Endometriosis - Conservative Surgery

In one study, laparoscopy achieved pain relief in over 62% of women. A more recent study conducted 3-12 months post-surgery in women with severe (stage III/IV) endometriosis suggested 88% of patients were satisfied with the procedure.

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In addition, pregnancy rates can range from 20% to over 50% after laparoscopy. (The procedure does not reduce the chances for pregnancy in women who must still undergo assisted reproductive techniques to conceive.) Still, recurrence rates for laparoscopy are no better than those with laparotomy -- the more invasive procedure.

Laparotomy uses a wide abdominal incision and conventional surgical instruments. It is more invasive and requires a longer recovery time. In some severe cases, the physician may need a wider view of the pelvic area and will perform this procedure. Laparotomy is typically used for infiltrating endometriosis, although the less invasive laparoscopy is showing increasing effectiveness, even for deep implants.

Complications after Surgery. Many patients experience temporary but severe discomfort in the shoulders after laparoscopy due to residual carbon dioxide gas that puts pressure on the diaphragm. The incisions, even with laparoscopy, may cause pain afterward, which can usually be treated effectively with mild pain relievers. There are small risks for bleeding, infection, and reaction to anesthesia. Surgery in the pelvic area may also cause scarring, which may cause pain and interfere with fertility. A lubricating gel, or adjuvant, called Intergel, appeared to reduce this risk, but was taken off the market due to adverse effects. A similar new product is currently in clinical trials. More studies are needed.

Pre- and Postoperative Drug Treatment

Preoperative Drug Treatment. Hormonal agents administered before laparoscopy or laparotomy are being investigated to reduce the size of endometrial cysts and so perhaps to improve outlook. A 2000 study, for example, reported that the GnRH agonist goserelin injected monthly twelve weeks before laparoscopy resulted in much smaller implants and better treatment of the disease than treatment with surgery alone.

Postoperative Drug Treatment. A number of studies have also been conducted to determine if taking hormonal agents after surgery can provide further pain relief. Results have been mixed, and the benefits, if any, are probably slight.

Nerve Destruction Techniques

There is some evidence that when the pain-conducting nerve fibers leading from the uterus are surgically severed, the amount of pain from dysmenorrhea diminishes. Two procedures, uterine nerve ablation and laparoscopic presacral neurectomy, are used to block such nerves. Small studies have shown benefits from these procedures, but stronger evidence is needed before they can be recommended for women with severe primary dysmenorrhea.