Endometriosis is known to have a remarkably negative effect on the Quality of Life of the women. Surgery is considered when medical therapy is unsuccessful or in the setting of infertility. A high recurrence rate is reported in advanced stages of endometriosis. Thus, Complete excision and prevention of recurrence is particularly important.

1. RECURRENT
ENDOMETRIOSIS
DR. NIRANJAN CHAVAN

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

4. 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.

5. SITES OF ENDOMETRIOSIS

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

7. 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

9. 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

10. 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

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

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

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

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

16. 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.

17. 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.

18. 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

19. 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

20. 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
PMID: 22729094.

21. 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

22. 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 examination is not
evidence of disease absence

23. 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

25. 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

27. 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

31. 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”

32. ASRM CLASSIFICATION

33. 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

34. 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

35. 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

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

37. LAPAROSCOPY IN RECURRENT
ENDOMETRIOSIS VIDEO

38. 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:
DINOGEST: 2 mg od for 3 months, causes symptomatic
relief
OCPs
• The recommended dose is 20 -30 µg ethinyl estradial
pill .
• It causes symptomatic relief in 65-90 % of cases.

39. MEDICAL MANAGEMENT
GnRH Agonists
• Suppresses hypothalamic –pituitary – ovarian axis to
produce a ‘medical oophorectomy’ or
‘pseudomenopause state’. It causes osteoporosis on
prolonged use . So Add back therapy is needed for long
term use of GnRh agonist therapy
Danazol
Aromatase Inhibitors- preferred drug in deep infiltrating
endometriosis in pod
Progestin like Medroxyprogesterone acetate, Mirena
NSAIDS may be used for pain management

40. 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

41. 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.

42. 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.

43. SECONDARY PREVENTION
European society guidelines 2014 for secondary prevention:
• In women operated on for an endometrioma (≥4cm), 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.

44. 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.

45. 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.

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

47. RECURRENT ENDOMETRIOSIS AND
INFERTILITY

48. 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

49. 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

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

52. 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

53. 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

54. 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