Why Endometriosis Can Return Even After Surgery

Recurrence rate of endometriosis

Research has shown that the recurrence rate of endometriosis is between 20 and 40 percent within five years following conservative surgery [1].

CAUSES

Why does endometriosis sometimes recur following surgery?

It is unknown why endometriosis can recur following surgery. It is also unknown what causes endometriosis to begin with. There are several theories on the development of endometriosis [2]. These are:

• Structural and functional abnormalities of the uterus: Structural defects of the uterus could contribute to abnormal uterine contractions promoting retrograde menstruation [2].

• Retrograde menstruation: The backward flow of menstrual debris carrying endometrial cells, which implant and start growing outside the uterus [5].

• 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 [3].

• Genetic predisposition: Although no causative gene has been identified, women who have a family member with endometriosis tend to be more likely to develop the disease [4].

• Immune dysfunction: Many studies suggest that endometriosis may be caused by immune dysfunction, where the immune system cannot recognize or eliminate extra-uterine endometrial growths as it should [6].

Any of these factors could cause a woman to develop or have a recurrence of endometriosis following surgery.

Factors affecting the recurrence of endometriosis

There are three main factors that can increase the chance of recurring endometriosis following surgery: 

• 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: the use of hormonal contraceptives following surgery 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 [7].

SYMPTOMS

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 [8]. 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, and the rate of recurrence is usually greater as more time goes by [9].  

DIAGNOSIS

How can doctors determine whether or not I have relapsing endometriosis?

The best way to diagnose relapsing endometriosis is laparoscopic excision surgery. 

TREATMENT

What can I do to stop endometriosis from returning after surgery?

Hormonal treatment

Research has shown that the long-term use of oral contraceptive therapy following surgery may reduce the recurrence of endometriosis [10]. 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

• Aromatase-inhibitors

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.

Pregnancy

Research suggests that becoming pregnant following endometriosis surgery may have a protective effect against the recurrence of endometriosis and pain associated with the disease [11].

How is recurrent endometriosis treated?

Recurrent endometriosis can be treated with a second surgery. A study published in BJOG reported that 62 percent of women who had undergone surgery to treat their endometriosis had further surgery within five and a half years of their first surgery. 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 [12].   

REFERENCES

1. Endometriosis: Recurrence & Surgical Management 
2. What causes endometriosis?, Tamer Seckin, MD
3. Stem cell and endometriosis: new knowledge may be producing novel therapies, by Jing Yang and Fengying Huang 
4. Endometriosis: A Genetic Diseas, by  Rene Wenzl, Ludwig Kiesel, Johannes C Huber, Fritz Wieser
5. Pathophysiology and Immune Dysfunction in Endometriosis, by Soo Hyun Ahn, Stephany P. Monsanto, Caragh Miller, Sukhbir S. Singh, Richard Thomas, and Chandrakant Tayade 
6. Recurrence in Deep Infiltrating Endometriosis: A Systematic Review of the Literature,  Manuel Maria Ianieri, MD Daniele Mautone, MD Marcello Ceccaroni, MD, PhD
7. After Endometriosis Surgery, by Tamer Seckin, MD  
8. Recurrence of endometriosis; risk factors, mechanisms and biomarkers; review of the literature, İlker Selçuk and Gürkan Bozdağ 
9. Post-operative use of oral contraceptive pills for prevention of anatomical relapse or symptom-recurrence after conservative surgery for endometriosis, by R. Seracchioli, M. Mabrouk, L. Manuzzi, C. Vicenzi, C. Frascà, A. Elmakky, S. Venturoli 
10. Systematic review of the effects of aromatase inhibitors on pain associated with endometriosis, S Patwardhan A Nawathe D Yates GR Harrison KS Khan 
11. Impact of endometriosis on risk of further gynaecological surgery and cancer: a national cohort study, L Saraswat D Ayansina KG Cooper S Bhattacharya AW Horne S Bhattacharya