Endometriosis surgery: what you need to know

Published February 2023 | 5 min read
Expert contributor Dr Pav Nanayakkara, gynaecologist and surgeon at Jean Hailes for Women's Health
Words by Charmaine Yabsley

If you need surgery for endometriosis, here’s how to prepare and what to expect.

Endometriosis is a chronic inflammatory condition where cells similar to those that line the uterus grow in other parts of your body – most commonly in the pelvis. Endometriosis affects one in nine women in Australia. Instead of leaving your body during menstruation, they bleed, causing pain and inflammation. These cells heal, creating scar tissue and ‘adhesions’ between the uterus, ovaries, fallopian tubes and bowel, which can be painful and affect fertility.

Dr Pav Nanayakkara, gynaecologist and advanced laparoscopic surgeon at Jean Hailes for Women's Health, answers the questions you need to ask your doctor before having surgery for endometriosis.

Lifestyle treatments for endometriosis

“Endometriosis is a condition where we suggest three prongs of management in order to get the best outcome,” says Dr Nanayakkara. “Surgery alone isn’t necessarily the solution. Endometriosis can return, especially if your lifestyle or hormone therapy isn’t managed.” The holistic approach to endometriosis includes lifestyle management, hormone therapy and surgery.

The first approach is to make sure your lifestyle is as healthy as it can be. “Endometriosis is an inflammatory condition, so it’s important you reduce your stress and anything that causes inflammation, before and after your surgery,” she says. This approach includes eating healthy foods (a low FODMAP or low-dairy and low-gluten diet may help), sleeping at least seven hours a night, and making sure you get enough vitamin D. Speak to a registered dietician before making changes to your diet.

Hormone therapy for endometriosis

The second approach is hormone therapy, which is used as a treatment for many stages of endometriosis or as a combined therapy as it works by suppressing the growth of tissue. This may involve the combined oral contraceptive pill, progesterone-only pill, or the insertion of a hormone-coated intrauterine device (IUD).

What kind of surgery will I need for endometriosis?

Surgery is the important third approach: “You don’t always need surgery to manage your symptoms,” says Dr Nanayakkara. “Surgery is used for diagnosis and to remove visible endometriosis and repair damage caused by the condition.” As with any surgery, there are risks related to the surgical procedure itself, as well as the anaesthetic used.

Surgery for endometriosis may involve any or more of the following approaches:

Laparoscopic surgery

“Laparoscopy surgery is keyhole surgery performed under a general anaesthetic,” says Dr Nanayakkara. A thin telescope with a light is inserted into the abdominal cavity through small cuts made into the skin. “Laparoscopy allows you to look for endometriosis and remove any endometrial tissue, cysts or nodules, while minimising blood loss and scarring, which may lead to adhesions.

“The first operation for treatment of endometriosis gives the best chance of long-term outcomes, to achieve as complete a removal as possible, and minimise residual disease. This means it’s important to choose a surgeon experienced in endometriosis and advanced laparoscopic surgery, otherwise it can make it harder for subsequent surgeons to go in and operate.”

After endometriosis surgery you’ll need to rest for two weeks and avoid strenuous activity or lifting any heavy object for six weeks.

“Endometriosis can return, especially if hormone therapy isn’t on board,” she says. Hormone therapy, like an IUD, can be inserted at the time of surgery. “Even after surgery, it’s likely you’ll need hormone therapy to reduce the chances of more surgery.”

“If you have an IUD inserted, you may experience bleeding – light spotting – up to six months after your operation,” says Dr Nanayakkara. “A small proportion of women will have mild pain and cramping for a few weeks as it settles in and the body becomes accustomed to it.”

Hysterectomy

If a woman’s quality of life is significantly affected by endometriosis or severe period pain and they have completed their family, a hysterectomy may be recommended.

“We remove the uterus and tubes but strongly encourage leaving the ovaries behind. For women who have had their ovaries removed for other reasons (like cancer risk reduction), they may need to manage their hormones through hormone replacement therapy,” says Dr Nanayakkara.

In the context of endometriosis, this is often combined hormone replacement therapy (oestrogen and progesterone), even though there's no longer a uterus, to prevent reactivation of any endometrial cells that may be present.

In some cases, endometriosis can form nodules within the bowel or bladder organs. “In which case, a specialist in these areas will often be consulted,” she says.

How to find an endometriosis surgeon

Organisations like Jean Hailes for Women’s Health, Endometriosis Australia and Australasian Gynaecological Endoscopy and Surgery Society (AGES) can offer recommendations for surgeons with advanced laparoscopy and endometriosis experience.

“It’s important you feel comfortable with your surgeon,” says Dr Nanayakkara. “You can ask them for their level of experience in treating varying stages of endometriosis.”

“Your surgeon will be able to talk you through your procedure – they can explain it in as much detail as you want. This often includes a thorough assessment of the organs in your abdomen and pelvis for any traces of the disease. The surfaces of your bladder and bowel, your appendix and your diaphragm (the muscles separating your chest from your abdomen) are also checked for any endometrial cells.”

After surgery you may experience referred shoulder pain, due to the carbon dioxide used to fill up the abdomen to allow your surgeon a clearer view of the organs. “Heat packs and peppermint oil can help but we also have a few surgical techniques to minimise this discomfort,” she says.

It’s important to understand surgery and/or a hysterectomy will only help with period pain itself and won’t necessarily fix endometriosis if there are endometrial cells elsewhere that aren't removed. The chronic effects of having had pain over many years must also be considered. Some women who have a hysterectomy may find they continue to experience pelvic pain.

“This can be related to pelvic muscle spasms, which are the body’s response to recurrent pain. The nerves in the pelvis can also become sensitive and remain ‘switched on’,” says Dr Nanayakkara. “Pelvic floor physiotherapy, nerve-related medication and a pain specialist can help you train the brain to minimise this nerve pain.”

What does endometriosis surgery mean for my fertility?

Around one third of women with endometriosis will have trouble with fertility or conception.

“When your body is inflamed, the endometrial cells create a hostile environment,” says Dr Nanayakkara. “Sometimes the body then doesn’t think it’s the right time for pregnancy. Adhesions and scarring from surgeries can also prevent the tubes from working correctly, resulting in subfertility [when trying to conceive takes longer than expected].”

Many women do go on to have successful pregnancies following treatment for their condition.

Jo’s story of being diagnosed with endometriosis

Jo, 51, has endometriosis that took many years to formally diagnose. She has a son, 12, and currently feels better than she has in years.

“I was 47-years-old when I was formally diagnosed with stage four (severe) endometriosis, after more than 20 years of pain.

“My situation was complicated because I'd had a bowel resection as a child. Whenever I experienced endo symptoms, such as burning pelvic pain, my GP would put it down to adhesions caused by operations I’d had earlier in life.

“I suffered years of chronic constipation as a result of adhesions and FODMAP sensitivities. To help with my bowel issues, I went on a low FODMAP diet – this should only be done under the care of a dietitian as it’s difficult to manage. You need to temporarily take out several whole food groups, then slowly introduce them back in – all the while watching for recurrence of symptoms. I found that I can only handle small amounts of wheat, garlic, onions and legumes.

“When I was 38, I found out I was pregnant with twins. This was discovered during a routine ultrasound to check for polyps, as I’d had one removed nine months earlier but I was still bleeding heavily. At five weeks, I lost one of the embryos. Thankfully I was able to carry my son to full gestation. He is now a healthy 12-year-old.

“Thankfully, four years ago, I finally found a specialist gynaecological radiologist who knew what to look for, and a new GP who persisted in getting a diagnosis of endometriosis. As I had extensive adhesions between my bowel and uterus, I had a gynaecologist and bowel surgeon working together during the surgery. It took several months to recover from the surgery – I still experienced burning and sharp pulling painful symptoms.

“I’m now post-menopausal and on an HRT patch and a more natural progesterone prescribed by my endocrinologist. My symptoms have finally settled down and I feel the best I’ve felt in 20 years. I’ve learnt that it’s important to practise self-care whenever I feel pain: I practise mindful self-compassion, use hot packs and take the time to rest. I hope that in the future it won’t take so long for women to receive a diagnosis of endometriosis – mine has been a long and exhausting journey.”

If you have any questions or concerns about endometriosis, chat to your GP.

If you’re considering surgery, call us on 13 13 34 to find out if your chosen hospital is an HCF participating provider or use the Find a Participating Hospital tool.

To find out if your doctor participates in our provider network, use our Find a Provider tool to check if you can expect to pay any out-of-pocket expenses.