Why Can Endometriosis Return After Surgery?
Causes of endometriosis
It is not clear why endometriosis can recur following surgery. It is also not clear what causes endometriosis to begin with. There are several theories on the development of endometriosis.
Structural and functional abnormalities of the uterus
Structural defects of the uterus could contribute to abnormal uterine contractions promoting retrograde menstruation.
The backward flow of menstrual debris carrying endometrial cells, which implant and start growing outside the uterus could also cause endometriosis.
The stem cell hypothesis
Stem cells can differentiate into many cell types, implant outside of the uterus, and then start forming tissue resembling the lining of the uterus, causing endometriosis.
Although research has not yet identified a causative gene, women who have a family member with endometriosis tend to be more likely to develop the disease.
Any of these factors could cause a woman to develop or have a recurrence of endometriosis.
Factors affecting the recurrence of endometriosis following surgery
There are three main factors that can increase the risk of recurring endometriosis:
- The severity of the disease at the time of surgery: the more severe the disease, the more likely it seems to come back.
- The completeness of lesion removal: if some lesions are left behind during surgery they may regrow with time.
- The use of medical suppressive therapy following surgery: this usually reduces the recurrence of pain symptoms of endometriosis.
A study published in The Journal of Minimally Invasive Gynecology suggests that young age and high body mass index (BMI) may also be factors associated with the recurrence of deep infiltrating endometriosis.
Symptoms of recurring endometriosis
Although many patients report symptom relief following endometriosis surgery, there is no guarantee that surgery will treat the symptoms of endometriosis.
The healing process following surgery
The healing process can vary from one patient to the next, and it is normal to experience pain just after the surgery. However, this should not last longer than a few days. Patients may also experience:
- vaginal bleeding lasting for about two weeks post-surgery
- tenderness in the abdominal area, lasting one to three days after surgery
- shoulder pain lasting up to two days after surgery.
The symptoms of endometriosis may return within one year of surgery. The rate of recurrence is usually greater as more time goes by.
Diagnosing recurring endometriosis
How can doctors determine whether or not I have recurring endometriosis?
The best way to diagnose recurring endometriosis is laparoscopic excision surgery.
Treatment of recurring endometriosis
What can I do to stop endometriosis from returning after surgery?
Research has shown that the long-term use of oral contraceptive therapy following surgery may reduce the recurrence of endometriosis. Women who do not wish to become pregnant are usually treated with a combination of oral contraceptives and non-steroidal anti-inflammatory drugs (NSAIDs) to relieve pain. Some women may choose other contraceptive options such as vaginal rings or patches.
Other options instead of hormonal contraceptives include:
- gonadotropin-releasing hormone (GnRH) receptor agonists
- progestin-only medications
- testosterone derivatives
A study published in the British Journal of Obstetrics and Gynaecology (BJOG) showed that treatment with aromatase inhibitors together with progestogens, oral contraceptives, or GnRH receptor agonists could reduce pain and the size of lesions. The study also showed that this combined treatment improved the quality of life of women with endometriosis.
Research suggests that becoming pregnant following endometriosis surgery may have a protective effect against the recurrence of endometriosis and pain associated with the disease.
How is recurrent endometriosis treated?
Recurrent endometriosis can be treated with a second surgery. A study published in BJOG reported that 62% of women who had undergone surgery to treat their endometriosis had further surgery within 5.5 years. However, repeat surgery may have limited benefits and decrease a woman’s fertility due to the loss of ovarian tissue. A second surgery may also be more challenging than the first due to the development of adhesions caused by chronic inflammation.
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