Recurrence of endometriosis is fairly common; some studies suggest the rate of recurrence to be as high as 40%. Most common cause of recurrence is incomplete resection in primary surgery and microscopic foci which escapes detection.

1. ENDOMETRIOSIS - An ENIGMA… !!!

2. Dr. Niranjan Chavan
MD, FCPS, DGO, DFP, MICOG, DICOG, FICOG
Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H
Chairperson, FOGSI Oncology and TT Committee (2012-2014)
Treasurer, MOGS (2017- 2018)
Chair and Convener, FOGSI Cell- Violence against Doctors (2015-2016)
Chief Editor, AFG Times (2015-2017)
Editorial Board, European Journal of Gynecologic Oncology
Editor of FOGSI FOCUS, MOGS, AFG & IAGE Newsletters
Member, Managing Committee, IAGE (2013-2017)
Member , Oncology Committee, AOFOG (2013 -2015)
Recipient of 6 National & International Awards
Author of 15 Research Papers and 19 Scientific Chapters
Course Co-Ordinator, of 11 batches, of MUHS recognized Certificate Course of
Basic Infertility Management Including Endoscopy (BIMIE) at LTMGH

3. He Who Knows Endometriosis Knows Gynaecology
- Sir William Osler

5. INTRODUCTION
It’s a clinical entity characterised by presence of tissue
resembling functioning endometrium outside uterine
cavity.
Characteristics of disease was described at least as far
back as 1600 BCE
Schrön described a “female disorder in which ulcers
appear[ed] in the abdominal, the bladder, intestines and
outside the uterus and cervix, causing adhesions”
1ST described by Von Rokintansky in 1860.

6. SITES OF ENDOMETRIOSIS

7. PREVALENCE
 Endometriosis affects 6%
to 10% of reproductive age
women
 Prevalence can be as high
as 50% infertile women

8. NATURAL HISTORY OF ENDOMETRIOSIS
According to Falcone and Lebovic’s analysis of findings of
follow – up laparoscopies performed 6 to 39 months
following initial diagnostic procedure among 162 patients :
There was almost equal distribution of those with
progressive disease(31%), unchanged (31%) and improvent
in extent of lesions (38%).

9. HISTIOGENESIS
• Reflux and Direct Implantation theory
• Coelomic Metaplasia Theory
• Vascular Dissemination Theory
• Autoimmune Disease Theory
PROMOTING FACTORS
• Estradiol >60pg/ml
• Platelet-derived
growth factor
• Macrophage derived
growth factors
• Increased expression
of P-450
• Overexpression of
metalloproteinase

11. Approximately 0.7% to 1.0% of patients with
endometriosis have lesions that undergo malignant
transformation with most common histological type
being Endometrioid Adenocarcinoma

12. SYMPTOMS

13. RECURRENCE IN ENDOMETRIOSIS
The recurrence rate at 3 and 5 years
after initial conservative surgery is
13.5% and 40.3 %
ACOG practice bulletin 2010 says the
most common site of recurrence are
large and small bowel after
hysterectomy

14. RECURRENCE IN ENDOMETRIOSIS
• Neither the initial staging or the ability to conceive after the
initial surgery affect the recurrence rate
• Repeat conservative surgery for recurrent endometriosis has
similar efficacy and limitations and a similar cumulative
recurrence rate ranging from 20% to 40%
• Laparoscopic cystectomy of ovarian endometriomas >3cm
has a cumulative rate of ultra sonographic recurrence of
11.7% and 57 % over 48 months and 60 months respectively

15. SYMPTOMS OF RECURRENCE
• Chronic pelvic pain
• Dyspareunia
• Vaginal or rectal bleed
• Rectal pain
• Low back pain
• Painful defecation

16. CAUSES OF RECURRENCE
• Deep endometriotic lesion left behind especially in sub peritoneal
spaces

17. CAUSES OF RECURRENCE
• Atypical or non – pigmented lesions difficult to recognize i.e. clear
or white endometriotic spot

19. CAUSES OF RECURRENCE
• Lesions hidden by peritoneal adhesions of the Pouch Of Douglas

20. CAUSES OF RECURRENCE
• Hormone replacement therapy
According to ACOG practice bulletin
2010, in the current era of HRT, it has
become increasingly important to
make an effort to remove all deep
lesions as they carry a risk for
symptomatic recurrence and rarely
malignant transformation.

21. CAUSES OF RECURRENCE
• Microscopic foci of disease
(invisible at the time of
surgery) could progress to
clinically significant disease. *
Pelvic peritoneal biopsy shows characteristic
features of endometriosis, with endometrioid
glands surrounded by stroma (hematoxylin and
eosin stain
* Redwine D. Evidence for asymmetric distribution of sciatic
nerve endometriosis. Obstet Gynecol. 2003 Dec;102(6):1416;
author reply 1416-7. PubMed PMID: 14662240.

22. CAUSES OF RECURRENCE
• Lymphatic spread may
contribute to recurrence :Lymph
node involvement is reportedly
involved in 25-40% of
rectosigmoid endometriosis *
* Abrao MS, Podgaec S, Dias JA Jr, Averbach M, Garry R, Ferraz Silva LF, Carvalho FM. Deeply infiltrating
endometriosis affecting the rectum and lymph nodes. Fertil Steril. 2006 Sep;86(3):543-7. Epub 2006 Jul 28.
PubMed PMID: 16876165

23. CAUSES OF RECURRENCE
• Ovarian preservation surgery:
women undergoing hysterectomy
for symptomatic endometriosis with
ovarian conservation carries a 6.1
fold risk of recurrent pain and 8.1
fold risk of re-operation. *
Peritoneal endometriosis visualized along the
course of left ureter causing persistent pain
after laparoscopic hysterectomy.
* Namnoum AB, Hickman TN, Goodman SB, Gehlbach DL, Rock JA. Incidence of symptom recurrence after hysterectomy for
endometriosis. Fertil Steril. 1995 Nov;64(5):898-902. PubMed PMID: 7589631
Namnoum AB, Hickman TN, Goodman SB, Gehlbach DL, Rock JA. Incidence of symptom recurrence after hysterectomy for endometriosis. Fertil Steril. 1995 Nov;64(5):898-902. PubMed PMID: 7589631.

24. CAUSES OF RECURRENCE
• Ovarian remnant syndrome :
recurrent endometriosis has
been associated with the
presence of residual tissue
after oophorectomy. *
Kho RM, Abrao MS. Ovarian remnant syndrome: etiology, diagnosis, treatment and impact of endometriosis. Curr Opin Obstet Gynecol. 2012 Aug;24(4):210-4. doi: 10.1097/GCO.0b013e3283558539. Review. PubMed
* Kho RM, Abrao MS. Ovarian remnant syndrome: etiology, diagnosis, treatment and impact of endometriosis.
Curr Opin Obstet Gynecol. 2012 Aug;24(4):210-4. doi: 10.1097/GCO.0b013e3283558539. Review. PubMed
PMID: 22729094.

25. DIAGNOSIS: CLINICAL
• The ESHRE GUIDELINES 2014 recommends diagnosis of endometriosis, in the
presence of :
Gynaecological symptoms:
Dysmenorrhoea
Non-cyclical pelvic pain
Deep dyspareunia
Infertility
Fatigue
Non-gynaecological cyclical
symptoms:
Dyschezia
Dysuria
Haematuria
Rectal bleeding
Shoulder pain

26. DIAGNOSIS: CLINICAL
• Physical examination has poor sensitivity, specificity, and predictive
value in the diagnosis of endometriosis
• “Pain mapping” may help isolate
location-specific disease such as nodular
masses in posterior rectovaginal septum
• Absence of evidence during exam is not evidence of disease
absence

27. DIAGNOSIS: IMAGING
ULTRASOUND
• Transvaginal sonography (TVS) is useful for identifying or ruling out rectal
endometriosis
• Diagnosis of ovarian endometrioma is based on the following ultrasound
characteristics: ground glass echogenicity and one to four compartments
and no papillary structures with detectable blood flow

29. DIAGNOSIS: IMAGING
MRI
• MRI may detect even smallest of lesions and distinguish
hemorrhagic signal of endometriotic implants; superior to CT scan
in detecting limits between muscles and abdominal subcutaneous
tissues
Clinicians can assess ureter, bladder and bowel involvement by
additional imaging like Barium enema, transvaginal sonography (TVS)
and transrectal sonography

31. DIAGNOSIS: LAPAROSCOPY
• The combination of laparoscopy and the histological verification of
endometrial glands and/or stroma is considered to be the GOLD
STANDARD for the diagnosis of the disease.
Clinically visualized findings may
represent “tip of
the iceberg” ; thus emphasizing the
importance of diagnostic
laparoscopy for diagnosis and
staging

32. ENDOMETRIOSIS AND INFERTILITY
• Approximately 20 to 40% of women with endometriosis are infertile.

33. RECURRENT ENDOMETRIOSIS AND INFERTILITY

34. Clinicians may consider Co2 laser vaporisation of endometriosis
instead of monopolar electrocoagulation as former is associated
with better cumulative spontaneous pregnancy rates
- Chang et al

35. ENDOMETRIOSIS AND INFERTILITY MANAGEMENT
ESHRE GUIDELINES 2014 makes following recommendations
• In infertile women with AFS/ASRM Stage I/II endometriosis, it is better
perform operative laparoscopy(excision or ablation of the endometriosis
lesions) including adhesiolysis, rather than performing diagnostic
laparoscopy only, to increase on going pregnancy rates
• Clinicians may consider Co2 laser vaporisation of endometriosis instead
of monopolar electrocoagulation as former is associated with better
cumulative spontaneous pregnancy rates
• In infertile women with ovarian endometrioma undergoing surgery,
clinicians should perform excision of the endometrioma capsule, instead
of drainage and electrocoagulation of the endometrioma wall, to
increase spontaneous pregnancy rates

39. CLASSIFICATION
“The American Society for Reproductive Medicine’s current
classification of endometriosis in stages 1−4 is the most widely used
and accepted staging system; however, it does not correspond well to
pain and dyspareunia, and fecundity rates cannot be predicted
accurately”

40. ASRM CLASSIFICATION

41. SURGICAL MANAGEMENT
• DEFINITIVE SURGERY: Total abdominal hysterectomy with bilateral
salphingo-oophorectomy, excision of peritoneal surface lesions or
endometriomas and lysis of adhesions
• A “SEMIDEFINITIVE”
procedure that preserves
an uninvolved ovary
increases 6 times the risk
of recurrence and 8 times
reoperation rate

42. SURGICAL MANAGEMENT
• SEE AND TREAT : When endometriosis is identified at laparoscopy, it is
recommended to surgically treat endometriosis, either by ablation or
excision
• CYSTECTOMY for ovarian endometriomas
• SURGICAL INTERRUPTION OF PELVIC NERVE
PATHWAYS e.g LUNA, Presacral neurectomy
• LAPAROTOMY for deep endometriosis
Laparoscopic Uterosacral Nerve Ablation

43. CASE REPORT
A 28 years old nulliparous woman, married since 9 years
complains of chronic pelvic pain and severe dysmenorrhoea.
Patient has a history of laparotomy with right ovarian cystectomy
done 4 years back.
USG pelvis is suggestive of 7cm x 6cm x 4.5cm right ovarian complex
cyst with ground glass echogenicity, most likely to be chocolate cyst

44. An endometrioma or "Chocolate Cyst" on ultrasound and On laparoscopy

45. LAPAROSCOPY IN RECURRENT MANAGEMENT

46. MEDICAL MANAGEMENT
Rationale is to induce amenorrhea and create hypoestrogenic environment,
by suppressing the hypothalamic ovarian axis, theoretically inhibiting
growths and promoting temporary regression
Agents used:
OCPs
• The recommended dose is 20 -30 µg ethinyl estradial pill .
• It causes symptomatic relief in 65-90 % of cases.

47. MEDICAL MANAGEMENT
GnRH Agonists
• Suppresses hypothalamic –pituitary – ovarian axis
to produce a ‘medical oophorectomy’ or
‘pseudomenopause state’
Danazol
Aromatase Inhibitors
Progestin like Medroxyprogesterone acetate,
Mirena
NSAIDS may be used for pain management

48. PRE OPERATIVE MEDICAL MANAGEMENT
• Combined hormonal contraceptive,
Progestins like Medroxyprogesterone
acetate, Mirena GnRH Agonists as it
reduces endometriosis-associated
dyspareunia, dysmenorrhoea and non-
menstrual pain
• There are no trials that compares
hormonal suppression of endometriosis
before and/or after surgery with surgery
alone

49. POST OPERATIVE MEDICAL TREATMENT
• Post surgical hormonal suppression of endometriosis compared to
surgery alone (either no medical therapy or placebo) showed no benefit
for the outcomes of pain or pregnancy rates but a significant
improvement in disease recurrence (AFS scores (WMD -2.30, 95% CI -
4.02 to -0.58)). *
• The available literature strongly supports the benefits of prolonged
administration of estroprogestins after surgery in preventing recurrence
of endometriomas . **
* Yap C, Furness S, Farquhar C. Pre and post operative medical therapy for endometriosis surgery. Cochrane Database Syst Rev.
2004;(3):CD003678. Review. PubMed PMID: 15266496.
** Somigliana E, Vercellini P, Vigano P, Benaglia L, Busnelli A, Fedele L. Postoperative medical therapy after surgical treatment of
endometriosis: from adjuvant therapy to tertiary prevention. J Minim Invasive Gynecol. 2014 May-Jun;21(3):328-34. doi:
10.1016/j.jmig.2013.10.007. Epub 2013 Oct 22. Review. PubMed PMID: 24157566.

50. SECONDARY PREVENTION
Secondary prevention is defined as interventions to prevent
the recurrence of pain symptoms or the recurrence of
disease in the long-term, defined as more than 6 months
after surgery.
The choice of intervention depends on patient preferences,
costs, availability and side effects.

51. SECONDARY PREVENTION
European society guidelines 2014 for secondary
prevention:
• In women operated on for an endometrioma (≥3 cm), clinicians
should perform ovarian cystectomy, instead of drainage and
electrocoagulation, for the secondary prevention of endometriosis-
associated dysmenorrhoea, dyspareunia and non-menstrual pelvic
pain. *
* Mircea O, Bartha E, Gheorghe M, Irimia T, Vlădăreanu R, Puşcaşiu L. Ovarian Damage after Laparoscopic Cystectomy for
Endometrioma. Chirurgia (Bucur). 2016Jan-Feb;111(1):54-7. PubMed PMID: 26988540.

52. SECONDARY PREVENTION
• After cystectomy for ovarian
endometrioma in women not
immediately seeking conception,
clinicians are recommended to
prescribe combined hormonal
contraceptives for the secondary
prevention of endometrioma. *
* Vercellini P, Meana M, Hummelshoj L, Somigliana E, Viganò P, Fedele L. Priorities for endometriosis research: a proposed focus
on deep dyspareunia. Reprod Sci. 2011 Feb;18(2):114-8. doi: 10.1177/1933719110382921. E pub 2010 Oct26. Review. PubMed
PMID:20978182.

53. SECONDARY PREVENTION
• In women operated on for endometriosis,
clinicians are recommended to prescribe
post-operative use of a LNG-IUS or a
combined hormonal contraceptive for at
least 18–24 months, as one of the options
for the secondary prevention of
endometriosis-associated dysmenorrhoea,
but not for non-menstrual pelvic pain or
dyspareunia. *
* Seracchioli R, Manuzzi L, Mabrouk M, Solfrini S, Frascà C, Manferrari F, Pierangeli F, Paradisi R, Venturoli S. A
multidisciplinary, minimally invasive approach for complicated deep infiltrating endometriosis. Fertil Steril. 2010
Feb;93(3):1007.e1-3. doi:10.1016/j.fertnstert.2009.09.058. Epub 2009 Nov 25. PubMed PMID: 19939374.

54. CONCLUSION
• Recurrence of endometriosis is fairly common; some studies suggest
the rate of recurrence to be as high as 40%.
• Most common cause of recurrence is incomplete resection in primary
surgery and microscopic foci which escapes detection.
• Laparoscopy remains the GOLD STANDARD for diagnosis of
endometriosis

55. CONCLUSION
• The combined surgical approach (of laparoscopic laser ablation,
adhesiolysis and uterine nerve ablation) is beneficial for pelvic pain
associated with minimal, mild and moderate endometriosis.
• Medical management only acts adjuvant to surgical management
which may help in reducing to recurrence.
• Interventions to prevent the recurrence of pain symptoms or the
recurrence of disease in the long-term used for more than 6 months
after surgery may be used for secondary prevention

56. REFERENCES
• Rizk B, Fischer AS, Lotfy HA, et al. Recurrence of endometriosis after hysterectomy. Facts, Views & Vision in ObGyn.
2014;6(4):219-227.
• Vercellini P, Barbara G, Abbiati A, Somigliana E, Viganò P, Fedele L. Repetitive surgery for recurrent symptomatic
endometriosis: what to do? Eur J Obstet Gynecol Reprod Biol. 2009 Sep;146(1):15-21. doi:10.1016/j.ejogrb.2009.05.007.
Epub 2009 May 30. Review. PubMed PMID: 19482404.
• Vercellini P, Abbiati A, Aimi G, Amicarelli F, De Giorgi O, Uglietti A. Gynecological endoscopy for symptomatic
endometriosis. Minerva Ginecol. 2009 Jun;61(3):215-26. Review. PubMed PMID: 19415065
• Vercellini P, De Giorgi O, Pisacreta A, Pesole AP, Vicentini S, Crosignani PG.Surgical management of endometriosis.
Baillieres Best Pract Res Clin Obstet Gynaecol. 2000 Jun;14(3):501-23. Review. PubMed PMID: 10962639.
• Shakiba K, Bena JF, McGill KM, Minger J, Falcone T. Surgical treatment of endometriosis: a 7-year follow-up on the
requirement for further surgery. Obstet Gynecol. 2008 Jun;111(6):1285-92. doi: 10.1097/AOG.0b013e3181758ec6. Erratum
in: Obstet Gynecol. 2008 Sep;112(3):710. PubMed PMID: 18515510.
• Namnoum AB, Hickman TN, Goodman SB, Gehlbach DL, Rock JA. Incidence of symptom recurrence after hysterectomy for
endometriosis. Fertil Steril. 1995 Nov;64(5):898-902. PubMed PMID: 7589631
• Kho RM, Abrao MS. Ovarian remnant syndrome: etiology, diagnosis, treatment and impact of endometriosis. Curr Opin
Obstet Gynecol. 2012 Aug;24(4):210-4. doi: 10.1097/GCO.0b013e3283558539. Review. PubMed PMID: 22729094
• Abrao MS, Podgaec S, Dias JA Jr, Averbach M, Garry R, Ferraz Silva LF, Carvalho FM. Deeply infiltrating endometriosis
affecting the rectum and lymph nodes. Fertil Steril. 2006 Sep;86(3):543-7. Epub 2006 Jul 28. PubMed PMID: 16876165