Human Reproduction, Vol. 19, No. 7, 1680-1681,
July 2004
© 2004 European Society of Human Reproduction and Embryology
‘Endometriosis rediscovered?’: Reply
Dear Sir,
I am happy to record that much of my own thinking about endometriosis has been influenced by the lifetime work of Professor Brosens and in particular by his concept that endometriosis exists in two different phenotypic forms (Brosens, 1993
). I was therefore particularly pleased to receive his comments about the paper on endometriosis syndromes (Garry, 2004). I was sorry, however, that he felt my suggestions would be a great injustice to the work of Cullen and Sampson. I had, of course, intended just the opposite effect. In using these terms, I wished to acknowledge the pivotal position of these two great pioneers in developing concepts about endometriosis while at the same time providing clinicians with a convenient ‘short-hand’ to aid the development of appropriate management strategies. Cullen did describe ‘adenomyoma’ involving multiple different sites inside and outside the pelvis, and Sampson did describe ‘superficial peritoneal’ endometriosis in great detail. I believe it is therefore not inappropriate to associate their names with the syndromes defined, but I do not suggest that the syndromes accurately summarize all the views of these two prolific writers.
Professor Brosens also took me to task over my decision to classify endometrioma as part of Cullen’s syndrome. I did not suggest that this classification implied that ovarian endometrioma are ‘invasive’ in nature, for this is certainly not my view. On the contrary, I specifically stated that the classification makes no attempt to determine the origin of the various lesions but merely describes the clinical implications of the lesions. As significant endometrioma will require detailed assessment and probable surgical management early in their evolution, I felt they were most suitably classified as part of Cullen’s syndrome.
I disagree with Professor Brossen’s opinion that the term invasive is misleading when applied to deep nodular lesions. The process I observe in the operating theatre on a daily basis involves endometriosis undergoing what can only be described as invasion. Endometriotic lesions outside body structures are found in close association or in continuity with similar lesions within their structure. Most organs in the pelvis including the rectum, colon, appendix, ureter, bladder, uterosacral ligaments, vaginal wall and indeed the uterus demonstrate, with depressing frequency, deposits of endometriosis within their musculature. Although we do not understand the mechanisms, I believe there can be no doubt that many cases of endometriosis invade surrounding structures. It is the rediscovery of this forgotten or suppressed clinical truth and the need to differentiate this serious clinical manifestation of endometriosis from the more common superficial implants that justifies the need for a classification such as the one I propose.
I am grateful for the opportunity to emphasize that these proposals are intended simply to be a pragmatic attempt to help clinicians determine the most appropriate management in a confused and difficult area. I acknowledge in the paper that this clinically orientated analysis will not stand the rigours of harsh scientific scrutiny but, despite these significant shortcomings, I believe such a classification may make it easier for patients, doctors and health care providers to optimize their management and treatment options. I completely agree with Professor Brosens’s suggestion that the optimum way forward is to ensure that residents learn how to operate, when to operate and when not to operate, and hope that our suggested classification may help in some small way towards this goal.
Ray Garry
References
Brosens I.A (1993) Classification of endometriosis revisited. Lancet 341,630.[Web of Science][Medline]
Garry R (2004) The endometriosis syndromes: a clinical classification in the presence of aetiological confusion and therapeutic anarchy. Hum Reprod 19,760–768
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||