal of the uterus (hysterectomy), fallopian tubes (salpingectomy), deep endometrial implants (debulking) and scar tissue (fibrinolysis). The ovaries may also be removed (oophorectomy) to prevent fluctuation of estrogen levels, which may cause any remaining endometrial implants to continue to grow. In such cases,

associated with endometriosis: conservative and definitive.

with. Hence, most women could seldom complete this type of treatment.

endometriosis (Kennedy, 2004).

thinning (Pierce *et al.*, 2000).

**1.1.3 Surgical treatment** 

**1.1.3.1 Conservative surgery** 

up to 40% at 10 years post surgery.

**1.1.3.2 Definitive surgery** 

estrogen medication would be given to prevent menopausal symptoms to occur in the patients. Likewise, woman who underwent oophorectomy for endometriosis has greater pain relief and less likelihood of repeated surgery than those operated by hysterectomy with ovarian preservation (Namnoum *et al.*, 1995). In addition, the rate of recurrence in patients with definitive surgery is much lower than in those with conservative surgery.
