Surgery for endometriosis

Endometriosis can often be treated during a laparoscopy. In this minimally invasive (keyhole) surgery procedure, the doctor inserts narrow tubes with a camera and surgical instruments into your abdomen (belly) through small cuts. In rare cases, the surgery is done using a classic abdominal incision. Known as a laparotomy, this involves making a larger cut across the wall of your abdomen. Laparoscopy is a more gentle procedure.

In both of these approaches, endometriosis tissue is removed under general anesthesia. The tissue can be removed in two ways, known as ablation and excision:

• In ablation, the tissue is destroyed and removed using heat, electricity (diathermy) or other energy source.
• In an excision, the tissue is cut out.

These two approaches are considered to be similarly effective. But research has found excision to be somewhat better.

The procedure can either be done as a day procedure or as an outpatient procedure, where you need to stay overnight. Whether you need to stay in the hospital afterwards, and for how long, will depend on things like how big the surgery was and whether you have chronic pain. Doctors usually recommend that you take it easy for about two to three weeks, and avoid lifting heavy objects or doing intense exercise during that time. The right time to return to work will vary from woman to woman, too. That will depend on how big the surgery was and what kind of work you do. If your job isn’t very physically demanding, you will probably be able to return to work soon after leaving the hospital.

If problems like a fever, severe abdominal pain or bleeding occur after the surgery, it’s important to see a doctor as soon as possible.

There are only a few good-quality studies on how well this surgery works in endometriosis. These suggest that it can relieve the symptoms in some women. After six months, endometriosis pain had decreased in

• about 27 out of 100 women who had no surgery and
• about 72 out of 100 women who had surgery.

The research mainly focused on surgery to remove areas of endometriosis tissue (implants) in mild to moderate endometriosis. There is a lack of good-quality research on more severe forms of the disease.

In about 1 out of 100 women, the surgery leads to organ injuries or other complications such as infections and heavy bleeding. And the symptoms may not go away after the surgery, or may return after some time. This is because endometriosis tissue can grow again.

Whether or not surgery helps will also depend on where the endometrial implants are located in the body. If there are a lot of them in many different places, surgery will be more complicated and carry greater risks. This is particularly true of implants that are found deep inside the pelvis, around the bladder and on the bowel. Then surgery is more likely to result in bladder or bowel injuries.

If you've already had endometriosis surgery once, further endometriosis surgery is generally not recommended because it could make chronic pain worse, in particular.

Some women use certain hormone-based treatments before and/or after having a laparoscopy. The options here include progestins, the birth control pill, the hormonal coil (IUD) and GnRH analogs.

The hormones are meant to shrink endometrial implants, reduce the activity of endometriosis tissue that hasn't been removed, and prevent new tissue from growing. Research suggests that using hormones after the surgery reduces the risk of new endometrial implants growing. But using hormones before the surgery has not been proven to have any benefits. Women who are already using hormones don't have to stop using them before the surgery, though.

Endometriosis can reduce your fertility. But removing endometriosis tissue through laparoscopic surgery can increase your chances of getting pregnant. Research found that women who had this surgery were more likely to become pregnant: After one year, around 20 out of 100 women who did not have surgery were pregnant, compared to around 30 out of 100 women who had surgery.

The research focused on surgery to remove endometriosis tissue in mild to moderate forms of the disease. It is not clear how much surgery can help in more severe forms.

If endometriosis causes fertility problems, other treatments can be considered – including hormone therapy and artificial insemination. You can contact a fertility center for advice on these options.

Hysterectomy (surgery to remove the womb) is rarely recommended in the treatment of endometriosis. Women generally only consider having a hysterectomy if their endometriosis is a major problem in everyday life, other treatments haven't helped, and they're sure that they don't want to have any (more) children. Having this kind of surgery only makes sense if it's likely to lead to an improvement in symptoms. This is mainly the case if the endometriosis tissue is inside the wall of the womb. Endometriosis tissue found near to the womb can be removed during this surgery, too.

Two types of hysterectomy can be done: In a partial hysterectomy, only the womb is removed. The cervix, fallopian tubes and ovaries remain in place. In a total hysterectomy, the womb and cervix are removed completely. Depending on the situation, the fallopian tubes and ovaries may be removed as well.

Removing the womb alone doesn't guarantee that the endometriosis will be gone afterwards. If the ovaries aren't removed as well, women are more likely to still have endometriosis symptoms.

If the ovaries are removed too, then any remaining endometriosis tissue in the body will stop getting the hormones it needs to grow. This won't happen if only one of the ovaries is removed. But if both ovaries are no longer there, no female sex hormones will be made, and you will enter menopause quite abruptly. That can lead to things like hot flashes, sleep problems, vaginal dryness and mood swings. So it's important to carefully consider the pros and cons of removing the ovaries before making a decision.

In some women, the problems caused by the drop in hormones after surgery are so severe that they wish to take estrogen. This hormone therapy might make the endometriosis symptoms return.

In about 5 out of 100 women, a hysterectomy leads to complications such as organ injuries, bleeding or infections. Like all types of abdominal surgery, it can also result in adhesions (scarring that causes tissue to stick together), which can lead to pain or bowel problems.