Recurrence of endometriosis refers to the reappearance of endometrial-like tissue after it has been completely surgically removed. This can manifest as new lesions or the regrowth of previously excised disease. True recurrence differs from persistence, which results when endometriosis is left behind and not actually fully excised. Recurrence may be clinically suspected based on symptoms and can be confirmed through imaging or surgical findings.

Apart from surgery, are there any other risk factors that can lead to recurrence?

Apart from incomplete surgery, some factors can contribute to the recurrence of endometriosis, including but not limited to the presence of other gynepathologies, such as adenomyosis and/or concomitant adhesion; higher stages of disease; lesion subtype such as the presence of bowel lesions; and whether pharmacological therapy is used postoperatively or not. It is critical to note that the recurrence or persistence of pain is not always synonymous with the presence of endometriosis; secondary pain generators may often be present.

How does hormone medication work as a method of prevention for recurrence?

Hormonal medication aims to suppress the stimulation of endometrial-like tissue and inhibit its growth during therapy. It is intended to treat endometriosis-associated pain and theoretically can suppress recurrence while used. Drugs to treat endometriosis‐related pain include synthetic progestins, combined hormonal contraceptives, GnRH analogs, aromatase inhibitors, danazol, SERMs and SPRMs. While more recent publications indicate reduced reoperation rates for endometriosis in those who are treated with hormones in association with their surgery, a 2020 Cochrane Review exploring the effectiveness of hormonal suppression before, after or both before and after surgery for endometriosis determined that “the data was inconclusive.” Still, there is evidence that hormone suppression may help prevent postoperative recurrence, particularly endometriomas.

What is the rate of recurrence in endometriosis after excision and for what period of time?

Recurrence rates after endometriosis surgery vary widely and are operator-dependent. Rates are heavily influenced by factors such as extent of disease and completeness of surgical excision. Rates have been previously reported between 20%-40% within 5 years; however, more current data published by dedicated centers of expertise indicates overall rates of recurrence of less than 10%.

Is endometriosis a disease that can be cured?

There is no universal, definitive cure for endometriosis. Multidisciplinary treatments is directed at symptom management and meticulous removal of disease to reduce recurrence and persistence, with goals directed at alleviating symptoms and improving quality of life.

Is the presence of an endometrioma after surgery a sign of recurrence?

Endometriomas have a high recurrence/persistence rate, and their presence after surgery can indicate both persistence or true recurrence of the disease.

Why is the rate of recurrence higher in women under 25 years old or a bit older?

While risk predictors remain under debate, younger patients may have higher recurrence rates due to increased hormonal activity, i.e., higher plasma estrogen levels, more aggressive disease and disease subtype may be associated with endometriosis recurrence. In contrast, still other data indicates that those in the 35 + age group are positively associated with recurrence when compared to non-endometriosis controls, driving home the importance of patient-centric care adapted to the individual in order to apply tailored therapies for every patient.

What is the recurrence rate for bowel endometriosis based on the procedure done?

While the recurrence rate after colorectal surgery for endometriosis may be as high as up to 50% at 5 years, as with all forms of the disease this may vary based on the skill of the surgeon and type of surgical intervention. For example, current data implies that that the risk of recurrence is lower when segmental resection or disc excision is performed than when rectal shaving is performed.

What are the signs of endometriosis returning?

Clinical signs of endometriosis recurrence may be the same as or include those experienced at primary onset, i.e., pain (for example, persistent or new pelvic pain), changes in menstrual patterns, such as increased pain or heavy bleeding, recurrence of pain during or after sex, GI or urinary dysfunction/pain, bloating, fatigue and more. As with initial onset, timely diagnosis and effective intervention are key towards isolating and treating the diagnosis.

Can some of these symptoms be caused by adhesions?

Yes, symptoms such as pelvic pain and discomfort during intercourse can also be caused by adhesions, which are scar tissues that can form after surgery or due to chronic inflammation. Adhesions can cause similar symptoms to endometriosis and complicate the diagnosis and management, as can a number of other conditions including but not limited to adenomyosis, for example.

References

Nirgianakis K, Ma L, McKinnon B, Mueller MD. Recurrence Patterns after Surgery in Patients with Different Endometriosis Subtypes: A Long-Term Hospital-Based Cohort Study. J Clin Med. 2020 Feb 11;9(2):496. 

Magnani, L., Marchi, N., & Alvino, M. (2021). Genetic and epigenetic factors in endometriosis. Reproductive Biology and Endocrinology, 19(1), 92.

Schippert C, Witte Y, Bartels J, Garcia-Rocha GJ, Jentschke M, Hillemanns P, Kundu S. Reproductive capacity and recurrence of disease after surgery for moderate and severe endometriosis – a retrospective single center analysis. BMC Womens Health. 2020 Jul 13;20(1):144. Giudice LC, Oskotsky TT, Falako S, Opoku-Anane J, Sirota M. Endometriosis in the era of precision medicine and impact on sexual and reproductive health across the lifespan and in diverse populations. FASEB J. 2023 Sep;37(9):e23130.

Holdsworth-Carson SJ, Chung J, Machalek DA, Li R, Jun BK, Griffiths MJ, Churchill M, McCaughey T, Nisbet D, Dior U, Donoghue JF, Montgomery GW, Reddington C, Girling JE, Healey M, Rogers PAW. Predicting disease recurrence in patients with endometriosis: an observational study. BMC Med. 2024 Aug 7;22(1):320.

Chiu CC, Hsu TF, Jiang LY, Chan IS, Shih YC, Chang YH, Wang PH, Chen YJ. Maintenance Therapy for Preventing Endometrioma Recurrence after Endometriosis Resection Surgery – A Systematic Review and Network Meta-analysis. J Minim Invasive Gynecol. 2022 May;29(5):602-612.

Vercellini P, Bandini V, Viganò P, Di Stefano G, Merli CEM, Somigliana E. Proposal for targeted, neo-evolutionary-oriented, secondary prevention of early-onset endometriosis and adenomyosis. Part I: pathogenic aspects. Hum Reprod. 2024 Jan 5;39(1):1-17. 

Zakhari A, Delpero E, McKeown S, Tomlinson G, Bougie O, Murji A. Endometriosis recurrence following post-operative hormonal suppression: a systematic review and meta-analysis. Hum Reprod Update. 2021 Jan 4;27(1):96-107

Vercellini P, Somigliana E, Viganò P, De Matteis S, Barbara G, Fedele L. Post-operative endometriosis recurrence: a plea for prevention based on pathogenetic, epidemiological and clinical evidence. Reprod Biomed Online. 2010 Aug;21(2):259-65.

Ceccaroni M, Clarizia R, Mussi EA, Stepniewska AK, De Mitri P, Ceccarello M, Ruffo G, Bruni F, Rettore L, Surico D. “The Sword in the Stone”: radical excision of deep infiltrating endometriosis with bowel shaving-a single-centre experience on 703 consecutive patients. Surg Endosc. 2022 May;36(5):3418-3431.

Lv H, Liu B, Dai Y, Li F, Bellone S, Zhou Y, Mamillapalli R, Zhao D, Venkatachalapathy M, Hu Y, Carmichael GG, Li D, Taylor HS, Huang Y. TET3-overexpressing macrophages promote endometriosis. J Clin Invest. 2024 Aug 14:e181839.

Fallon L, Lau AYS, Ciccia D, Duckworth TJ, Pereira C, Kopp E, Perica V, Sherman KA. Perceived challenges in treatment decision-making for endometriosis: healthcare professional perspectives. Health Psychol Behav Med. 2024 Aug 1;12(1):2383469.

Holdsworth-Carson SJ, Chung J, Machalek DA, Li R, Jun BK, Griffiths MJ, Churchill M, McCaughey T, Nisbet D, Dior U, Donoghue JF, Montgomery GW, Reddington C, Girling JE, Healey M, Rogers PAW. Predicting disease recurrence in patients with endometriosis: an observational study. BMC Med. 2024 Aug 7;22(1):320. 

Kikuchi I, Takeuchi H, Kitade M, Shimanuki H, Kumakiri J, Kinoshita K. Recurrence rate of endometriomas following a laparoscopic cystectomy. Acta Obstet Gynecol Scand. 2006;85(9):1120-4.

Guo SW. Recurrence of endometriosis and its control. Hum Reprod Update. 2009 Jul-Aug;15(4):441-61.

Holdsworth-Carson SJ, Chung J, Machalek DA, Li R, Jun BK, Griffiths MJ, Churchill M, McCaughey T, Nisbet D, Dior U, Donoghue JF, Montgomery GW, Reddington C, Girling JE, Healey M, Rogers PAW. Predicting disease recurrence in patients with endometriosis: an observational study. BMC Med. 2024 Aug 7;22(1):320.

Martire FG, Piccione E, Exacoustos C, Zupi E. Endometriosis and Adolescence: The Impact of Dysmenorrhea. J Clin Med. 2023 Aug 29;12(17):5624. 

Bendifallah S, Vesale E, Daraï E, Thomassin-Naggara I, Bazot M, Tuech JJ, Abo C, Roman H. Recurrence after Surgery for Colorectal Endometriosis: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol. 2020 Feb;27(2):441-451.e2.

Alborzi S, Roman H, Askary E, Poordast T, Shahraki MH, Alborzi S, Hesam Abadi AK, Najar Kolaii EH. Colorectal endometriosis: Diagnosis, surgical strategies and post-operative complications. Front Surg. 2022 Oct 4;9:978326.

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The pathophysiology of postoperative adhesions involves a cascade of events regulated by various cellular and humoral factors, including insufficient peritoneal fibrinolytic capacity (Hellebrekers & Kooistra, 2011). The formation of postoperative adhesions is a natural consequence of surgical tissue trauma and healing (“Control and prevention of peritoneal adhesions in gynecologic surgery”, 2006). Animal studies have shown that administration of TGF-␤ to the postoperative abdomen enhances the formation of adhesions, while blockade of TGF-␤1 via inhibitory antibody treatment decreases the formation of adhesions (Boland & Weigel, 2006). 

Furthermore, it has been suggested that insufficient peritoneal fibrinolytic capacity is the main factor in determining postoperative adhesion formation (Hellebrekers & Kooistra, 2011). Despite meticulous surgical techniques, postoperative adhesions develop in the majority of patients undergoing abdominopelvic surgery (Diamond, 2016). 

To prevent the formation of postoperative adhesions, various strategies have been proposed, including the use of bioabsorbable materials (Hamaji et al., 2015), ovarian suspension in patients undergoing laparoscopic surgery for endometriosis (Giampaolino et al., 2019), and pharmacologic agents such as anti-inflammatories, antiestrogens, and antioxidants (Öner & Ulug, 2015). Additionally, the use of neurokinin-1 receptor antagonists (Reed et al., 2008), naproxen nanoparticle-loaded thermosensitive chitosan hydrogel (Wang et al., 2019), and traditional Japanese medicine Tokita et al. (2011) have also been investigated for their potential in preventing postoperative adhesions. 

Moreover, the effectiveness of sodium hyaluronate, sesame oil, and liquid paraffin in preventing postoperative surgical adhesion formation has been evaluated (Khorshidi et al., 2017; Kataria & Singh, 2016). Other studies have examined the use of bioresorbable hyaluronate-carboxymethylcellulose membranes (Mueller et al., 2000), interferon γ, and plasminogen activator inhibitor 1 Ohashi et al. (2014) as potential preventive measures. 

In conclusion, the prevention of postoperative adhesions is a complex and multifaceted issue, and various approaches have been explored to address this challenge. Further research, including pre-clinical and clinical studies, is necessary to evaluate the effectiveness of these prevention strategies and to develop comprehensive guidelines for their implementation. 

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There is no definite link between obesity and endometriosis, but there are studies that mention obesity as one of the risk factors for endometriosis. Among them are studies that show that women with endometriosis who are obese have a severe degree of endometriosis.

One such study was conducted in Australia on 700 women surgically diagnosed with endometriosis. The study’s findings showed that although the incidence rate of endometriosis in obese women is lower compared to those of normal weight, they have a higher risk of having severe endometriosis.

But there are also studies that suggest that for every 5 kg/m2, the risk of developing endometriosis is reduced by 33%. This is a meta-analysis, including a quantitative investigation of 11 studies, entitled “What is the link between endometriosis and obesity?”, and was conducted in Korea. The study’s authors suggest, however, that women with a high BMI are less likely to be recommended for surgery for pelvic pain, thereby reducing the chances of endometriosis being diagnosed laparoscopically.

Another study conducted in Australia, published in 2022 in Obesity Research & Clinical Practice, to see if there is a link between body mass index and endometriosis diagnosis, which analysed data from 11,794 young women, the findings show that overweight women had a lower risk of confirmed endometriosis compared to women of normal weight. On the other hand, the risk of clinically suspected endometriosis was higher among overweight women compared to those of normal weight.

Cause or effect?

Although an exact cause between obesity and endometriosis has not yet been established, certain aspects of endometriosis can lead to weight gain. Menopause-inducing hormone treatments often recommended for endometriosis can have the side effect of either weight gain or make weight loss difficult. Specifically, in menopause, estradiol, the hormone that helps regulate metabolism and body weight, decreases. Lower estradiol levels can lead to weight gain.

The risks of obesity

One of the risks of obesity for women is the impact on fertility. Being overweight leads to hormonal dysregulation but also to high levels of androgens, which combined can cause a dysfunction of the secretion of hypothalamic gonadotropin hormones, resulting in a reduction in the number of follicles, as well as the level of progesterone.

Intra and postoperative risks

Being overweight increases the risks associated with surgery often required for endometriosis. Obesity is a significant risk factor for wound infection, blood loss, and longer operative time. Recovery can be more difficult and lengthy, and hospitalisation can also be longer.

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At the end of the surgery, certain endometriosis tissues from different locations such as ovaries, fallopian tubes, peritoneum, intestine are sent to a laboratory in special containers. Once they arrive in the laboratory, staff starts preparing, a process consisting of several stages, such as:

• Macroscopic examination and sampling of the necessary tissue fragments;
• Embedding in paraffin (wax);
• Microtomy and slide mounting;
• Staining and mounting on slides;
• Microscopic examination of slides;
• Drafting of the histopathological report by the medical anatomopathologist;
• Archiving.

All these stages are done with great care, by qualified personnel, following current protocols.  At the end of this process, the pathologist’s findings will be included in a histopathology report.

What is the histopathology report?

A histopathological report is a medical document, written by a pathologist following the processing and interpretation of samples taken during surgery. The report contains the final diagnosis, which, when indicated, can be used to determine the treatment and prognosis of the condition.

The data that are included in the histopathological report are:

• Patient data
• Referral diagnosis
• Parts sent: ovary, fallopian tube, nodule, uterus, etc
• The referring physician

Apart from these data, the report must also contain:

• macroscopic description – what the specialist sees with the naked eye;
• microscopic description – what the doctor sees under the microscope. This stage is very important, and it’s dependent on the experience and knowledge of the anatomopathologist, as this one will confirm the diagnosis.
• diagnostic conclusion – to diagnose endometriosis, the examined tissue must contain both glands and stroma.
• the signature and initials of the pathologist.

Is diagnosis easy to make?

In the microscopic examination, the specialist identifies at least 2 features:

Endometrial glands formed from Müllerian epithelium. The specialist will also analyse whether the glands show degenerative atypia or metaplasia.

The endometrial stroma, usually containing a fine capillary network, may in turn undergo changes such as fibrosis or decidual changes.

There are also cases when the only component identifiable under the microscope is the stroma, and in this case we are dealing with a type of stromal endometriosis.

Although the histopathological diagnosis of endometriosis is easy to make; there may be difficulties resulting from changes in the endometriotic tissue over time. These changes may consist of alteration or absence of glands or stroma.

The stromal component can be altered by fibrosis, but also by myxoid changes and decidual changes. Also, the inflammatory and reactive changes that occur in endometriosis can complicate the histological results.

Another difficulty that can arise in histopathological diagnosis is when endometriosis tissues are associated with another condition, such as peritoneal leiomyomatosis or gliomatosis, resulting in a potentially confusing histological appearance.

The authors of a study carried out in Norway to find out the histological confirmation of endometriosis in various peritoneal lesions, show that of the 152 patients, endometriosis consisting of glands and stroma was diagnosed in only 78 patients. If the diagnostic criteria would have been extended to include stromal endometriosis, then 82 patients would have been diagnosed with endometriosis.

Immunohistochemistry, a plus in the diagnosis of endometriosis

In the case of specimens difficult to evaluate with classical histology, immunohistochemistry can be used to obtain a definite diagnosis. In such cases, the histopathological examination will be completed by the immunohistochemical examination of the paraffin-embedded tissue. The pathologist can use different immunohistochemical markers to confirm the diagnosis, such as CD10 – which will be positive in the endometrial stroma and ER, PR and PAX2 – which will be positive in the endometrial glands and endometrial stroma.

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The origins of endometriosis include many concepts. For me from 1970 to 1992, the question of origin had one answer: retrograde dissemination of endometrium during menses, implantation during a window of opportunity, and growth. 

In 1992, it was apparent that congenital misplacement was needed for some endometriosis. By 2016, I used five concepts and theories and the last time I counted, it took 23 concepts and theories to begin a discussion and many more to continue. Currently the window of opportunity is highest in adolescents. It can be speculated that it might be like acne and may have to do with neuroimmune maturation. There are more concepts, hypotheses, theories, and speculations than solid findings. There is no one answer that covers all the questions. The review covers some of the possibilities.

One concept of the origin is a discussion of the origin of the recognition of signs and symptoms. Nezhat et al. reviewed pelvic symptoms reported by Egyptians in 1855 BC. Knapp’s review of the 17th description of pelvic “ulcers” with symptoms suggesting endometriosis may be the first anatomic description. The first histologic description was by Rokitansky in 1860. There were many early names for “endometriosis” before this term was suggested by Sampson in 1925.

A second concept of origin regards the cell or substance of origin. The potential cells of origin included the endometrium, misplaced precursors during embryonic development, peritoneum undergoing metaplasia, and bone marrow stem cells. In addition to possible cells, there may be substances that induce metaplasia in other cell types. Those substances may be inflammatory products such as cytokines, Schwann cells, Levander substances or Merrill factor.

A third concept is how endometriosis, a mullerian disease, gets to a site outside of its expected mullerian area. For endometrium, that means mullerian-type tissue is outside of the uterine cavity where babies grow. A similar disease, adenomyosis, has that type of tissue outside the cavity but in the uterine muscular wall. When tissue like endometrium is found outside the uterus, it is commonly called endometriosis. However, Sampson noted that endometriosis was different than endometrium “both in structure and in function.” The common definition of “ectopic tissue like endometrium” does not include that the original tissue and endometriosis have biochemical, immunologic, epigenetic, and other differences. Alternate definitions include considerations for inflammation, fibrosis, epigenetic modifications, bleeding, and other characteristics. There is no single definition that satisfies all scientists, physicians, or patients.

The fourth concept is what causes the transition from a cell or origin to endometriosis. The initiator for that transition may be the inflammatory action of estrogens, withdrawal of progesterone preceding menses, infection, trauma and repair or other possibilities. The development of medicines or holistic health habits that prevent this transition may offer the best chance of preventing the progression of endometriosis. Early clinical diagnosis and treatment was associated with a limitation to mild endometriosis over 10.2 years by Knox, et al. None of the adolescent patients in that study developed moderate or severe endometriosis. Waiting 6 to 10 years for a diagnosis that requires surgery may be avoidable. Early treatment of pain is the correct management of pain and may decrease problems with endometriosis. Although this may not be useful for those with long delays and deep endometriosis, it might be for their daughters and other young adolescents.

As can be seen in the short summary, the origin of endometriosis is a complex subject. My monograph “Endometriosis Concepts and Theories” has more than 650 references for readers interested in research or in additional information.

References are available on request. Email danmartinmd@gmail.com

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Endometriosis of the somatic nerves, as the name suggests, affects the functionality of the somatic nerves, i.e. the nerves that innervate the skeletal muscles, the skeletal sciatic muscles, and in principle, affects the presacral plexus. This structure is the origin of the main somatic nerves in the pelvis: the sciatic nerve, the obturator nerve, the pudendal nerve, the femoral nerve and the gluteal nerve branch of the sciatic nerve.

Endometriosis of the sciatic nerves is a difficult pathological entity to treat, because as Prof. Possover said, the pelvis is a black box, i.e. it is an area that no speciality can find itself in. More specifically, a gynaecologist does not have the necessary neurological knowledge, even though gynaecological surgeons who practise advanced surgery have the knowledge of the anatomy of the retroperitoneum, they do not have the knowledge of neurology.

Also, neurosurgeons with knowledge of neurology do not address this area of the body, they mainly treat conditions of the cranial box and spine, less peripheral nerves and never pelvic nerves. And that’s why this pathological entity has somehow been neglected over time, and so to fill this gap neuropelveology appeared, which is an independent specialty founded and developed by Prof. Marc Possover, an area that receives more and more followers.  

Regarding endometriosis of somatic nerves, so a chapter of neuropelveology, there are other renowned doctors who developed and supported research in this field, such as Prof. Horace Roman, Prof. Rabischong, Prof. Khazali. Their interest and findings made the path of somatic nerve surgery much clearer and they made the access techniques that give satisfaction easier.

Somatic nerves have two functions: a sensory one and a motor one. The sensory function basically collects the stimuli from the muscle and integumentary structures located in the territory that the nerve serves and transmits them to the brain.

The motor function achieves the voluntary conscious control of the respective muscles that are involved in movement; walking, running or finer motor functions such as erection and voluntary bladder control.

The type of nerve pain is a fixed point pain, a burning sensation, and allodynia. The location of the pain is exact, and depending on the location of the neuropathic pain, we know which nerve is affected.

The characteristic of pain in nervous endometriosis is that this neuropathic pain is a cyclical pain that mainly occurs during menstruation or ovulation, or it is a chronic pain that is exacerbated during menstruation and ovulation.

“In order to diagnose the affected nerve, knowledge of the functional anatomy of the somatic nerves, respectively of the territories they serve, which are called dermatomes, is needed. This also orients the clinician and thus determines the appropriate treatment”

That is why it is very important for the endometriosis surgeon who addresses this pathological entity, to know how to conduct a neurological examination to complement the usual gynaecological examination.

Regarding surgical indication, we must take into account the fact that somatic nerve endometriosis surgery is an extremely difficult and extremely frustrating surgery. Because, on one hand, each somatic nerve is difficult to access, and on the other hand, any nerve destruction is irreversible, so surgery must be as frugal as possible. Some aspects that we often deal with are sequelae lesions, perineural fibrosis following surgery, postoperative scars that can affect the somatic nerve and consequently generate pain similar to the initial pain caused by endometriosis.

So, in other words, even if we establish a correct diagnosis, perform a correct surgery, it may happen that after surgery the patient’s body develops a scar tissue that includes the nerve path, creates a nerve entrapment, and generate pains similar to the initial pains, which nullifies the benefit of the surgical act.

That is why the balance is very fine regarding surgical indication because we have to balance between, as I said before, the delicates of the operation, the surgical risks, the complications given by the postoperative scar, but on the other hand we have to take into account that nervous endometriosis, slowly but certainly, destroys the affected nerve and every mm of the nerve path counts, and in fact, here is another peculiarity of nerve endometriosis surgery, namely, we are dealing with a tissue that does not regenerate, we are dealing with extremely fine structures and it is crucial to intervene at the opportune moment.

From my point of view, the indication for surgery in endometriosis of the somatic nerves is a disabling, intractable pain, that does not respond to any kind of analgesics, a pain that practically makes the patient’s life a nightmare, and or especially, if there are signs of defunctionalization of the nerve, respectively muscle atrophy in the territory served by that nerve and with functional impairments of the nerve served.

It is known that the nerve once affected by endometriosis after a certain time can suffer the wallerian degeneration phenomenon, i.e. downstream of the endometriosis lesion the nerve begins to die and this is the moment when motor dysfunction appears in the served territory and the moment when we are obliged to intervene. 

Once we establish the indication for surgery, somatic nerve endometriosis surgery must be extremely accurate, the surgeon must have thorough knowledge of the anatomy of the pelvis. The instruments with which the surgeon works around the nerve must be extremely fine, cold instruments are always preferred, the use energies around the nerve its not recommended, because can irreversibly damage the nerve, and most of the time, surgery is good to be done in a multidisciplinary team, meaning that even if they are not part of the operation, it is very good to ask the opinion of a neurosurgeon at the moment we do such an operation, because as I was telling you, they have thorough neurological knowledge.

“When we operate on nerves it is good to ask the opinion of a neurosurgeon, as they have thorough neurological knowledge”

After surgery for endometriosis of the somatic nerves, recovery through physical therapy is very important because these therapies help heal the nerve and help prevent the formation of perineural scar tissue, as mentioned above. Somatic nerve surgery is carried out in a few centres in the world, and is becoming more and more known. I support the centralization of these cases because, as I told you, somatic nerve endometriosis is extremely rare, and then it would be good for these cases to be directed to centres that already have experience in this field, so that the patient benefits from the best experience and expertise.

As far as I’m concerned, I have a series of at least 40 nervous endometriosis surgeries involving all the previously described nerves, sciatic nerve, obturator nerve, pudendal nerve. Most of them had favourable results, but even so, I consider this surgery to be a great challenge and must always be viewed very seriously and even humbly by the surgeon, I might say.

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Research shows that the most common symptoms of endometriosis among affected women are chronic pelvic pain (71.1%), dysmenorrhea (69%), back pain (54%), pain during intercourse (45.2%) and painful defecation (36.5%), while only 22.8% of diagnosed women are asymptomatic.

Depending on the type of symptoms and the type of disease, there might be some ways in which the pain can be relieved to increase the quality of life in this battle with the condition. Here are some of them.

1. Heat therapy

Heat therapy is a simple but effective method to ease the intensity of pain caused by endometriosis. Applying a heating device or a hot water bottle to the lower abdomen can help relax the muscles, relieve cramps and reduce pain.

Warm baths or showers can also provide relief. Heat therapy is a non-invasive and affordable option that you can use in the comfort of your own home to manage pain during periods or painful episodes.

2. Physical exercises

Exercise tailored to address pelvic floor dysfunction may be beneficial for people with endometriosis. Pelvic floor exercises aim to improve muscle function, relieve tension and reduce pain in the pelvic region.

A qualified physical therapist can also guide you through exercises and techniques to strengthen and relax the pelvic floor muscles, giving you relief from endometriosis pain. This approach is especially valuable for people who have pelvic pain or discomfort during intercourse.

Yoga is another beneficial practice for people with endometriosis. The combination of movement, breath control and meditation can relieve pain symptoms, but also reduce stress and better manage anxiety.

3. Lifestyle changes

Making certain lifestyle changes can help manage endometriosis pain. Regular exercise, low-impact activities such as walking or swimming, can help improve general well-being and reduce pain.

In addition, eating a balanced and nutritious diet can help reduce inflammation and support overall health. Some people find pain relief by incorporating anti-inflammatory foods such as fruits, vegetables and omega-3 fatty acids into their diet.

Avoiding triggers such as caffeine and alcohol during flare-ups can also help manage symptoms.

4. Mind-body techniques

Mind-body techniques, including mindfulness, meditation, and deep breathing exercises, can be powerful tools in managing endometriosis pain. These practices focus on promoting relaxation, reducing stress, and improving overall mental well-being.

Epsom salt baths are one of the techniques used successfully for pain relief and relaxation. Also, people with chronic pain and high stress levels can benefit from regular relaxation massages.

Mindfulness-based stress reduction (MBSR) and progressive muscle relaxation are examples of techniques that have shown promise in helping individuals cope with chronic pain conditions. Integrating mind-body practices into your daily routine can contribute to a more positive outlook and a better ability to navigate the challenges of life with endometriosis.

Living with endometriosis can be challenging, but effective pain management strategies can significantly improve the quality of life for people dealing with the condition. Combining medical interventions with lifestyle changes and mind-body techniques creates a holistic approach to managing endometriosis pain.

By exploring some of these methods and finding the right combination for individual circumstances, people affected by endometriosis can take proactive steps to regain control of their lives and experience relief from chronic pain.

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Education 

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