Is Uterus Removal The Only Treatment For Endometriosis?

Endometriosis is more common than you think. It affects 1 in every 10 women and leads to pain and infertility. As per the World Health Organisation (WHO) it is a disease in which tissue similar to the lining of the uterus grows outside the uterus. It causes severe pain in the pelvis and can start at a person's first menstrual period and last until menopause.

This happens when the tissue that lines the uterus or the womb grows outside of it and in other parts of the abdomen and pelvis, such as the bowel and bladder.

If you have these symptoms, your doctor would ask you to get an MRI, a pelvic exam and a minor surgical procedure called a laparoscopy done, to confirm endometriosis. The extremely painful conditions one faces with endometriosis lead to seeking the last resort of hysterectomy or uterus removal. However, it is not always helpful.

Dr Archana Kankal, Director, Obstetric and Gynaecology, Sahyadri Hospitals MomStory, Pune, says, "Although it can relieve symptoms, it doesn’t always completely solve the problem because endometriosis can occur outside of the uterus and remain even after the uterus is removed. Therefore, when deciding to go forward with this surgery, it's important that all the endometriosis is removed to improve the chances of relieving symptoms."

Several factors influence the decision to opt for a hysterectomy in cases of endometriosis, explains Dr Kankal. The severity and location of the disease play a crucial role; if endometriosis has spread to other organs like the ovaries or fallopian tubes, more extensive surgical measures may be required. Age and fertility aspirations also significantly influence this decision. "Younger patients who wish to have children may opt for more conservative treatments, while those who have completed their families or are not concerned about fertility might consider this surgery as a viable option," explains Dr Kankal.

Additionally, how well other treatments such as hormonal therapies or pain management strategies have worked can also determine whether or not to proceed with a hysterectomy. There are alternatives to avoid hysterectomy, including medical management. This is where hormonal treatments like birth control pills, patches or vaginal rings can help with the growth of endometriosis tissue and reduce symptoms. Through conservative surgery like laparoscopy, doctors can remove endometriosis tissue through small cuts in the abdomen, without removing the uterus. Some people, suggests Dr Kankal, also find changes in diet or exercise can help manage symptoms.

It is possible for endometriosis to persist or to come back after a hysterectomy. "This happens if not all the endometriosis was removed during surgery or if the ovaries are left in place. These ovaries can continue to produce hormones that might cause the remaining endometriosis tissue to act up. This, a comprehensive surgical approach, sometimes including the removal of the ovaries, might be necessary to reduce the likelihood of the disease returning," says Dr Kankal.

While a hysterectomy can significantly alleviate the symptoms of endometriosis, it can come with potential long-term effects. The removal of ovaries with the uterus can lead to immediate menopause, regardless of the patient's age. "This can lead to typical menopausal symptoms like hot flashes, night sweats, and mood changes. There's also an increased risk of developing cardiovascular diseases and osteoporosis due to the decrease in hormone levels. Additionally, some women experience significant emotional or psychological impacts after the surgery, which may require support and counselling," explains Dr Kankal.

Dr Maunica Sorakayalapeta, IVF Specialist, Ferty9 Fertility Center, LB Nagar talks about the treatment for patients who want to preserve fertility. "GnRH agonists are another treatment option, inducing a temporary menopause-like state to alleviate symptoms. However, these drugs must be used with caution due to potential side effects, such as bone density loss," she says. In addition, aromatase inhibitors may be used to lower oestrogen levels and are often combined with other treatments to enhance their effectiveness.

The focus remains on effective pain management, as it is critical and usually involves non-steroidal anti-inflammatory drugs (NSAIDs) to directly address discomfort. Some patients also find relief through alternative methods such as acupuncture, physical therapy, and dietary changes, which can offer a more natural approach to symptom management.

Sorakayalapeta also points out that regular monitoring of the patient’s response to treatment is important to allow for timely adjustments and ensure that patients receive ongoing support as they navigate their fertility journey. "For those considering fertility treatments, these follow-ups are crucial in preparing them physically and emotionally for the next steps," she says.

There are fertility options for those who wish to conceive, including ovulation induction using hormonal medications to stimulate ovulation and increase the chances of conception. "Intrauterine insemination (IUI) may be an option for patients with mild endometriosis and no additional fertility issues. In cases of more advanced endometriosis or unsuccessful treatments, in vitro fertilization (IVF) can offer an effective solution, allowing for egg retrieval while bypassing any blockages caused by endometriosis," she explains.