Treating Endometriosis

As my surgical practice continues to evolve, I am seeing many more patients referred from other physicians and from patients for surgical management of endometriosis. Due to the nature of my fellowship with the AAGL and Dr. Liu, I have become a fan of excising endometriosis as opposed to just coagulation/vaporization with electrical energy or laser. This is especially true in the cases of extensive endometriosis.

Endometriosis can be treated in many different ways. Initially it is prudent to control symptoms of endometriosis with medical therapy in patients who may not want surgery. Common medical therapies for endometriosis include medications such as ibuprofen, birth control pills, depoprovera injection, levonorgestrel IUD, danazol and depo-lupron. The goal of any of these medical therapies is to control the symptoms of endometriosis. They do not cure the disease. Symptoms usually recur when therapy is stopped and some of the medications can only be used for a limited time.

Although surgical excision is not the perfect treatment for endometriosis (the perfect treatment is not available) it does provide the highest cure rate of any therapy. Surgery combined with post operative medical therapy has been shown to give the longest pain free period for patients with endometriosis.

Surgical excision of endometriosis requires very advanced laparoscopic skills. These are by far the most difficult surgeries I have encountered. Endometriosis tends to cause a great deal of internal scarring. Also approximately 10% of endometriosis is of an invasive nature. It does not stay on the superficial lining tissue of the pelvis treated with coagulation or vaporization.

To make it more difficult, invasive endometriosis may involve structures such as the bowel or rectum, the bladder, the ureters, the cervix and uterus and the vagina. Except in the cases of endometriosis of the vagina, cervix and rectum, it can be very difficult to know the extent of endometriosis prior to surgery. I have assisted many surgeons in residency and practice, who have looked inside and ended the surgery because the disease was too extensive and beyond their skills to treat surgically. This is appropriate. Many of these patients are pushed to the realm of Lupron. Although Lupron can treat symptoms in some patients, I have found through experience that it does not control symptoms of invasive endometriosis where tissue damage has already occurred.

A recent article in Ob.Gyn. News stated that failure of medicines to control pain does not suggest that endometriosis is not the cause. In fact some of the most advanced cases of endometriosis I have encountered are in patients in their mid to late twenties who have never had a surgical diagnosis or treatment.


Because of the uncertain nature of endometriosis, having a surgeon skilled in advanced laparoscopy is essential. On his website, www.endometriosissurgeon.com, Dr. David Redwine lists questions that you should ask your physician prior to endometriosis surgery. These questions will assure the most appropriate surgical management of your disease.

Rectovaginal Endometriosis