By Dr Sean Copson, Gynaecologist and AGES Advanced Laparoscopic Surgeon, West Perth.
Endometriosis is a chronic inflammatory condition defined by the presence of endometrium-like tissue outside the uterine cavity.
Affecting approximately one in seven females, or those assigned female at birth, its hallmark symptoms include dysmenorrhoea, dyschezia, dyspareunia, dysuria, and non-cyclical pelvic pain.
While not all women with endometriosis are symptomatic, pain and infertility remain its most prominent clinical features.
Pain management strategies include analgesia, hormonal suppression, and surgery. All symptomatic women should be offered these options, with individualised care plans developed in partnership with the patient.
RELATED: Endometriosis and infertility: understanding the link and exploring treatment options
Surgery is an effective treatment option, particularly for patients with persistent pain despite medical management. It may also be appropriate as a first-line intervention in women who decline hormonal therapies or where a definite diagnosis is desired.
Laparoscopic surgery is the gold standard for endometriosis management. It is favoured over open surgery due to benefits such as reduced postoperative pain, shorter hospitalisation, faster recovery, and improved cosmetic outcomes. Even in cases involving large endometriomas, laparoscopy should be the preferred approach.
Prior to surgery, all patients with suspected endometriosis should undergo a high-quality pelvic ultrasound by a dedicated women’s imaging service, as the accuracy of diagnosis is operator dependent.
Advanced imaging helps avoid ‘peek and shriek’ surgeries, where extensive disease is discovered unexpectedly intra-operatively, and no definitive treatment can be provided.
Recommendations for surgical interventions
When treating superficial peritoneal endometriosis, clinicians may choose between excision and ablation. Meta-analysis of four RCTs showed no statistically significant difference between the two, although excision demonstrated a trend toward better outcomes for dysmenorrhoea and dyspareunia.
International guidelines recommend excision where possible, given its potential for greater symptom relief and the added benefit of obtaining tissue for histopathology.
Surgical excision is the preferred technique for deep infiltrating endometriosis (DIE), as ablative methods may not achieve complete lesion removal. DIE requires careful preoperative planning and often necessitates referral to an advanced laparoscopic surgeon due to the complex anatomy involved.
RELATED: Endometriosis and its impact on fertility
Complete excision of lesions improves pain outcomes and reduces recurrence.
Up to 60% of patients with an ovarian endometrioma will have concurrent DIE. Pre-operative imaging with either a DIE ultrasound or, if not feasible, for example due to patients wanting to avoid a transvaginal ultrasound or rural patients where DIE ultrasounds are not available locally, MRI may be appropriate.
If DIE is confirmed, patients should be referred to a gynaecologist with formalised training in advanced laparoscopic surgery for reasons detailed above.
Management should involve cystectomy (cyst wall stripping) rather than simple drainage and coagulation. Cystectomy is associated with lower recurrence rates, improved pain control, and less ovarian damage. However, it also carries a risk of diminished ovarian reserve, and patients must be counselled accordingly.
Options for fertility preservation, including oocyte cryopreservation, should be discussed, especially in cases where repeat surgery may be required on the same ovary as this is a major risk factor in infertility and failed IVF.
Postoperative hormonal suppression is recommended to reduce recurrence. Endometriomas greater than 5cm carry a small but notable malignancy risk (approximately 0.8%) and should be excised to obtain a histological diagnosis.
Pain outcomes following surgery
Surgical intervention provides significant pain relief in the majority of patients, with 70–80% experiencing a significant reduction in symptoms. However, 20-30% may have persistent symptoms postoperatively, and a small proportion (1–2%) report worsened pain. It is crucial to set realistic expectations and provide comprehensive preoperative counselling.
Persistent or worsening pain post-surgery may reflect other contributing factors, such as neuropathic pain, central sensitisation, myofascial dysfunction, or other gynaecological conditions like adenomyosis. Identifying and addressing these elements preoperatively can optimise the pain outcomes for patients.
Surgery is a valuable tool in the management of endometriosis-associated pain, particularly when conservative measures are ineffective or declined.
A high-quality preoperative assessment – including expert pelvic imaging – is essential to guide management, avoid unnecessary diagnostic laparoscopies, and ensure optimal surgical planning.
Patients should be thoroughly counselled about the risks, benefits, and expected outcomes of surgery. A multidisciplinary approach that includes consideration of pain mechanisms beyond the disease itself will deliver the best outcomes for women living with endometriosis.
Key messages
- Laparoscopic surgery improves pain in 70–80% of patients with endometriosis. It is a suitable option when medical therapy fails, is declined, or in those preferring surgery as first line treatment
- High-quality pelvic ultrasound detects almost all cases of severe endometriosis helping avoid ‘peek and shriek’ surgeries
- Preoperative counselling is a key part of the process and allows for informed decision making
Author competing interests – nil
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