Endometriosis is found in approximately 10% of women and can cause severe pelvic pain and infertility. It is important to diagnose endometriosis early and start management as soon as possible. Hormonal management is often the first line of treatment and may consist of continuous birth control pills, progesterone, hormonal IUD and other options. However, if this fails, surgery is usually the next step. It is imperative to have an experienced surgeon perform the surgery since endometriosis can be subtle and easily missed in early stages and extremely challenging to excise fully in later stages. Generally, the disease starts to develop at the onset of menses and gradually develops from then. The endometriosis lesions usually start at the surface of the lining of the abdomen, but with time they invade deeper into the tissues. If the patient is not adequately diagnosed and treated, endometriosis can start to invade pelvic organs such as the bowel, bladder, ureter and nerves and it may also invade the diaphragm and thoracic cavity. There are two main surgical methods to treat endometriosis, ablation, and excision. Ablation basically means burning the lesion with electrosurgery while excision means cutting away the lesion and removing it. While both may work well for superficial lesions, excision is clearly superior in deeper more fibrotic lesions and it also has the advantage of getting pathologic confirmation of what was treated in the patient. Also, even in superficial lesions, excision is probably better since this method allows the surgeon to remove good margins around visible lesions, thereby reducing the risk of recurrence. Endometriosis can come back, even in the best of hands and the risk of recurrence is associated with age, i.e. it is more common in young patients. The overall risk of recurrence varies, with a recent study showing the risk of reoperation in expert hands being 28% within 10 years. The risk of reoperation is reduced if a hysterectomy is performed, but this is reserved for patients who have completed their childbearing. This reduction of risk may be due to the fact that many patients with endometriosis also have a condition called adenomyosis, which is essentially endometriosis of the uterine wall. Adenomyosis is found in all age groups, but is more common in patients who are in their 30’s and 40’s. Adenomyosis may not be seen during the surgery for endometriosis since it is inside the uterine muscle, but it is generally seen on imaging. Preoperative imaging is very important in patients with suspected endometriosis and adenomyosis and may consist of pelvic ultrasound and MRI.

It is important to set appropriate expectations in patients having surgery for endometriosis and pelvic pain. Pelvic pain may be multifactorial, i.e. not just from endometriosis and therefore not all patients get better after surgery. Many get partially better and some are completely better. In a recent study by Dr. Einarsson, he found that patients that had surgery had on average pain at 9 out of 10 before surgery, but 4 out of 10 after surgery. This means most patients experienced significant symptom relief, but not all of them. Patients also on average missed 3.6 fewer days of work or school after surgery as compared to before surgery. Their quality of life was also significantly improved. In patients who do not fully improve, it is important to continue to seek for reasons and solutions. For example, many women with chronic pelvic pain have pelvic floor dysfunction and it is important to recognize and treat this. Sometimes collaboration with other specialties such as gastroenterology and urology is needed as well.