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Do Cesareans Cause Endometriosis? The Data Accumulate

 Today on Science & Sensibility, regular contributor Henci Goer takes a look at a new retrospective study looking at the potential relationship between cesarean birth and endometriosis development in the mother in the years after her surgery.  Did you know that research indicates an increase in endometriosis for those women who have undergone a cesarean delivery?  Henci shares this new study and asks us to continue to look further. – Sharon Muza, Community Manager, Science & Sensibility.

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© Patti Ramos Photography

My very first post in Science & Sensibility back in 2009 was a round-up of case studies and series reporting on the formation of endometriosis—also called “endometrioma” because the cells formed a solid mass—in the cesarean wound. I commented that case studies could serve to draw attention to possible serious complications worthy of further investigation and ended the post with the hope that researchers would take a closer look at this one. Now I have run across a study that does exactly that.  I wanted to share it with you today.

Swedish investigators, Andolf, Thorsell, and Kallen (2010), used a national in-patient data registry linked to a birth registry to identify all women giving birth to their first child between 1986 and 2004. After excluding women who had a diagnosis of endometriosis before their first birth, 709,090 women remained, of whom 3110 were diagnosed with endometriosis and treated in hospitals after their first birth. Investigators tracked women from the date they gave birth to their first child to either the date of the first diagnosis of endometriosis, the date of their 55th birthday, or December 31, 2004, the date on which investigators retrieved the dataset, whichever came first.

Investigators looked both at cesarean-scar endometrioma and general pelvic endometriosis. They postulated that since endometriosis results from uterine lining cells taking hold and growing outside of the uterus, cesarean surgery could disperse these cells throughout the pelvis, not just seed them into the uterine wound.

After accounting for factors that were associated both with endometriosis and cesarean delivery (maternal age at first delivery; BMI; smoking; and years of involuntary childlessness before first delivery), none of which had any appreciable effect, they found that having at least one cesarean nearly doubled the risk of developing endometriosis (hazard ratio: 1.8). This calculated to 1 additional case of endometriosis within 10 years for every 325 women undergoing cesarean surgery. Having multiple cesareans didn’t appear to further increase the risk. Both women with only vaginal births and women with cesareans had new diagnoses of endometriosis, but a graph of the cumulative incidence rates showed that the line angled upward much more steeply as time passed in women with cesareans compared with women with only vaginal births.

The incidence rate of cesarean-scar endometrioma specifically was 1 per 1000 among women having cesareans. This may be considered a minimum since the data registry would not capture women who had cesarean-scar endometrioma but who either never received the correct diagnosis or were never admitted to a hospital for treatment.

The Swedish analysis has added to our knowledge of the relationship between cesarean surgery and endometriosis. It gave us an incidence rate for cesarean-scar endometrioma and showed that cesarean surgery also is associated with increased likelihood of developing generalized pelvic endometriosis of sufficient severity to require in-hospital treatment.  Preventing that primary cesarean can play a critical role in reducing the number of women who will deal with the pain, complications and need for treatment of endometriosis that resulted from their cesarean surgery.  When considering cesarean surgery, women should be told of the excess risk of developing generalized pelvic endometriosis and cesarean-scar endometrioma and their consequent complications (pain, irregular bleeding, infertility) as part of the informed decision-making process.

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Did you know that an increase in endometriosis rates is a possible consequence of cesarean section? Are the women you are teaching and  working with aware of this potential development and what it might mean?  Do you consider this something that you would share in your role as Doula? Childbirth Educator? Midwife? OB?  Let us know in the comments. – SM

References

Andolf, E., Thorsell, M., & Kallen, K. (2010). Cesarean delivery and risk for postoperative adhesions and intestinal obstruction: a nested case-control study of the Swedish Medical Birth Registry. American Journal of Obstetrics & Gynecology, 203(4), 406 e401-406.

 

Cesarean Birth, Childbirth Education, Guest Posts, informed Consent, Maternity Care, Medical Interventions, New Research, Research, Uncategorized , , , , , , ,

  1. avatar
    Jenny
    September 12th, 2013 at 14:34 | #1

    I had a 2×3 cm scar endometrioma removed 6 days ago and am home recovering. The pain began 11 months ago. Initially my PCP denied being able to feel the lump and diagnosed me with constipation. After 2 months of laxatives (no fun) I went back and he sent me for a pelvic ultrasound. They used intravaginal ultrasound and although I could clearly feel the mass myself, they said there was nothing there. After another month with no relief, doc sent me for a CT scan which apparently didn’t scan at the appropriate level to see the mass which was right under the skin or the radiologist missed it. After another month with more pain, went for another vaginal ultrasound which was again apparently “normal”. At this point the doc said he was stumped and sent me to my OBGYN. She was able to palate the mass and she believed the likely reason was incisional hernia but mentioned endometrioma as a small and unlikely possibility. So, off to the general surgeon! He thought hernia was possible but as I had been having some bowel irregularities he wanted a CT scan as well as a colonoscopy. After both lovely tests, my colon was apparently “normal” (although I’m not sure I trust that result in general anymore) and my CT scan showed a 4.5 cm cyst on my ovary as well as a 2×2 cm “soft tissue mass” which the radiologist hypothesized could be suture granuloma. OBGYN wasn’t worried about the cyst and I have a history of cysts so that had been left alone for now. The general surgeon decided to remove the mass and run pathology. I did have two more surface ultrasounds on the area and this ultrasound technician found it no problem twice. A month before surgery I felt another lump on the right side which the surgeon couldn’t palpate but he did find it when operating and removed it as well. Pathogy results came back yesterday and the original mass was an endometrioma and the smaller one was a lipoma. I have three inch incisions on each side of my pelvis and a bruise the size of a hot dog bun on my lower abdomen from where the endometrioma was removed. I’m 29, have a history of csection 6 years and 4 years ago. No intrapelvic endometriosis detected. Needless to say, yes, one “little” endometrioma has caused me nearly a year of pain, several missed days of work for doctors visits and now surgical recovery, exposure to 2 CT scans, 4 ultrasounds, one
    X-ray, and a colonoscopy followed finally by surgical intervention. So, although endometriomas may seem “rare” and insignificant, I assure you that they are not insignificant to those who have them occur. Pain and anxiety from an “unknown abdominal mass” is highly unpleasant. Thank goodness I have good insurance, a forgiving work schedule, a supportive spouse, and available medical care. I could not imagine going through the last 11 months as a single mom with no insurance. And, no, endometrioma was never discussed as a possible side effect of a csection. In fact, my first OBGYN encouraged me to have a csection 9 days before my due date because “the baby is going to be 9 pounds and its your first baby and you will probably have to have one anyway”. Being 23, hot and miserable in July in the south, and trusting my doctor, I had a csection as advised without any attempt to induce labor. I never had one contraction. Oh, and my baby was 7lbs. Hope this helps raise awareness of this unpleasant possible complication of csections, especially potentially unnecessary csections.

  2. September 13th, 2013 at 06:37 | #2

    Jenny, this is a heartbreaking story! best wishes to you as you recover. Thank you for sharing.

  3. September 15th, 2013 at 22:57 | #3

    I am sorry for your nightmare experience. I sympathize with your frustration and hope that you have now made a speedy and complete recovery. Personally, I think there are far more cases of cesarean-scar endometrioma and cesarean-related general endometriosis than the research literature suggests because the only cases we know about are the ones in women admitted to the hospital for treatment. I suspect these cases may be the tip of the iceberg and that many more women either never seek treatment for their symptoms or give up when they are told there is nothing wrong with them or decide they would rather live with their symptoms than undergo surgery.

  1. August 15th, 2013 at 15:15 | #1
  2. August 21st, 2013 at 00:20 | #2