Endometriosis may not be a chronic disease An alternative theory offering more optimistic prospects for our patients

Michel Canis, M.D., Ph.D., Nicolas Bourdel, M.D., Céline Houlle, M.D., Anne Sophie Gremeau, M.D., Revaz Botchorishvili, M.D., Sachiko Matsuzaki, M.D.

Volume 105, Issue 1, Pages 32-34


For more than a century, endometriosis has been described as unexplained, poorly understood, or enigmatic. As a result treatments are not based on the pathophysiology of the disease, which consequently cannot be cured effectively, meaning that the symptoms, which have major consequences on women’s quality of life, will almost inevitably recur. Such pessimistic perspectives have devastating consequences, particularly on the results of treatments for chronic pelvic pain. All the mechanisms proposed, whether retrograde menstruation, metaplasia, lymphatic and vascular metastasis, embryology, stem cells, and müllerianosis, may occur in all women.

  • mcanis

    I do thank you very much for your comment. I am convinced that there many other different trauma possible. Dr Khan from Japan recently raised the issue of infection as a possible cause of endometriosis. So this may explain endometriosis in patients without previous surgical trauma. This may even cases where the disease apparently worsened over the years. I had a patient whose husband was a radiologist. When she came for surgery, he said at least her disease is getting worse and worse. As a matter of fact we found endometriosis and a tubal abscess. We a sigmoid resection and a left salpingectomy. She became spontaneously pregnant a few months later.
    So there as many trauma, as different phenotypes may be found.

  • G. Tabandeh

    While the issues brought up in this article are quite considerable, an important aspect of the disease seems to be neglected, and that’s the fact that there are a considerable number of cases of severe Endometriosis in patients with absolutely -no- previously reported surgical manipulations, scar tissue, labor and known or unknown diseases that could possibly lead to any cause of mechanical trauma.

    The remaining question is whether or not other kinds of traumatic experiences -rather than trauma left in the body tissue due to surgical or post-operative events- contribute to the onset and progression of the disease.

    I believe this topic is also of extreme importance, since there are many cases that report almost no body of evidence in terms of previous mechanical trauma -as of mine, diagnosed with stage 4 Endometriosis and a frozen pelvis in age 32, after 3,5 years of suffering, with absolutely no history of any previous operations, births, and/or other diseases.

    Perhaps a new body of research, embedding neuroscience and psychoanalyses with Endometriosis in patient-centered studies would contribute to discovering the underlying causes of this disease.

    Huge thanks to Dr. Michel Canis et al. and the conducting team behind this research.

  • Sue Chitwood

    This article has given me new hope and a possible explanation for my 22 years of suffering from severe endometriosis pain.
    I’m obviously not a Dr., but a patient whom was diagnosed with Stage 2 at age 26. I had a laparoscopy with removal of my lesions on one ovary and walls of the uterus. My Dr. had noticed that I had a staple that was embedded into my skin from an appendectomy performed by laparoscopy 3 years prior.
    I don’t recall having any pain before the appendectomy, which was performed prior to starting my Masters Degree. After finishing school, I was in debilitating pain. My Dr. didn’t believe the staple had anything to do with my endometriosis, but now I’m questioning it again.
    I’m now 47, have luckily had 2 daughters, but had Lupron Depot, Depo-Provera, Mirena IUD, an ablation, Nuvaring and am now off everything because eventually the stabbing endometriosis pains occur more than monthly.
    After reading your study, I had to send you my story because my current Gynecologist is at a loss of where to go from here. Could you please contact me with some direction of whom I could speak with? Thank you!

  • It was a pleasure to read this stimulating opinion paper by
    Michel Canis et al. The authors question the concept that endometriosis is a
    progressive and/or recurrent disease and discuss the role of trauma and of the local
    tissue of implantation.

    We fully agree that most endometriosis lesions must have
    been progressive in the past but at the moment of diagnosis, most typical or
    deep lesions are no longer progressive as suggested by clinical observation. Some
    deep lesions however seem to be different. A small number of deep lesions (in
    our experience some 6 in 3000 deep nodules) is growing fast and is very proliferative at
    surgery. In addition, some deep lesions might react differently to steroid hormones
    as evidenced by bowel perforations during pregnancy.

    To the concept of trauma as initiating and growth promoting factors
    we would like to add IVF in the presence of a recto-vaginal nodule. A few IVF cycles with puncture through the
    nodule seems strongly associated with a frozen pelvis, active endometriosis and
    very difficult subsequent surgery. It seems as if the trauma of oocyte pick-up
    reactivates the deep endometriosis. If substantiated this, would be a strong argument to perform surgery before IVF is started, at
    least in low deep endometriosis.

    To the concept of the interaction between tissue of implantation
    and endometriosis we would add the specific hormonal environment of the ovary. The local concentrations in the ovary indeed
    are much-much higher than in plasma and the local immunosuppressive effect of
    the huge progesterone concentrations have been linked to the preferential
    metastasis in the ovary, known as the Krükenberg tumour. Along the same line we like to remind that
    also in peritoneal fluid both estrogen and progesterone concentrations are much
    higher than in plasma, also in the follicular phase.

    The concept described in this article still considers
    endometriosis as ectopic endometrium. For arguments detailed in the
    Endometriotic disease theory of 1999, especially that deep and cystic endometriosis are clonal in origin,
    we prefer to consider typical, deep and cystic endometriosis as a genetic
    mutation, similar to most myoma’s. Subtle endometriosis thus becomes a normal
    phenomenon occurring intermittently in most women.

    Philippe R. Koninckx

    Anastasia Ussia

    Gruppo Italo Belga, Villa del Rosario, Rome

    • Michel Canis

      We thank doctor Koninckx and Usia for their comments. I aggree with their comments about the hormonal environment particulalrly in the ovary. IVF is certainly sometimes followed by severe and or extensive pelvic adhésions which may also be related to underestimated or undiagnosed post IVF infection..
      we have no strong opinion on the origin of endometriotic tissue, different origins do not make much difference, the question is rather why the disease starts and is this cause permanent or not. If the cause is not permanent, we do not understand why most experts consider that endometriosis is a chronic disease with an almost 100% risk of recurrence. If this risk is so high, I do not understand the rationale for surgery. In contrast in our practice, the risk of true recurrence, new disease after complete excision seems to be rather rare. So that endometriosis is probably not a chronic disease in most cases.
      We are looking for a correct, reliable and convenient way to diagnose endometritis associated with endometriosis and would be interested in opinion of this important question, as we have the impression that this association is more common that usually reported
      Michel Canis

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