Endometriosis Explained  Episode 8

🤔When Is Surgery Needed for Endometriosis?

Surgery is not automatically required for every woman with endometriosis.

According to current guidance, the decision should be individualized according to:

• Severity of pain

• Response to medical treatment

• Organ involvement or dysfunction

• Fertility goals

• Extent and complexity of disease

• Previous surgery and ovarian reserve.

The 2026 SOGC guideline specifically states that surgery should be planned around the patient’s goals, symptoms and disease extent, with indications including pelvic pain, organ dysfunction and infertility. 

💥When may surgery be considered?

Surgery may be appropriate when:

• Pain remains severe despite adequate medical therapy

• There is significant distortion of pelvic anatomy

• An endometrioma requires treatment

• Deep endometriosis affects the bowel, bladder or ureter

• There is obstruction or threatened organ function

• Fertility may benefit from surgical treatment in selected patients

• Imaging or clinical findings raise concern requiring definitive assessment or treatment.

🥺Excision or ablation?

Current evidence favours excision over ablation, especially for deep lesions, because excision removes the full depth of disease and allows histopathological confirmation. The guideline recommends aiming for complete excision when feasible. 

😱What about ovarian endometriomas?

For endometriomas, cystectomy is generally more effective than cyst ablation for pain, recurrence prevention and fertility outcomes.

But there is an important trade-off:

Cystectomy can reduce ovarian reserve, particularly in women with:

• Low pre-operative AMH

• Large endometriomas

• Bilateral endometriomas

• Previous ovarian surgery.

So preserving ovarian tissue should be part of the surgical plan. 

🤔Does hysterectomy cure endometriosis?

Not necessarily.

Hysterectomy may reduce recurrence and reoperation risk in carefully selected women who do not desire future fertility, especially when uterine disease or adenomyosis contributes to symptoms.

But removing the uterus does not automatically remove all endometriosis, because lesions may exist outside the uterus.

And importantly:

Routine removal of both ovaries in premenopausal women is not recommended.

The guideline notes that bilateral oophorectomy does not reliably improve pain or satisfaction, while increasing risks such as cardiovascular disease, osteoporosis and sexual dysfunction. 

📖 Guideline Pearl

The goal of endometriosis surgery is not simply to “remove everything.” It is to treat disease while preserving organ function, fertility and quality of life whenever possible.

💜 Surgery should be tailored to the woman not just to the stage of disease.

Dr Rabab Cares

#DrRababCares

#EndometriosisExplained #EndometriosisSurgery #Endometrioma #PelvicPain #Fertility #WomensHealth

 Endometriosis Explained  Episode 7

💥How Is Endometriosis Treated?

There is no single treatment that is right for every woman with endometriosis.

Treatment should be individualized according to:

• Severity and pattern of symptoms

• Desire for pregnancy now or in the future

• Age and ovarian reserve

• Extent and location of disease

• Previous treatment response

• Side-effect profile and personal preferences.

1. Pain relief

Simple analgesics and anti-inflammatory medications may help control symptoms, particularly during painful episodes.

2. Hormonal treatment

For women who are not trying to conceive immediately, hormonal suppression is a major treatment option and may be used long-term for symptom control.

Options may include:

• Combined hormonal contraceptives

• Progestins

• Levonorgestrel intrauterine system

• GnRH agonists or antagonists in selected patients.

• Add-back therapy when appropriate

The choice should be made through shared decision-making, because different options have different benefits, risks and side-effects.

3. Give treatment enough time

One important update from current guidelines:

Do not label a hormonal treatment as a failure too early.

If side-effects are tolerable, treatment should usually be continued for at least 3 months before its effectiveness is properly assessed.

4. Surgery

Surgery may be considered when there is:

• Persistent or severe pain

• Organ dysfunction

• Extensive disease

• Endometrioma in selected cases

• Infertility where surgery may offer benefit.

But surgery is not automatically required simply because endometriosis is present.

The surgical plan should depend on the patient's goals, symptoms and complexity of disease. 

5. Fertility treatment

If pregnancy is the priority, the treatment pathway changes.

Hormonal suppression may improve pain, but it does not improve fertility in women with endometriosis-associated infertility.

🤔 Fertility evaluation, surgery in selected cases, IUI or IVF may be considered depending on age, ovarian reserve, tubal status and other factors. 

📖 Guideline Pearl

For patients not seeking immediate pregnancy, hormonal therapy should be offered and may be used long-term for symptom control. Treatment choice should be individualized not prescribed as a one-size-fits-all approach. 

💜 The goal is not only to treat the lesions. It is to treat the woman, her symptoms, her fertility plans and her quality of life.

Dr Rabab Cares

#DrRababCares

#EndometriosisExplained #EndometriosisTreatment #PelvicPain #Fertility #WomensHealth

Endometriosis Staging: Does Stage IV Always Mean Worse Disease?

Endometriosis is commonly classified into four stages:

Stage I – Minimal

Stage II – Mild

Stage III – Moderate

Stage IV – Severe

These stages are mainly based on what is seen during surgery, including:

• The number, size and depth of endometriosis lesions

• The presence of ovarian endometriomas

• The extent of pelvic adhesions

• The involvement of the ovaries and fallopian tubes.

But here is the important point:

A higher stage does not always mean more severe symptoms.

A woman with Stage I endometriosis may experience severe, disabling pain.

Another woman with Stage IV disease may have only mild symptoms—or may only be diagnosed during an infertility assessment.

This is because pain depends on several factors, including:

• Where the lesions are located

• Whether nerves are involved

• The depth of the disease

• The presence of fibrosis and adhesions

• Individual pain sensitivity

The stage also does not accurately predict fertility on its own.

When assessing fertility, doctors must also consider:

• Age

• Ovarian reserve

• Tubal function

• Previous ovarian surgery

• Male-factor infertility

• The Endometriosis Fertility Index (EFI) after surgery.

Current guidelines therefore recommend that management should not be based on the stage alone. Treatment should be individualized according to the patient’s symptoms, reproductive plans, organ involvement and personal priorities. 

So, does Stage IV matter?

Yes.

Stage IV usually means more extensive anatomical disease, such as:

• Dense adhesions

• Large or bilateral endometriomas

• Distortion of pelvic anatomy

• More complex surgery

• Possible bowel, bladder or ureter involvement.

Deep endometriosis may sometimes impair organ function, including causing bowel or ureteric obstruction, so extensive disease requires careful imaging, surgical planning and specialist care. 

Guideline Pearl

The stage describes the anatomical extent of endometriosis. It does not fully describe the severity of pain, the impact on quality of life, or the chance of pregnancy.

💜 Treat the woman not just the stage.

Dr Rabab Cares

#DrRababCares

#EndometriosisExplained  #EndometriosisStaging #StageIVEndometriosis #PelvicPain #Fertility #WomensHealth

💜 We’re back — and continuing our Endometriosis Explained series.

After a short pause, Dr Rabab Cares is back with more clear, practical, and guideline-based information about endometriosis.

We’ve already discussed what endometriosis really is, why it causes pain, how it can affect fertility, when severe period pain should raise concern, and how diagnosis is made.

Now, we’re moving deeper into the disease itself.

✨ Coming next: Episode 6 

Because when it comes to endometriosis, the stage does not always tell the whole story.

Stay tuned. 💜

Dr Rabab Cares

#EndometriosisExplained #Endometriosis #WomensHealth #PelvicPain #Fertility #DrRababCares

🌸 Endometriosis Explained – Episode 5

How Is Endometriosis Diagnosed?

For many years, endometriosis was considered a disease that could only be confirmed through surgery.

Current guidelines support a more modern, patient-centred approach: diagnosis can begin clinically and does not always require immediate laparoscopy. The 2026 SOGC management guideline complements the 2024 SOGC guideline dedicated to diagnosis and impact.

1. Clinical assessment

Diagnosis begins with a detailed history of symptoms, including:

• Severe or progressively worsening period pain

• Chronic pelvic pain

• Pain during sexual intercourse

• Painful bowel movements or urination, particularly during menstruation

• Difficulty conceiving

• A personal or family history suggestive of endometriosis

A focused pelvic examination may identify tenderness, reduced mobility of pelvic organs, nodularity, or an adnexal mass. However, a normal examination does not exclude endometriosis.

The SOGC recognises a clinical diagnosis based on symptoms, physical examination and appropriate basic ultrasound, even without advanced imaging or surgical confirmation. 

2. Ultrasound

A routine pelvic ultrasound may detect ovarian endometriomas, but a specialised transvaginal ultrasound performed by a trained examiner can also assess deep endometriosis, adhesions, organ mobility and involvement of structures such as the bowel or bladder.

Ultrasound is highly useful—but it is operator-dependent, and normal imaging cannot reliably exclude superficial endometriosis.

3. Magnetic resonance imaging

MRI may be used when:

• Deep endometriosis is suspected

• Ultrasound findings are unclear

• Bowel, bladder, ureteric, abdominal-wall, diaphragmatic or nerve involvement is suspected

• Detailed mapping is required before complex surgery

Advanced ultrasound and MRI are particularly important for surgical planning and determining whether referral to an endometriosis centre is appropriate.

4. Laparoscopy

Laparoscopy is no longer recommended simply as the automatic first step for every woman with suspected endometriosis.

With better clinical assessment and advanced imaging, the role of purely diagnostic laparoscopy has become limited. It may still be considered when symptoms remain highly suggestive despite inconclusive assessment, because superficial lesions may not appear on imaging.

When laparoscopy is performed, it should ideally be done by a surgeon able to:

• Recognise the different appearances of endometriosis

• Systematically inspect the pelvis and abdomen

• Treat visible disease during the same procedure when appropriate

• Obtain tissue for histopathology if the diagnosis is uncertain

This helps avoid an unnecessary second operation.

Guideline Pearl

A normal ultrasound does not rule out endometriosis, and surgery is not required before every patient can receive a clinical diagnosis or begin appropriate management.

Diagnosis should be based on the complete picture: symptoms, examination, imaging findings, reproductive goals and individual preferences—not on one test alone.

💜 Listening to the patient is the first diagnostic tool.

Dr Rabab Cares

#Endometriosis #EndometriosisDiagnosis #PelvicUltrasound #PelvicPain #WomensHealth #Gynaecology #DrRababCares