Can Endometriosis Come Back After Surgery?

by Dr. Firuza Parikh

It has been estimated that over 200 million women worldwide are affected by endometriosis. It is a condition wherein the tissue (endometrium) that is supposed to line the uterus grows outside of her uterus. While science and medicines have helped in providing relief for some patients, a common concern is whether it can come back after surgery.

This blog aims to delve into the likelihood of endometriosis recurrence following a surgical procedure.

Can Endometriosis Come Back After Surgery?: TOC

What Is Endometriosis?

Endometriosis is a condition wherein tissue similar to the lining of the uterus, also known as endometrium, grows outside the uterus, generally in the pelvic region. This can cause period pain, pelvic pain, fertility issues, and other symptoms of painful defecation and painful intercourse. In many cases, even though surgery can provide relief by removing the endometriotic implants, there is still a risk for it to return.

Cause Of Endometriosis

The exact causes of endometriosis remain unclear, and while there is no definitive explanation, several theories have been shared by experts to understand the underlying cause:

Blood or lymph system transport: Endometrial tissues may be transported to different areas of the body via the blood or lymphatic systems, similar to how cancer cells can metastasize.
Direct transplantation: Another theory suggests that endometrial cells could attach to the abdominal walls or other body areas following surgical procedures such as C-sections or hysterectomies.
Genetics: Endometriosis tends to run in certain families, hinting at a potential genetic connection to the development of the condition.
Reverse menstruation: In some instances, it is proposed that instead of exiting the body during a woman’s menstrual period, endometrial tissue may travel into the fallopian tubes and the abdomen.
Transformation: Cells in the body unrelated to the endometrium may transform into endometrial cells, growing outside their usual location.

Recurrent Rate Of Endometriosis

The recurrence of endometriosis following surgery is dependent upon various factors, including the initial severity of the condition, the proficiency of the surgeon, and the quality of follow-up care. Research indicates that approximately 40-80% of women may experience a recurrence of the condition within a five-year period following surgery. However, as time progresses, the chances of developing symptoms decrease, and long-term relief is possible.

Factors Affecting The Recurrence Of Endometriosis Following Surgery

If endometriosis comes back after surgery, it can have a negative effect on one’s quality of life. Down the line, this can lead to repeated, difficult, and, in some cases, difficult surgeries.

According to a study conducted in Thailand that aimed to determine the recurrence rate of endometriosis after conservative surgery wherein 362 cases were analyzed, it was found that the 2-year recurrence rate was 23.2%, with an overall recurrence rate of 56.4%.

A number of risk factors have been identified as potential predictors of endometriosis recurrence after surgery, and they include

Pain during menstruation before surgery
Bilateral involvement of endometriosis lesions
History of previous surgeries
Presence of tender nodules in the cul-de-sac (area between rectum and vagina)
Younger age at surgery, possibly related to higher estrogen levels
Higher severity of the disease before surgery
Completeness of lesion removal during surgery (residual tissue may regrow)
Presence of larger cysts at the time of surgery.

Why Does Endometriosis Come Back After Surgery?

While the precise reasons for endometriosis coming back are not fully understood, certain factors can heighten the chances. If endometriotic implants aren’t entirely removed during surgery, tiny lesions may be left behind and could regrow later. Hormonal changes, genetic factors, and issues with the immune system also contribute to endometriosis recurrence. Additionally, undergoing multiple surgeries may result in adhesions, scarring, and harm to reproductive organs, impacting fertility. Importantly, inflammation is a precursor to endometriosis. Hence, the presence of inflammation enhances the chances of endometriosis.

Signs of Endometriosis Returning

Recurrence of endometriosis may not always show noticeable signs, but increasing or new pain during menstruation and pelvic discomfort are common indicators after surgery.

Symptoms of recurrent endometriosis can include:

Severe menstrual cramps
Chronic low-back and pelvic pain
Fertility issues
Pain during or after sex
Discomfort with urination or bowel movements Lower abdominal pain
Digestive problems like diarrhoea, bloating, constipation, or nausea
Heavy periods or bleeding between periods
Fatigue and lack of energy

Monitoring these signs is crucial for early detection and seeking appropriate medical care for recurrent endometriosis.

What Can I Do To Stop Endometriosis From Returning After Surgery?

Preventing the recurrence of endometriosis is still a challenge even today, with no guaranteed solution. Research has revealed that using oral contraceptives or letrozole for a longer time after surgery may make it less likely that endometriosis will come back. It is also believed that getting pregnant after endometriosis surgery might help prevent the return of endometriosis and reduce associated pain.

There are also other steps that can be taken take to potentially reduce the risk of recurrence:

Following the instructions given after surgery is of the utmost importance. Carefully follow the doctor’s instructions, take all prescribed medications, and show up for all follow-up appointments.
Adopting a healthy way of life is key. To improve your health as a whole, work out regularly and eat a balanced diet.
Identify and steer clear of known factors that may cause endometriosis flare-ups, such as stress, excessive caffeine intake and inflammation in the body.
Be attentive to any signs indicative of endometriosis recurrence. Early detection and immediate treatment are crucial for preventing further damage.

How Is Recurrent Endometriosis Treated?

While some women may experience a return of endometriosis even after surgery, others may not. If it does return, treatment often involves a second surgery. As per a study published in BJOG: An International Journal of Obstetrics and Gynaecology, 62% of women with endometriosis had a second surgery, usually within two years. Within 5.5 years, half of them had a repeat surgery, and one in five opted for a hysterectomy or removal of ovaries.

It is, however, important to remember that having more surgeries may not help much and might lower fertility because of losing ovarian tissue. The second surgery can also be harder than the first because of adhesions from ongoing inflammation.

FAQs

Can endometriosis return even after a complete surgical removal of the implants?

Yes, endometriosis can come back even after your doctor removes it completely.

How soon after surgery can endometriosis come back?

It can take years or even just six months after your surgery for endometriosis to come back.

Are there any preventive measures to reduce the risk of endometriosis returning?

While complete prevention is not guaranteed, you can help manage and potentially lower the risk of endometriosis recurrence by using hormonal treatments, preventing the presence of inflammation, making lifestyle adjustments, and having regular follow-up care.

What are the options for treating recurrent endometriosis?

If you experience recurrent endometriosis, your doctor may recommend a combination of medications for pain, hormone therapies, and, in severe cases, additional surgery.

Does endometriosis recurrence always cause infertility?

Endometriosis recurrence can cause infertility for some individuals.

Can pregnancy prevent endometriosis from coming back?

Pregnancy may temporarily improve endometriosis symptoms, but that doesn’t guarantee that endometriosis won’t return after delivery.

Are there any alternative treatments for recurrent endometriosis?

Trying alternative treatments like acupuncture, herbal medicine, or changing your diet might help with symptoms, but more research is needed to determine if they truly prevent the problem from coming back.

Conclusion: Can Endometriosis Come Back After Surgery?

To sum it up, endometriosis can return after surgery, and the likelihood depends on factors such as the initial severity, surgical expertise, inflammation in the body and postoperative care.

If you have endometriosis, seek treatment as soon as possible. If you had surgery for the same, however, keep in touch with your doctor to stay informed and aware.

Sources:

Seckin, Tamer. “Why Can Endometriosis Return after Surgery?” Seckin Endometriosis Center, 23 July 2023, drseckin.com/why-endometriosis-can-return-even-after-surgery/. Accessed 16 Jan. 2024.

“Women with Endometriosis Likely to Have Multiple Surgical Procedures.” Www.clinicalservicesjournal.com, 3 Oct. 2017, www.clinicalservicesjournal.com/story/23364/women-with-endometriosis-likely-to-have-multiple-surgical-procedures. Accessed 16 Jan. 2024.

Horne, AW, et al. “Surgical Removal of Superficial Peritoneal Endometriosis for Managing Women with Chronic Pelvic Pain: Time for a Rethink?” Bjog, vol. 126, no. 12, 1 Nov. 2019, pp. 1414–1416, www.ncbi.nlm.nih.gov/pmc/articles/PMC6852286/, https://doi.org/10.1111/1471-0528.15894.

John Hopkins Medicine. “Endometriosis.” John Hopkins Medicine, 2019, www.hopkinsmedicine.org/health/conditions-and-diseases/endometriosis. Accessed 16 Jan. 2024.

Jones, Heather. “Can Endometriosis Come Back after Surgery?” Verywell Health, www.verywellhealth.com/signs-of-endometriosis-returning-7375388.

Martin, Dan. “What Is Endometriosis? Causes, Symptoms and Treatments.” Endometriosis : Causes – Symptoms – Diagnosis – and Treatment , 21 May 2019, www.endofound.org/endometriosis.

Pongpan Ngernprom, et al. “Risk Factors for Recurrent Endometriosis after Conservative Surgery in a Quaternary Care Center in Southern Thailand.” PLOS ONE, vol. 18, no. 8, 10 Aug. 2023, pp. e0289832–e0289832, www.ncbi.nlm.nih.gov/pmc/articles/PMC10414623/, https://doi.org/10.1371/journal.pone.0289832. Accessed 16 Jan. 2024.

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