Endometriosis Recurrence: Understanding and Preventing it

The Endometriosis Roller Coaster, and How to Prevent It

Surgery remains central to confirming the diagnosis of endometriosis and can be highly effective for treatment. Yet it is not a guaranteed cure because the disease can recur. That reality stems from multiple intertwined causes: incomplete removal of lesions, hormonal imbalances, immune dynamics, toxin exposures, molecular drivers, and influences we likely do not yet fully understand. Thorough, meticulous initial excision is critical, but it is not the sole determinant of recurrence or progression. Below are the key factors in more detail, along with practical ways to reduce risk.

Incomplete Excision

The most frequent reason for post-surgical recurrence is residual disease. Endometriosis can infiltrate deeply into pelvic tissues and organs, and removal is harder when the uterus and/or ovaries are preserved. Even expert excisionists may leave behind microscopic or visually obscured implants because inflammation can hide disease and some lesions are simply not visible. Any remaining endometriosis can regrow over time; more residual disease may mean faster regrowth, but the relationship is not linear. Some lesions grow very slowly, and others may never reach a level that produces symptoms.

Improving the chances of an optimal first surgery involves understanding both the surgical approach and the surgeon’s training. Published research generally favors excision (removal) rather than fulguration (burning), particularly for deep infiltrating endometriosis and endometriomas. While debate exists, fulguration near delicate structures such as the ureters or bowel can be unsafe and is more likely to cause scarring or fibrosis, which itself can worsen pain even when lesions are destroyed.

The surgeon’s training matters. Excision-capable surgeons are essential rather than those who only fulgurate. General gynecologists thoroughly trained in excision are very uncommon, which is why many patients look to gynecologists who have completed additional training in excision and minimally invasive surgery. Many advanced excision surgeons complete a one- to three-year minimally invasive gynecologic surgery (MIGS) fellowship. These fellowships are usually sponsored by the AAGL (American Association of Gynecologic Laparoscopists), are not regulated or board-accredited, and depend heavily on mentor quality; therefore, skill levels vary. Due diligence about a surgeon’s background, outcomes, and patient experiences is still essential.

In the United States, MIGS fellowships often do not include bowel and urologic surgery and may not confer hospital privileges for such procedures. Excision surgeons frequently partner with general surgeons, urologists, and other specialists to address bowel and urinary tract involvement, which can work very well when coordination is strong. Where logistics are less streamlined, choosing a surgeon capable of handling most excision without a large team might be advantageous.

Another training pathway is a three- to four-year gynecologic oncology fellowship accredited by the American Board of Obstetrics and Gynecology (ABOG) and American Council for Graduate Medical Education (ACME). This training confers the ability to operate on any organ in the abdomen and pelvis, including the diaphragm. However, the emphasis is cancer, not the pathophysiology of endometriosis, so many gynecologic oncologists do not go beyond residency-level endometriosis management. In some cases, excisionists collaborate with gynecologic oncologists instead of general surgeons or urologists. A smaller subset of gynecologic oncologists do focus on advanced endometriosis.

If chest endometriosis is strongly suspected on imaging, thoracic surgery becomes part of the team for formal lung procedures. When imaging suggests involvement of major nerves such as the sciatic nerve, a neurosurgeon may also participate.

Regarding fertility, an ABOG/ACGME board-accredited fellowship in Reproductive Endocrinology can be relevant. Historically, this specialty was more surgically oriented in the United States; currently it is less so, but some reproductive endocrinology and infertility (REI) specialists remain surgically inclined and may be trained in excision.

Surgical strategy tailored to your situation also affects recurrence risk. Age, disease severity, and procedure type all matter. Older patients and those with more severe disease face higher recurrence risk unless the uterus and both ovaries are removed. Conservative surgery, which aims to preserve fertility and spare normal tissue, can be associated with greater recurrence risk than more aggressive approaches. That said, with the right surgeon and equipment, conservative surgery can still remove all visible disease in many cases. Aligning goals—such as prioritizing pain relief, fertility, or both—with your surgeon, especially when a multidisciplinary team is involved, is crucial for outcomes that match your priorities.

Hormonal Influences

Endometriosis is strongly influenced by estrogen, which supports growth of endometrial-like tissue outside the uterus. Hormonal therapies—including hormonal contraceptives, progestins, and gonadotropin-releasing hormone (GnRH) agonists and antagonists—can help manage these imbalances. Individual responses vary widely, and some therapies can cause side effects that feel worse than the disease. Biology often finds ways around our best attempts at suppression.

Even after menopause, natural or surgical, estrogen does not vanish. Endometriosis-affected tissues can produce estrogen locally, other hormones and toxins can be converted into estrogen within fat cells, and hormone replacement therapy adds exogenous sources, all of which can encourage recurrence.

Addressing hormonal imbalance after surgery lowers the chance of regrowth. Doing something is better than doing nothing, and reducing your estrogen load is a top priority. Progestins may be recommended to counter estrogen excess. Complete ovarian shut-down with GnRH analogs is situation-dependent and often suboptimal due to the systemic effects of inducing a menopausal state; newer regimens with partial estrogen add-back are improved but remain imperfect. Oral contraceptives are frequently used and are generally easier to tolerate than more aggressive strategies.

Optimizing the gut microbiome is a practical starting point to reduce estrogen burden. A nutrient-dense diet, avoidance of ultra-processed foods, and use of probiotics and prebiotics support gut bacteria that metabolize excess estrogen, which is then eliminated via bowel movements. When gut metabolism is impaired, estrogen can be reabsorbed and recirculated, raising overall load.

Weight loss also helps. Fat cells store xenoestrogens from environmental exposures and slowly release them into circulation. Moreover, higher fat mass drives conversion of other hormones into estrogens. While weight loss takes time, starting early is beneficial.

Stress reduction through mind-body practices can lower estrogen levels. Reducing alcohol intake supports liver function in estrogen breakdown. Certain supplements may help reduce estrogen: seaweed is notable, and Vitamin D, Magnesium, Milk Thistle, Omega-3 fatty acids (fish oil), Vitamin B6, and DIM (diindolylmethane) are often considered; DIM is present in cruciferous vegetables and can be increased through diet.

Only after implementing diet and lifestyle measures should more aggressive hormone-altering medications be considered. A wide spectrum of pharmaceutical and compounded options exists, but these decisions should be made with your physician. There is substantial evidence supporting the value of balancing estrogen and progesterone after surgery to reduce recurrence.

Immune Influences

The immune system is central to endometriosis progression. Implants produce inflammatory mediators that attract immune cells, fueling both inflammation and pain. Conversely, immune cells can help suppress recurrence. Postoperative healing requires a short-lived pro-inflammatory response, which is typically self-limited; interfering with acute inflammation is not desirable. Chronic inflammation, however, can drive recurrence. While research suggests that immune-modulating therapies—such as immunosuppressive agents and immunomodulatory cytokines—could help prevent recurrence, reliable pharmaceutical options are not yet available. Some studies indicate that natural killer (NK) cells are deficient in people with endometriosis. An integrative nutrition strategy to support NK cell number and function includes mushroom consumption; collaborate with an integrative specialist for guidance.

A related concept is the “bacterial contamination hypothesis,” which implicates bacterial endotoxin (lipopolysaccharide, LPS) in triggering pelvic inflammation. Individuals with prior pelvic infections, chronic endometritis, and SIBO have higher rates of endometriosis, potentially linked by LPS. Whether LPS reaches the pelvis via intestinal translocation (micro-leakage) or retrograde menstruation, its presence may stimulate growth and regrowth. In this context, natural or pharmaceutical antibiotics may help dampen chronic low-level infection-related inflammation.

Although not yet mainstream, this framework is plausible and supported by animal models and some human data. Maintaining a healthy microbiome, minimizing leaky gut, and monitoring for gynecologic infections represent prudent, low-risk measures.

Toxin Influences

Environmental exposures can influence both development and recurrence. Compounds like dioxins and polychlorinated biphenyls (PCBs) disrupt hormones—often acting as xenoestrogens—and can increase growth of endometriosis. Lifestyle adjustments that limit toxin exposure and emphasize a healthy diet may help lower recurrence risk after surgery.

Molecular Influences

Molecular alterations within implants contribute to both disease development and recurrence. Mutations in genes that regulate inflammation and hormone signaling, and environmentally driven changes in hormone receptor expression, can allow very small foci to respond to lower estrogen levels. These shifts may be due to genetic mutations or epigenetic changes that toggle normal and abnormal genes on and off.

Extensive molecular crosstalk links hormonal, inflammatory, immune, neurologic, and other pathways, creating the network that drives disease behavior and symptoms. If recurrence seems unusually rapid after high-quality excision, or if multiple recurrences occur—particularly in older patients or those with family histories of cancer or endometriosis—further evaluation is worth considering. While rare, endometriosis can transform into cancer or increase ovarian cancer risk, and mutations such as ARID1A, KRAS, and PIK3CA may underlie more aggressive variants. Genetic counseling and testing can clarify whether this applies in your case.

Surgical Equipment Influences

Minimally invasive surgery is the current gold standard for endometriosis, while large-incision laparotomy is generally avoided. After multiple prior surgeries, some may recommend laparotomy due to scarring or fibrosis and perceived risks of minimally invasive approaches. Although there are rare exceptions, this is not true for the vast majority of patients, and seeking additional opinions is reasonable. Laparotomy often creates more scarring than minimally invasive surgery. Because future procedures may be necessary, choosing an expert who can minimize risk now and later matters.

Minimally invasive surgery may be performed via laparoscopy or robot-assisted laparoscopy. For simple to moderate cases, either approach is acceptable. In complex disease and recurrences, the differences become more consequential. Imaging can hint at extent but often cannot fully predict disease volume or anatomic distortion before surgery. Repeat operations frequently involve greater distortion than the first.

From the perspective of a surgeon experienced with both laparoscopy and robotics over three decades—and who now uses robotics almost exclusively—technology does not replace surgical skill, but better tools can offer real advantages. Some surgeons have not adopted robotics or have only dabbled; dismissing robotics as a fad or “training wheels” often reflects lack of experience with its capabilities. Cost to the patient is the same, and any increase in operative time is typically measured in minutes. For difficult cases, precision may be worth more than finishing first in the recovery area.

Benefits of Robotic Surgery Over Laparoscopy

Robotic systems provide enhanced precision that can improve complete removal of implants, limit collateral tissue injury, reduce complications, and potentially shorten recovery.

Precise Instrumentation

Robotic platforms enable fine, tremor-filtered control, which is especially valuable in distorted anatomy and delicate fields. Traditional laparoscopy uses straight, inflexible instruments controlled by the surgeon’s hands from a distance of roughly twelve to seventeen inches, which can amplify small movements or tremors. In contrast, robotic instruments are micro-controlled and wristed, moving like miniature hands for greater dexterity and reliability. Laparoscopic tips can cut, push, pull, and tear but have constrained motion and can feel like using chopsticks—masterable but inherently limited. With improved precision, robotics can reduce unintended injury to nearby structures such as bowel, ureters, or blood vessels, thereby lowering complication risk and supporting faster healing.

Superior 3-Dimensional Optics

Robotics provides a magnified 3-D view with true depth perception. Most laparoscopic systems use 2-D imaging, though simulated 3-D options with glasses exist; without depth perception, distinguishing separation between tissues in distorted anatomy is harder. For example, bowel may be adherent to an endometrioma, or ovarian blood vessels may be hidden by inflammation, and safe dissection benefits from 3-D visualization. The functional difference is easy to imagine: try navigating tasks with an eye patch and you will misjudge distances—humans are designed for binocular vision. Operating in 2-D imposes a handicap that, regardless of skill, can matter in complex cases.

Conclusion

Recurrence after surgery arises from intersecting factors: incomplete excision related to surgeon experience or technology, hormonal imbalances, immune drivers, toxin exposures, and molecular influences. Take time to absorb these considerations and partner with the most qualified endometriosis specialist and surgeon available for your goals and circumstances.