Endometriosis surgery options: laparoscopy, laparotomy, hysterectomy

Getting an endometriosis diagnosis can be challenging. On average, it takes four to 11 years for doctors to confirm you have endometriosis. Part of the reason it takes so long is that the current standard to diagnose the condition is through laparoscopic surgery, making getting a diagnosis a longer and more anxiety-inducing process (Agarwal, 2019). Fortunately, this form of endometriosis surgery can also treat the disease, which means you may be able to get a diagnosis and some relief at the same time. 

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Endometriosis is an inflammatory condition that causes tissue similar to the uterine lining (endometrium) to grow outside the uterus. This endometrial-like tissue is typically found within the pelvic cavity on fallopian tubes, peritoneum, and ovaries. However, endometriosis can appear further away from your pelvic organs in spots such as the bladder, rectum, and other organs in your abdomen (Hirata, 2020). 

Endometriosis affects 5–10% of people assigned female at birth. Common symptoms of endometriosis include chronic pelvic pain, painful periods, pain during ovulation, pain during penetrative sex, lower back pain, painful bowel movements, painful urination, chronic fatigue, and infertility (Zondervan, 2018).

The most reliable way to diagnose endometriosis is through surgery (typically laparoscopy, which we will discuss below). Sometimes, doctors can see signs of endometriosis, such as blood-filled cysts known as endometriomas, through transvaginal ultrasound or MRI. However, imaging does not detect all endometriosis lesions. Surgery allows for much more visibility and further testing (Dunselman, 2014). 

During surgery, doctors can take a sample of a suspected endometriosis lesion and then send the biopsy to a lab to confirm it is endometriosis. Usually, this is done by performing a surgical procedure called a laparoscopy (Dunselman, 2014). 

If your doctor suspects you have endometriosis, they may want to try and see if hormone-based medications can relieve your pain before jumping to surgery. Hormone-based medications like oral contraception, intrauterine devices, and GnRH agonists have been shown to reduce pain associated with endometriosis.  However, symptoms and lesions can reappear once you stop taking the medications (Dunselman, 2014). 

If you have children or do not plan on getting pregnant, you can take some of these medications long-term, potentially reducing the need for surgery. If you plan on conceiving, you will not be able to continue taking medications since they prevent ovulation and pregnancy from occurring (Zondervan, 2018). 

Surgery comes up a lot in discussions about endometriosis. If your doctor suspects endometriosis, they may schedule you for exploratory surgery. The best way to see endometriosis is to look directly inside the body. An exploratory surgery allows your doctor to do this. 

Like almost all endometriosis surgeries, exploratory procedures are laparoscopic surgeries performed under general anesthesia. Laparoscopies use a tool called a laparoscope, a thin tube with a camera and light, to look inside your body. It is a minimally invasive technique that lets your doctor identify endometriosis without any major incisions. These small incisions are why laparoscopic surgery is sometimes referred to as keyhole surgery because the incision size is about a half-inch wide or the size of a keyhole in your door (Nezhat, 2013). 

Laparoscopic surgery requires an incision in your belly button and another two to four incisions, typically between your hip bones. How many incisions you need depends on the device used and where your doctor needs to look (Nezhat, 2013). 

Effectiveness of laparoscopy for treating endometriosis

Laparoscopy is the “gold standard” diagnostic tool for endometriosis (Agarwal, 2019). However, both diagnosis and treatment may rely on surgery, especially if medical therapy has failed. If you are going the surgical route, having a surgeon skilled at diagnosing and removing endometriosis is key in avoiding complications and further surgical procedures. Pain returns for about 20–40% of people who have surgery for endometriosis, 15–20% of whom will have additional surgeries. However, researchers note that this is a conservative estimate; actual numbers may be higher (Vercellini, 2009). 

Endometriosis is not thought to return if excised completely. Any lesions that appear in subsequent surgeries are likely either endometriosis lesions left behind during prior procedures or entirely new spots of disease (Ceccaroni, 2019). Unfortunately, it’s not always possible to remove all endometriosis lesions. Sometimes the risks outweigh the benefits, especially if removing the lesion requires removing part of an organ or damaging delicate tissue. That’s why the surgical technique your doctor uses is essential.

Excision surgery, which cuts and removes the entire lesion, has better outcomes compared to ablation surgery, a method that burns the lesion. Excision surgery decreases menstrual pain, chronic pelvic pain, and constipation at a rate higher than ablation (Pundir, 2017). 

In extremely rare cases, your doctor may need to perform a laparotomy, an older and more invasive technique that requires a larger incision and a longer recovery time. 

As part of the laparotomy, the surgeon cuts into the abdominal wall so they can see directly into your abdomen instead of looking through a laparoscope. Because they are so invasive, healthcare providers reserve laparotomies for rare cases where the surgeon can’t easily visualize extensive disease or need to perform multiple complex procedures on other organs (Zanelotti, 2017).  

Fortunately, thanks to advances in laparoscopic techniques, these invasive types of procedures are no longer standard. Laparoscopy is just as effective as laparotomy and is more likely to decrease pain during intercourse following surgery (Crosignani, 1996). 

Since endometriosis pain tends to be the worst during menstruation, removing the uterus and stopping menstruation can help reduce some symptoms. Having a hysterectomy with oophorectomy (removal of the ovaries) doesn’t guarantee a cure, especially since endometriosis exists outside of the uterus (Vercellini, 2009). 

Effectiveness of hysterectomy for endometriosis

If endometriosis lesions are left behind after your hysterectomy, pain can persist. Although your period will stop after a hysterectomy, that doesn't mean you'll go into menopause. Surgical menopause only happens if your surgeon removes your ovaries. A hysterectomy does not remove the ovaries. 

Approximately 15% of people who have a hysterectomy for endometriosis experience consistent pain after their hysterectomy, and about 3–5% have worsening pain or new problematic symptoms. You get better outcomes if you have your ovaries removed at the same time, but that is not without its own risks (Vercellini, 2009). 

Part of the reason hysterectomy might provide relief for people with endometriosis is because hysterectomy cures adenomyosis, a condition that causes painful menstruation and is common among people with endometriosis. Adenomyosis causes the endometrium, the lining of the uterus, to grow into the myometrium, the muscular wall of the uterus (Zondervan, 2018). 

It’s unclear how many people with endometriosis also have adenomyosis. Clinical studies show anywhere from 40–90% of people with endometriosis also have adenomyosis (Benagiano, 2014).

Other treatment options for endometriosis outside of surgery include (Zondervan, 2018): 

• Oral contraceptives

• Hormone therapy

• Intrauterine devices

• Pelvic floor physical therapy

• Pain management 

These therapies can effectively reduce pain and keep lesions from growing. However, symptoms and lesions commonly reappear after stopping hormone-based medications. Hormone-based medications are also not an option if you are trying to conceive, as they can stop ovulation or menstruation (Zondervan, 2018). If you have children or do not plan on getting pregnant, hormonal options may be enough to treat your symptoms without surgery.  

If you’re not ready to have surgery, non-surgical options can provide some pain relief and give you time to evaluate your options. Don’t be afraid to ask your gynecologist questions about the number of surgeries they perform and the techniques they use. Talking to your healthcare provider about what to expect can help reduce any apprehension you may feel.

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Current version

September 13, 2021

Written by

Jordan Davidson

Fact checked by

Felix Gussone, MD

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About the medical reviewer

Felix Gussone, MD, Ro

Felix Gussone is a physician, health journalist and a Manager, Medical Content & Education at Ro.