What Is Endometriosis?

Expert Excision Surgery

The gold standard of care for endometriosis is excision surgery. Ablation surgery, a common method of treatment currently, just burns the top layers of the endometriosis lesion off whereas excision surgery cuts out the disease much like a tumor is removed, all the way down and around until normal tissue is reached (Nancy’s Nook, n.d.). Medications can help suppress symptoms but do not treat the disease or stop its spread.

 

If this concept feels confusing, think of each endometriosis lesion like a tree. Ablation surgery takes off the top leaves and branches but the root system (the deepest cells causing that tissue to grow there in the first place) remains intact and the tree regrows. Excision surgery cuts out the tissue entirely, much like digging deep into the ground and removing both the root system and the tree. Furthermore, if the tissue is burned away through ablation, it cannot be sent to the laboratory for pathological testing, where the cells themselves are examined and confirmed to be endometriosis or identified as something else, as excision surgery allows.

 

Excision surgery has been shown through decades of research to result in a significant improvement in quality of life, a lower chance of disease recurrence (around 15% following excision surgery compared to 40%-60% following ablation), and improvement in fertility when compared to medication management or ablation (CEC, n.d.; Yeung et al., 2011; Nancy’s Nook, n.d.). However, excision is practiced only by select highly skilled OBGYN specialists who have received significant advanced training in endometriosis when compared to most OBGYN’s. As mentioned above, there are only about 100 excision specialists out of over 21,000 OBGYN’s in the United States (U.S. Bureau of Labor Statistics, 2022; Laux, 2023). It is not enough for an OBGYN to claim to specialize in endometriosis, successful treatment is dependent on seeking out an excision specialist as their knowledge of the disease is unparalleled. The additional training allows these specialized surgeons to better recognize endometriosis lesions, remove them more completely, and handle the complexity of cases involving multiple organ systems (CEC, n.d.; Nancy’s Nook, n.d.). This, in turn, provides the patient with a better quality of life.

The resources section of this website lists the four endometriosis excision surgeons in Minnesota and a comprehensive list of surgeons, both nationally and internationally, can be found on Nancy’s Nook Endometriosis Education facebook page under the files tab. The PDF is titled Surgeons_International Excision Surgeon Listing and is updated regularly.

 

 

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Supportive Therapies

Endometriosis is a systemic (whole body) disease and includes more changes than just the growth of endometriosis tissue. Expert excision surgery, considered the cornerstone of effective disease management for most patients, is only part of the journey. Managing endometriosis is a lifelong process that involves a diverse care team, tailored specifically to the care of each patient, and intentional lifestyle changes on the part of the patient. Years of pain and inflammation frequently have lasting effects on fatigue, digestion, etc. Many patients report a combination of dietary and lifestyle changes, holistic therapies such as acupuncture and herbal supplements, consultations with chiropractic and functional medicine providers, massage therapy, mental health support, and pelvic floor physical therapy to be crucial in living well with endometriosis both before and after excision surgery. Numerous research studies demonstrate the benefit of these various supportive therapies in ongoing disease management (Denman, n.d.; Nancy’s Nook, n.d.). For more information, visit the resources section of the website and scroll down to the bottom of the page.

 

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Hormonal Therapy and Ablation Surgery 

As discussed above, the vast majority of OBGYN’s are taught based on incorrect theories of disease origin and management, resulting in delayed diagnosis, mismanagement, and poor outcomes.

 

The two most common forms of endometriosis management, hormonal birth control and ablation surgery, are among these ineffective treatments. Endometriosis is an estrogen dependent disease, meaning it requires the hormone estrogen to grow and spread. It was originally believed that decreasing levels of estrogen (by suppressing the ovaries, where most of the estrogen in the body is formed) through hormonal birth control could minimize disease, as well as limit retrograde menstruation by stopping the menstrual cycle. If medical management fails, most OBGYN’s recommend ablation surgery where the endometriosis tissue is burned away.

 

In the 1990’s, as endometriosis began to be further studied, it was found that, while similar to the tissue that lines the uterus, endometriosis cells have distinct differences, including the ability to produce their own estrogen (Bulun et al., 2012.; Chantalat et al., 2020.; Nancy’s Nook, n.d.). Therefore, even if ovarian estrogen production is minimized through hormonal medication, the endometriosis cells can produce their own to continue growing, meaning hormonal treatments alone are not enough to stop disease spread. 

 

It should be noted that, while hormonal management of endometriosis is not enough to stop or cure the disease, it can be helpful for symptom management temporarily when prescribed appropriately by an endometriosis expert. The choice of whether to utilize medications is complex, therefore advantages and disadvantages are best discussed on a case by case basis (Nancy’s Nook, n.d.). For more information on medical vs. surgical management of endometriosis, follow the link below.

 

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The second common method of treatment, ablation surgery, results in incomplete disease removal and leaves behind cells that can grow back, causing pain and symptoms to return. This is one of the reasons endometriosis patients often have surgery every few years for much of their adult life as they attempt to control the effects of the disease. This failure to see significant improvement in symptoms often leads to an early hysterectomy, with the patient being told this will cure the disease. However, endometriosis doesn’t originate from the lining of the uterus and it can produce its own estrogen to grow and spread even without the ovaries and uterus. This means it can potentially start before the first menstrual cycle and continue even after a hysterectomy.