Surgery and endometriosis can be a tricky topic. A good rule of thumb is that more is NOT better.

Generally, surgery should take place after an attempt has been made to control the symptoms of endometriosis with medical options (see part 1 of 3 from last month).

There are a few indications for surgery that are clear cut:

1. surgery for diagnosis: you have never had surgery and there is the suspicion that you have endometriosis and you need confirmation (this is not medically necessary but is reasonable)
2. surgery after failure or intolerance of medical management: to explore possible sources of pain
3. surgery for a cyst: you may or may not already know that you have endometriosis and you have a cyst that needs to be removed
4. surgery for definitive treatment: removal of uterus, cervix, tubes, ovaries for the treatment of known endometriosis(this causes immediate and nonreversible menopause)

Of course there are other situations when surgery may be recommended but one thing is for certain, there is no role for repeat surgery without a clear indication.

Surgery for optimizing fertility is best left to the expertise of fertility specialists and should not be the first step in the work up of infertility.

Sometimes there is the thought that repeat surgery is needed to ‘clean up’ the endometriosis.  Since endometriosis is not a progressive condition (meaning it doesn’t necessarily proliferate or grow uncontrollably), this is not accurate and can lead to potential life altering complications.

A benefit of surgery is that your surgeon may be able to stage your endometriosis. Endometriosis is staged on a 1 through 4 scale. With stage 1 being minimal endometriosis findings and stage 4 being advance endometriosis findings. The stage does not correlate well with how someone feels but it is more useful in providing a way to quantify of the amount of endometriosis and by aiding communication between your health care providers.

There are other classifications that can be used after surgical evaluation and some can even try to predict fertility potential.

Surgery is usually performed laparoscopically. This is a procedure that requires general anesthesia (you will be completely asleep). Small incisions are made on your abdomen (1-4 incisions) that are normally between 5-8 mm. With a camera, your surgeon is able to look inside your abdomen and pelvis to see if there is evidence of endometriosis. If it is possible, your surgeon may be able to remove (excise) or burn (fulgurate) endometriosis lesions that are visible and accessible during surgery. The reason it is not clear which lesions can or can not be removed prior to surgery is because there is no imaging technique (ultrasound, MRI or CT) that can reliably confirm the presence or location of endometriosis prior to surgery.

The data available suggests that the decision whether to excise or fulgurate endometriosis has to do with the location and size/depth of the lesion. It is ideal to excise endometriosis but care must be taken to not damage other nearby structures, especially since there hasn’t been significant differences seen in pain relief between excision and fulguration.

Rarely, is surgery the answer to all endometriosis symptoms. Post surgical management may include medications or alternative treatments like acupuncture.

Even after surgery your doctor may recommend that you use hormonal medical options (i.e. birth control) to manage your symptoms. This does not mean that surgery failed but rather a multistep approach is best when dealing with endometriosis.  Research has suggested that  medical therapy after surgery can reduce recurrence of symptoms and need for repeat surgery.

Surgery is an important decision and a thorough discussion of the risks and benefits should be had with your surgeon prior to pursuing this option.