Endometriosis Surgery: Your Guide to Options & Recovery

Understanding Endometriosis Surgery  

What Are the Main Causes of Endometriosis Symptoms?

The main cause of endometriosis symptoms is the growth of the tissue that lines the inside of the uterus (womb) in places outside the uterus. Endometriosis affects reproductive organs such as the ovaries, fallopian tubes, and the lining of the pelvis. Different types of endometriosis lesions include:

• Superficial endometriosis in the lining of the pelvis.

• Cystic ovarian endometriosis (endometrioma) in the ovaries. 

• Deep infiltrating endometriosis in the wall between the rectum and vagina or on the bladder or bowel.

• Endometrial tissue outside the pelvis (rare).

Endometrial tissue outside the uterus undergoes changes with hormonal fluctuations (changes in progestin and estrogen levels) during the menstrual cycle. But, unlike the uterine lining, it is not eliminated from the body during a menstrual period. This causes symptoms of endometriosis. Irritation of surrounding tissue can lead to the formation of scar tissue.

Endometriosis symptoms include pain symptoms (painful menstrual cramps, pain during sexual intercourse, and pain with urination and bowel movements). In addition, endometriosis can cause heavy menstrual bleeding, bleeding between periods, and infertility. Besides endometriosis pain, other symptoms may include fatigue, nausea, bloating, diarrhea, and constipation.

Definition and Purpose of Endometriosis Surgery

Endometriosis surgery is a type of excision surgery. It is done to excise (remove) endometrial tissue from the body (tissue that is similar to the uterus lining grows in other places outside of the uterus)). Three main types of operations for endometriosis include laparoscopy, laparotomy, and hysterectomy. However, laparoscopy for endometriosis is the most common. 

How is Endometriosis Diagnosed?

Healthcare providers can diagnose endometriosis based on symptoms, medical history, a pelvic exam, and imaging tests (transvaginal ultrasound and magnetic resonance imaging or MRI). Sometimes, a laparoscopic procedure is done, which allows the surgeon to directly look at the inside of the abdomen for evidence of endometriosis tissue.

How is Endometriosis Treated?

Pain medications and hormone therapy are used to treat endometriosis and can usually improve symptoms of minimal or mild endometriosis. 

Over-the-counter and prescription nonsteroidal anti-inflammatory drugs (NSAIDs) can provide short-term pain relief. Hormone therapy can provide long-term relief, but the symptoms of endometriosis can come back after you stop treatment. 

Treatment options in hormone therapy for endometriosis may include:

• Oral contraceptives: Birth control pills, patches, vaginal rings, or shots help to regulate hormone levels to suppress ovulation and menstruation. You may need to take combination oral contraceptive pills without a break for 3 months. If you get relief, you may continue the treatment for 6-12 months. The chances of pregnancy after stopping treatment are 40-50%. Examples of birth control pills for endometriosis treatment include desogestrel and ethinyl estradiol (Ortho-Cept, Desogen, Velivet, Cyclessa, Azurette) and norgestimate ethinyl estradiol (Tri-Sprintec, Ortho-Cyclen, Ortho Tri-Cyclen).

• Progesterone-only medications to help stop menstruation and endometrial tissue growth. Examples include norethindrone acetate (Aygestin, Errin, Camila), medroxyprogesterone (Provera, Depo-Provera), and megestrol (Megace).

• Gonadotropin-releasing hormone (GnRH) agonists and antagonists to stop ovarian hormones that cause menstrual cycles. 

  • Gonadotropin-releasing hormone (GnRH) agonists: goserelin (Zoladex), leuprolide (Eligard, Lupron Depot), and nafarelin (Synarel).

  • Gonadotropin-releasing hormone (GnRH) antagonists: elagolix (Orilissa) and relugolix/estradiol/norethindrone (Myfembree).

• Synthetic steroid analogs such as danazol (Danocrine) to relieve painful symptoms of endometriosis.

• Aromatase inhibitors such as letrozole (Femara) to lower estrogen levels. However, this is not routinely used. Aromatase inhibitors are prescribed off-label in some cases to treat endometriosis for patients who aren’t planning to get pregnant. 

Note: It is common for people with endometriosis to experience infertility (trouble getting pregnant). For women who wish to become pregnant, other treatments such as assisted reproduction, for example, medications to stimulate ovulation or in vitro fertilization (IVF) are potential options.

When is Surgical Treatment Recommended to Treat Endometriosis?

Doctors recommend surgical treatment for endometriosis in women who have severe symptomatic endometriosis and in whom medical treatment has not helped. In this case, a healthcare provider may recommend a surgical procedure for the treatment of endometriosis.

Types of Surgical Management for More Severe Endometriosis

Treatment of endometriosis with surgery can be broadly classified as:

• Conservative endometriosis surgery: This type of endometriosis surgery involves removing only the affected tissue while leaving the ovaries and uterus intact. It is done to relieve symptoms in women who are trying to get pregnant or plan to have children in the future.

• Hysterectomy and bilateral salpingo-oophorectomy: This type of endometriosis surgery involves the removal of the uterus, cervix, and both ovaries and fallopian tubes. It is typically reserved as a last resort in women with significant symptoms from endometriosis who have not responded to medications used to treat endometriosis. Some experts in reproductive medicine recommend careful removal of endometriosis tissue over hysterectomy surgery for endometriosis, even in severe cases.

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Surgical Options for Endometriosis  

The three main types of operations for endometriosis are:

Laparoscopy Surgery

Laparoscopy surgery is the most common type of endometriosis surgery. It is a minimally invasive procedure (keyhole surgery) done by skilled surgeons with specialist training. Laparoscopy endometriosis surgery involves making one or more small incisions (cuts) in the abdominal wall. A thin instrument called a laparoscope is inserted through an incision. This instrument has a camera at its tip that allows the surgeon to visualize and remove endometrial tissue.

Laparotomy Surgery  

Laparotomy surgery is a more invasive procedure and involves making one large incision in the abdomen. The surgeon may recommend this surgical procedure if you have severe endometriosis or cannot undergo a minimally invasive procedure. Laparotomy surgery is not a commonly done endometriosis surgery because of how invasive it is. 

Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy

Hysterectomy and bilateral salpingo-oophorectomy is a major surgery that involves surgical removal of the uterus, cervix, both ovaries and fallopian tubes through an incision in the abdomen. 

This endometriosis surgery will stop menstrual periods. You cannot become pregnant or bear children afterward (this is called surgical menopause). You may experience menopausal symptoms such as hot flashes and vaginal dryness post-hysterectomy. Other risks of hysterectomy include bone loss, increased cardiovascular risk, and increased risk of age-related conditions such as dementia. These risks are particularly high when women under 35 years of age undergo a hysterectomy.

Preparing for Endometriosis Surgery  

Pre-Surgery Evaluations 

In preparation for endometriosis surgery, your medical team will perform or obtain:

• A preoperative history and physical exam. The physical exam may consist of a pelvic exam to assess for areas of tenderness, masses, or abnormalities.

• List of current medications and medication allergies.

• Functional assessment to evaluate the need for assistance after hospital discharge

• Laboratory tests to monitor known medical conditions

• Imaging studies such as ultrasound or MRI

• Cardiology consultation if you have cardiovascular disease.

• Pulmonary assessment, chest X-ray, and pulmonary function testing if you have a history of lung disease.

• Nutritional assessment.

Patient Considerations  

The extent of your pre-surgical evaluation will depend on your age and medical history. For example:

• If you are under 40 years of age and otherwise healthy, your healthcare team may check hemoglobin and a urine test for pregnancy before laparoscopy endometriosis surgery.

• If you are above 40 years of age, they may add a blood glucose and ECG test.

• If you are having more invasive open surgery, you may need to undergo a more extensive pre-anesthesia evaluation.

• If you have a history of heart disease and/or diabetes, pre-surgical tests may also include a stress test, ECG, chest X-ray, Cardiology consultation, blood glucose, hemoglobin, BUN, creatinine, and electrolytes.

Risks and Complications  

Endometriosis surgery is generally safe. However, like with all surgical procedures, there is a risk of complications such as infection, damage to blood vessels and bleeding, injury to other pelvic organs such as the bowel or bladder, and fistula formation (abnormal connections between two organs).

Post-Surgery Recovery and Care  

Recovery Timelines

Immediate Post-Operative Care

Once you are discharged from the hospital after endometriosis surgery, you should plan on getting plenty of rest. However, it is also important to gradually start gentle movements and physical activities as advised by your surgeon. 

In addition, proper wound care is essential to prevent infections. You should follow your surgeon’s instructions on caring for your incisions. Seek immediate medical care if you develop increasing pain, redness, swelling, oozing or discharge from the incision, fever of 101 F or higher, heavy vaginal bleeding, or inability to empty your bladder.

Long-Term Recovery  

People with severe symptoms and advanced endometriosis usually take 6 weeks for full recovery, while those with mild endometriosis typically heal faster. In general, recovery is faster after laparoscopy endometriosis surgery compared to open surgery.

Follow-up Care and Monitoring  

You will need to see your doctor in 2-6 weeks for follow-up after your endometriosis surgery to make sure the incisions have healed well.

Outcomes and Prognosis of Endometriosis Surgery  

Endometriosis Pain Relief  

Endometriosis surgery is an effective treatment, and most patients experience significant relief from symptoms of endometriosis after the procedure. However, surgery does not relieve symptoms in about 1 in 5 patients. In patients who do get initial improvement after endometriosis surgery, the symptoms can return over time.

Fertility Outcomes  

In many cases, endometriosis surgery improves the chances of becoming pregnant. A systematic review of studies shows:

• Between 45 and 75% of women are able to get pregnant after endometriosis surgery.

• About 60% of these are natural conceptions achieved without assisted reproductive technology.

However, undergoing surgery for early-stage endometriosis to improve fertility is controversial. Also, if you don’t become pregnant within 6-8 months after endometriosis surgery, it is unlikely that a repeat surgical procedure will be helpful. 

Long-Term Outlook  

Endometriosis surgery is usually successful in providing pain relief, but the symptoms of endometriosis can come back if some endometrial tissue remains and hormonal changes cause it to grow. For this reason, your doctor may prescribe medications such as combined oral contraceptives or progestin-only medications to suppress hormone production by the ovaries.

Common Concerns and Questions  

Is Endometriosis Surgery a Major Surgery?

A laparoscopic endometriosis surgery (minimally-invasive or keyhole surgery) is not a major surgery. This is the most common operation for endometriosis pain. However, treatment of endometriosis with open surgery (laparotomy) or hysterectomy is sometimes necessary and these are major surgeries.

What Is The Best Surgery for Endometriosis?

Laparoscopy is considered the best surgery for endometriosis. This endometriosis medical procedure is minimally invasive and carries a lower risk of complications, such as bleeding, infection, and injury to nearby organs, compared to open surgery (laparotomy or hysterectomy). In addition, laparoscopic endometriosis surgery requires a shorter hospital stay and has a faster recovery time.

What Happens If Endometriosis Is Left Untreated?

Untreated endometriosis can result in chronic pelvic pain and consequent anxiety and depression. Up to half of all people with this condition experience endometriosis-related fertility problems. Seeking timely treatment can improve fertility outcomes in patients desiring a pregnancy. This means that the sooner you get a proper diagnosis and treatment for endometriosis, the higher your chances of getting pregnant after treatment for endometriosis. Other complications of severe endometriosis can include: 

• Ovarian cyst formation (these are called chocolate cysts or endometriomas).

• Bowel and bladder problems if endometriosis affects the pelvic area.

• Chest pain and shortness of breath if the endometriotic tissue grows on the diaphragm or lungs.

Can Surgery Cure Endometriosis?  

There is currently no cure for endometriosis. However, in addition to pain management and hormone therapy, laparoscopic surgery for endometriosis can remove affected tissue, reduce endometriosis pain, and preserve fertility in patients who desire a pregnancy.

What are the Alternatives to Surgery? 

The alternatives to endometriosis surgery are pain medications and hormone therapy. Some people with endometriosis may benefit from complementary treatments and alternative therapies such as acupuncture, chiropractic manipulations, herbal remedies (licorice root, cinnamon), and dietary supplements (vitamin B1, omega-3 fatty acids, magnesium). Doctors recommend surgery for endometriosis when conservative treatments do not help. Remember that herbal supplements should not be used in place of medications. You should talk to your healthcare provider before taking over-the-counter products and herbal supplements to prevent drug interactions leading to harmful complications.