Endometriosis is a chronic disease. In that sense, there is no cure for endometriosis, but the symptoms can
Surgical treatment involves the elimination of endometriosis lesions, division of adhesions and interruption of nerve pathways. Laparoscopic (key hole) surgery is preferred to laparotomy (open surgery) as it improves visibility of lesions and is associated with better patient outcomes such as less pain, smaller incisions, faster recovery and less risk of infection. Elimination of endometriosis may be achieved by excision, other techniques in use are called ablative techniques (diathermy/coagulation/evaporation). Adhesions are divided to help restore pelvic anatomy, and interruption of pelvic nerve pathways is carried out with the intention of improving pain control.
The evidence showing differences between excision and ablation is lacking, due to poorly performed studies, no randomised control trials, no difference been made between stages of endometriosis and not considering surgeon skill and experience in the reviews carried out. It is hoped that with current research that stronger evidence will be found. In speaking to surgeons who carry out hundreds of endometriosis surgeries annually, their method of choice is excision. There are many ways to excise, but the end results are the same – the physical removal of the endometriosis lesion and surrounding tissue. This is important for a number of reasons – endometriosis lesions can be wide as well as deep – but most importantly the tissue can be sent to the laboratory for histopathology. This examination at microscopic level will show that the lesions removed were endometriosis (or not) and if there are clear margins around the lesion. When ablation is used, the tissue is vaporised and destroyed. There is no tissue to send to the laboratory. Ablation can also lead to localised inflammation and endometriosis being left in place under the charred surface of the peritoneum.
The ESHRE guideline group concluded that “Ablation and excision of peritoneal disease are thought to be equally effective for treatment of endometriosis-associated pain. However, this information comes from one small study and a larger one with suboptimal design; hence their conclusions should be treated with caution. Excision of lesions could be preferred with regard to the possibility of retrieving samples for histology. Furthermore, ablative techniques are unlikely to be suitable for advanced forms of endometriosis with deep endometriosis component.”
ESHRE Recommendations
When endometriosis is identified at laparoscopy, clinicians are recommended to surgically treat endometriosis, as this is effective for reducing endometriosis-associated pain i.e. ‘see and treat’
Clinicians can consider performing surgical removal of deep endometriosis, as it reduces endometriosis-associated pain and improves quality of life
Recommends that clinicians refer women with suspected or diagnosed deep endometriosis to a centre of expertise that offers all available treatments in a multidisciplinary context.
Surgical Interruption of Nerve Pathways
Severing the nerves to the pelvic and uterine area was considered a possible treatment for endometriosis related pain.
LUNA - Laparoscopic Uterosacral Nerve Ablation and PSN - PreSacral Nerve Ablation are the two most commonly used techniques. Both techniques are offered as part of a surgical treatment plan for endometriosis.
It can be concluded that LUNA is not beneficial as an additional procedure to conservative surgery for endometriosis, as it offers no additional benefit over surgery alone (Proctor, et al., 2005).
PSN is beneficial for the treatment of endometriosis-associated midline pain as an adjunct to conservative laparoscopic surgery, but it should be stressed that PSN requires a high degree of skill and is associated with increased risk of adverse effects such as bleeding, constipation, urinary urgency and painless first stage of labour.
Surgical treatment of ovarian endometrioma (Chocolate Cysts)
Ovarian endometrioma are difficult to treat, a paper produced by a European working group looked at the different types of surgery for endometrioma. They concluded that drug therapies may be used to treat endometriosis, but when endometriomas are found and need treatment, surgery is often required. There are risks associated with surgery as it can damage the follicles in the ovaries and reduce fertility. The working group looked at the main types of surgery which are used to treat endometriomas in women who may want to have children in the future. They considered cystectomy, where the cyst is cut out, ablation, where the cyst lining is removed by using a laser beam or plasma energy, and electrosurgery, where an electric current is used. They also looked at the effectiveness of combining different types of surgery.
Removal of endometrioma is a balance between effective removal and preservation of ovarian reserve (fertility) and this should be carefully discussed with the surgeon. Removal of endometrioma can cause damage to the ovarian reserve (fertility). It is important to discuss this with your surgeon and consider the risks and outcomes. Your surgeon may offer a blood test to estimate AMH (Anti Mullerian Hormone) and a scan (Antral Follicle Count) to help determine fertility potential prior to surgery and again at a minimum of 6 months post surgery.
Treating endometrioma is a case by case decision, be sure to ask for individual guidance from your surgeon and fertility specialist (if necessary). It is important to choose a skilled and experienced surgeon.
Hysterectomy and Oopherectomy
Hysterectomy (removal of the uterus with or without the cervix and fallopian tubes)
If a woman has no future desire to have children (or has completed her family) and the uterus is considered a source of pain, removal of the uterus (hysterectomy) can be considered. Conditions that can lead to pain include adenomyosis and fibroids. Adenomyosis is a condition that causes similar pain to endometriosis. It can only be definitively diagnosed by removing the uterus and sending it to the laboratory. Heavy periods (menorrhagia) is another reason that women choose a hysterectomy. It is important to note that removing the uterus will not impact on endometriosis. Endometriosis does not come from the uterus. All endometriosis should be removed at the time of hysterectomy. If the disease is left behind it may continue to cause symptoms. Endometriosis will not "dry up" or disappear when the uterus is removed.
Removal of the ovaries is radical surgery, it results in so-called surgical menopause with the side effects of menopause and long term health effects. It has to be mentioned that hysterectomy alone will not solve the problem since most of the time endometriosis is left behind and hence the pain symptoms remain present.
Removing the ovaries (when the tissue is healthy) has a long term impact on the health and quality of life for the woman. It is not a decision to take lightly. Removing the ovaries will not cause the endometriosis lesions to "dry up" or disappear. The removal of hormones (produced by ovaries) can help reduce symptoms, but it is important to note that endometriosis lesions can create their own oestrogen. This combined with residual oestrogen and the risk of ovarian remnant syndrome can lead to persistence of severe symptoms.
It is essential to discuss both a hysterectomy and oopherectomy (ovarian removal) with your surgeon. It should be made very clear that the removal of your organs alone will not treat endometriosis.
The ESHRE guideline recommends that clinicians only consider hysterectomy with removal of the ovaries and all visible endometriotic lesions, in women who have completed their family and failed to respond to more conservative treatments. Women should be informed that hysterectomy and removal of the ovaries will not necessarily cure the symptoms or the disease.
Medical Treatment Pre/Post Surgery
Medical (Hormonal) Treatments
There is some controversy on this subject as hormonal treatment is so widespread.
The ESHRE guideline group does not recommend hormonal treatment before surgery to improve the results of the surgery. Of course, many women in pain get hormonal treatment during a waiting period before surgery. After surgery, starting with an oral contraceptive pill or using a levonorgestrel-intrauterine device (Mirena) may prevent recurrence of pain.
Recommendations
Clinicians should not prescribe preoperative hormonal treatment to improve the outcome of surgery for pain in women with endometriosis
After cystectomy for ovarian endometrioma in women not immediately seeking conception, clinicians are recommended to prescribe hormonal contraceptives for the secondary prevention of endometrioma (chocolate cysts)
In women operated on for endometriosis, clinicians are recommended to prescribe postoperative use of a levonorgestrel-releasing intrauterine system (Mirena) or a combined hormonal contraceptive for at least 18–24 months, as one of the options for the secondary prevention of endometriosis-associated dysmenorrhea (period pain), but not for non-menstrual pelvic pain or dyspareunia (painful sex).
-
Surgical Interruption of Nerve Pathways
Severing the nerves to the pelvic and uterine area was considered a possible treatment for endometriosis related pain.
LUNA - Laparoscopic Uterosacral Nerve Ablation and PSN - PreSacral Nerve Ablation are the two most commonly used techniques. Both techniques are offered as part of a surgical treatment plan for endometriosis.
It can be concluded that LUNA is not beneficial as an additional procedure to conservative surgery for endometriosis, as it offers no additional benefit over surgery alone (Proctor, et al., 2005).
PSN is beneficial for the treatment of endometriosis-associated midline pain as an adjunct to conservative laparoscopic surgery, but it should be stressed that PSN requires a high degree of skill and is associated with increased risk of adverse effects such as bleeding, constipation, urinary urgency and painless first stage of labour.
-
Surgical treatment of ovarian endometrioma (Chocolate Cysts)
Ovarian endometrioma are difficult to treat, a paper produced by a European working group looked at the different types of surgery for endometrioma. They concluded that drug therapies may be used to treat endometriosis, but when endometriomas are found and need treatment, surgery is often required. There are risks associated with surgery as it can damage the follicles in the ovaries and reduce fertility. The working group looked at the main types of surgery which are used to treat endometriomas in women who may want to have children in the future. They considered cystectomy, where the cyst is cut out, ablation, where the cyst lining is removed by using a laser beam or plasma energy, and electrosurgery, where an electric current is used. They also looked at the effectiveness of combining different types of surgery.
Removal of endometrioma is a balance between effective removal and preservation of ovarian reserve (fertility) and this should be carefully discussed with the surgeon. Removal of endometrioma can cause damage to the ovarian reserve (fertility). It is important to discuss this with your surgeon and consider the risks and outcomes. Your surgeon may offer a blood test to estimate AMH (Anti Mullerian Hormone) and a scan (Antral Follicle Count) to help determine fertility potential prior to surgery and again at a minimum of 6 months post surgery.
Treating endometrioma is a case by case decision, be sure to ask for individual guidance from your surgeon and fertility specialist (if necessary). It is important to choose a skilled and experienced surgeon.
-
Hysterectomy and Oopherectomy
Hysterectomy (removal of the uterus with or without the cervix and fallopian tubes)
If a woman has no future desire to have children (or has completed her family) and the uterus is considered a source of pain, removal of the uterus (hysterectomy) can be considered. Conditions that can lead to pain include adenomyosis and fibroids. Adenomyosis is a condition that causes similar pain to endometriosis. It can only be definitively diagnosed by removing the uterus and sending it to the laboratory. Heavy periods (menorrhagia) is another reason that women choose a hysterectomy. It is important to note that removing the uterus will not impact on endometriosis. Endometriosis does not come from the uterus. All endometriosis should be removed at the time of hysterectomy. If the disease is left behind it may continue to cause symptoms. Endometriosis will not "dry up" or disappear when the uterus is removed.Removal of the ovaries is radical surgery, it results in so-called surgical menopause with the side effects of menopause and long term health effects. It has to be mentioned that hysterectomy alone will not solve the problem since most of the time endometriosis is left behind and hence the pain symptoms remain present.
Removing the ovaries (when the tissue is healthy) has a long term impact on the health and quality of life for the woman. It is not a decision to take lightly. Removing the ovaries will not cause the endometriosis lesions to "dry up" or disappear. The removal of hormones (produced by ovaries) can help reduce symptoms, but it is important to note that endometriosis lesions can create their own oestrogen. This combined with residual oestrogen and the risk of ovarian remnant syndrome can lead to persistence of severe symptoms.
It is essential to discuss both a hysterectomy and oopherectomy (ovarian removal) with your surgeon. It should be made very clear that the removal of your organs alone will not treat endometriosis.
The ESHRE guideline recommends that clinicians only consider hysterectomy with removal of the ovaries and all visible endometriotic lesions, in women who have completed their family and failed to respond to more conservative treatments. Women should be informed that hysterectomy and removal of the ovaries will not necessarily cure the symptoms or the disease.
-
Medical Treatment Pre/Post Surgery
Medical (Hormonal) Treatments
There is some controversy on this subject as hormonal treatment is so widespread.
The ESHRE guideline group does not recommend hormonal treatment before surgery to improve the results of the surgery. Of course, many women in pain get hormonal treatment during a waiting period before surgery. After surgery, starting with an oral contraceptive pill or using a levonorgestrel-intrauterine device (Mirena) may prevent recurrence of pain.Recommendations
Clinicians should not prescribe preoperative hormonal treatment to improve the outcome of surgery for pain in women with endometriosis
After cystectomy for ovarian endometrioma in women not immediately seeking conception, clinicians are recommended to prescribe hormonal contraceptives for the secondary prevention of endometrioma (chocolate cysts)In women operated on for endometriosis, clinicians are recommended to prescribe postoperative use of a levonorgestrel-releasing intrauterine system (Mirena) or a combined hormonal contraceptive for at least 18–24 months, as one of the options for the secondary prevention of endometriosis-associated dysmenorrhea (period pain), but not for non-menstrual pelvic pain or dyspareunia (painful sex).
References
Ahmad G, Duffy JM, Farquhar C, Vail A, Vandekerckhove P, Watson A and Wiseman D. Barrier agents for adhesion prevention after gynaecological surgery. Cochrane Database Syst Rev 2008:CD000475. https://doi.org/10.1002/14651858.CD000475.pub2
Beretta P, Franchi M, Ghezzi F, Busacca M, Zupi E and Bolis P. Randomized clinical trial of two laparoscopic treatments of endometriomas: cystectomy versus drainage and coagulation. Fertil Steril 1998; 70:1176–1180. https://doi.org/10.1016/S0015-0282(98)00385-9
Bergqvist A. Extragenital endometriosis. A review. Eur J Surg 1992; 158:7–12.
Joseph J and Sahn SA. Thoracic endometriosis syndrome: new observations from an analysis of 110 cases. Am J Med 1996; 100:164–170. https://www.ncbi.nlm.nih.gov/pubmed/1348646
Busacca M, Riparini J, Somigliana E, Oggioni G, Izzo S, Vignali M and Candiani M. Postsurgical ovarian failure after laparoscopic excision of bilateral endometriomas. Am J Obstet Gynecol 2006; 195:421–425. https://doi.org/10.1016/j.ajog.2006.03.064
Carmona F, Martínez-Zamora MA, Rabanal A, Martínez-Román S and Balasch J. Ovarian cystectomy versus laser vaporization in the treatment of ovarian endometriomas: a randomized clinical trial with a five-year follow-up. Fertil Steril 2011; 96:251–254. https://doi.org/10.1016/j.fertnstert.2011.04.068
Daraï E, Dubernard G, Coutant C, Frey C, Rouzier R and Ballester M. Randomized trial of laparoscopically assisted versus open colorectal resection for endometriosis: morbidity, symptoms, quality of life, and fertility. Ann Surg 2010; 251:1018–1023. https://doi.org/10.1097/SLA.0b013e3181d9691d
Daraï E, Lesieur B, Dubernard G, Rouzier R, Bazot M and Ballester M. Fertility after colorectal resection for endometriosis: results of a prospective study comparing laparoscopy with open surgery. Fertil Steril 2011; 95:1903–1908. https://doi.org/10.1016/j.fertnstert.2011.02.018
De Cicco C, Corona R, Schonman R, Mailova K, Ussia A and Koninckx P. Bowel resection for deep endometriosis: a systematic review. BJOG 2011; 118:285–291. https://doi.org/10.1111/j.1471-0528.2010.02744.x
Donnez J and Squifflet J. Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by the shaving technique for deep rectovaginal endometriotic nodules. Hum Reprod 2010; 25:1949–1958. https://doi.org/10.1093/humrep/deq135
Duffy JMN, Arambage K, Correa FJS, Olive D, Farquhar C, Garry R, Barlow DH, Jacobson TZ. Laparoscopic surgery for endometriosis. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD011031. DOI: https://doi.org/10.1002/14651858.CD011031.pub2.
Furness S, Yap C, Farquhar C and Cheong YC. Pre and post-operative medical therapy for endometriosis surgery. Cochrane Database Syst Rev 2004:CD003678. [New search for studies, and content updated (no change to conclusions), published in Issue 1, 2011.] https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003678.pub2/epdf/full
Hart RJ, Hickey M, Maouris P, Buckett W. Excisional surgery versus ablative surgery for ovarian endometriomata. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD004992. DOI: https://doi.org/10.1002/14651858.CD004992.pub3.
Healey M, Ang WC and Cheng C. Surgical treatment of endometriosis: a prospective randomized double-blinded trial comparing excision and ablation. Fertil Steril 2010; 94:2536–2540. DOI https://doi.org/10.1016/j.fertnstert.2010.02.044
Jacobson TZ, Duffy JM, Barlow D, Koninckx PR and Garry R. Laparoscopic surgery for pelvic pain associated with endometriosis. Cochrane Database Syst Rev 2009:CD001300. https://doi.org/10.1002/14651858.CD001300.pub2
Jubanyik KJ and Comite F. Extrapelvic endometriosis. Obstet Gynecol Clin North Am 1997; 24:411–440.
Liang CC, Tsai CC, Chen TC and Soong YK. Management of perineal endometriosis. Int J Gynaecol Obstet 1996; 53:261–265.
Kondo W, Bourdel N, Tamburro S, Cavoli D, Jardon K, Rabischong B, Botchorishvili R, Pouly J, Mage G and Canis M. Complications after surgery for deeply infiltrating pelvic endometriosis. BJOG 2011; 118:292–298. https://doi.org/10.1111/j.1471-0528.2010.02774.x
Martin DC. Hysterectomy for treatment of pain associated with endometriosis. J Minim Invasive Gynecol 2006; 13:566–572. https://doi.org/10.1016/j.jmig.2006.06.022
Marinis A, Vassiliou J, Kannas D, Theodosopoulos TK, Kondi-Pafiti A, Kairi E and Smyrniotis V. Endometriosis mimicking soft tissue tumors: diagnosis and treatment. Eur J Gynaecol Oncol 2006; 27:168–170. https://www.ncbi.nlm.nih.gov/pubmed/3989058
Meuleman C, D'Hoore A, Van Cleynenbreugel B, Tomassetti C and D'Hooghe T. Why we need international agreement on terms and definitions to assess clinical outcome after endometriosis surgery. Hum Reprod 2011a; 26:1598–1599; comment on Donnez and Squifflet, 2010; author reply 1599–1600. https://doi.org/10.1093/humrep/det457
Meuleman C, Tomassetti C, D'Hoore A, Van Cleynenbreugel B, Penninckx F, Vergote I and D'Hooghe T. Surgical treatment of deeply infiltrating endometriosis with colorectal involvement. Hum Reprod Update 2011b; 17:311–326. https://doi.org/10.1093/humupd/dmq057
Mossa B, Ebano V, Tucci S, Rega C, Dolce E, Frega A and Marziani R. Laparoscopic surgery for the management of ovarian endometriomas. Med Sci Monit 2010; 16:MT45–50. https://www.medscimonit.com/download/index/idArt/878489
Nezhat C, Hajhosseini B and King LP. Robotic-assisted laparoscopic treatment of bowel, bladder, and ureteral endometriosis. JSLS 2011; 15:387–392. https://doi.org/10.4293/108680811X13125733356396
Nissotakis C, Zouros E, Revelos K and Sakorafas GH. Abdominal wall endometrioma: a case report and review of the literature. AORN 2010; 91:730–742; quiz 743-735. https://doi.org/10.1016/j.aorn.2010.01.014
Nisolle M, Pasleau F and Foidart JM. [Extragenital endometriosis]. J Gynecol Obstet Biol Reprod (Paris) 2007; 36:173–178. https://doi.org/10.1016/j.jgyn.2006.12.010
Proctor M, Latthe P, Farquhar C, Khan K and Johnson N. Surgical interruption of pelvic nerve pathways for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev 2005:CD001896. [Edited (no change to conclusions), published in Issue 11, 2010.] https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001896.pub2/full
Saridogan, E., Becker, C., Feki, A., Grimbizis, G., Hummelshoj, L., & Keckstein, J. et al. (2017). Recommendations for the Surgical Treatment of Endometriosis. Part 1: Ovarian Endometrioma†‡¶. Human Reproduction Open, 2017(4). doi: https://doi.org/10.1093/hropen/hox016
Song JY, Borncamp E, Mehaffey P and Rotman C. Large abdominal wall endometrioma following laparoscopic hysterectomy. JSLS 2011; 15:261–263. https://dx.doi.org/10.4293%2F108680811X13071180407078
Trew G, Pistofidis G, Pados G, Lower A, Mettler L, Wallwiener D, Korell M, Pouly JL, Coccia ME, Audebert A et al. Gynaecological endoscopic evaluation of 4% icodextrin solution: a European, multicentre, double-blind, randomized study of the efficacy and safety in the reduction of de novo adhesions after laparoscopic gynaecological surgery. Hum Reprod 2011; 26:2015–2027 https://doi.org/10.1093/humrep/der135
Veeraswamy A, Lewis M, Mann A, Kotikela S, Hajhosseini B and Nezhat C. Extragenital endometriosis. Clinical obstetrics and gynecology 2010; 53:449–466 https://doi.org/10.1097/GRF.0b013e3181e0ea6e
Wright J, Lotfallah H, Jones K and Lovell D. A randomized trial of excision versus ablation for mild endometriosis. Fertil Steril 2005; 83:1830–1836. DOI https://doi.org/10.1016/j.fertnstert.2004.11.066
Download our Brochure
Download the Endometriosis Assocation Of Ireland Brochure [PDF Format]