Posted by Article on 2/5/2002, 11:03 am

Is My Endometriosis Coming Back? post-operative events that cause concern by Robert B. Albee, MD When a woman has had surgery for her endometriosis, she often experiences a time when her confidence in her results is, at best, shaky. Nothing has ever worked before, and, although she wants to believe she is better, she is almost afraid to hope too strongly for fear of being disappointed yet again. When such a woman has pain or any other symptom resembling the symptoms she had before surgery, she might draw (or be given) an erroneous conclusion that, "the endo is back". This article tries to explain what some of these symptoms might mean, when they are worrisome, and what you can do about them. General Information Each case of endometriosis is unique, because of the locations of the implants and the depths to which the tissue was invaded. Therefore, it is a bad idea to try to compare your recovery to anyone else’s, or even to yourself at a previous operation. Even if the surgeries seem very similar, recovery varies due to a number of host (that’s you) factors including the following: immune system status nutritional status percentage body fat blood clotting factors differences in anatomy smoking status chronic lung disease, or inadequate oxygen delivery to the tissue ambulatory activity attitude medications other disease processes life stresses and pressures compliance with post-op directions number of prior surgeries type of anesthesia co-dependency factors (environmental, social, and personal factors that can cause certain responses to pain and stress). The first approach about any concern: Do the symptoms suggest a need for immediate attention to evaluate a new problem or a surgical complication? Consult the post-operative instructions you were given to check your doctor’s guidelines about what is normal and what is not. If you have reasonable doubt, always call for advice. The Healing Process Healing begins as soon as the surgery ends. First, injured blood vessels clot and the body speeds host defense mechanisms into the area. Each location injured by excision begins to have local edema with an infusion of serum. Multiple blood-borne factors and cells are rushed into place. The tissue swells and nerve endings are irritated and sensitive to these changes. Adhesions may form over the area in an attempt to wall it off. The body then begins to lay down new blood vessels and new peritoneum to cover the injuries. Soft tissues are amazingly reconstructed. This is your body’s natural response. The deeper the surgical dissection that was needed to remove all your endometriosis, the more injury there is to heal. For the completion of this process we estimate that 10-12 weeks need to pass. This time period can increase due with factors such as those listed above, or complications such as infection or bleeding. First Menses Your first menstrual period after laparoscopic excision surgery (LAPEX) can be extremely heavy and painful. Many women report clots and cramps to a much greater degree than before surgery. This can be very frightening. However, it is my opinion that several factors are involved to produce this event. There is a natural congestion of blood into the injured areas where endometriosis was excised. This may affect the ability of the uterine muscle to contract normally. This, in turn, can result in heavy flow, clots, and cramps. Another possibility is that the anesthetic drugs used to relax the body during surgery have long-lasting effects on the uterine muscle, with the same outcome. Physical inactivity during the post-operative period may be a third factor leading to a change in uterine muscle responsiveness. I am not aware of any specific way to prevent this from happening. I suggest treating it with cautious observation and the knowledge that this has not proven to be a long term or recurring problem. Generally, only the first one or two menstrual cycles are affected. First Ovulation The first ovulation after LAPEX also has the potential to create unusual symptoms. If the ovaries were involved in the excision of endo, they may be extremely sensitive. When an endometrioma is excised from an ovary, a defect in the capsule of the ovary is left, and this can require a good deal of time to heal. The area may be bruised, tender, and swollen with increased circulation. If, as part of the natural processes, an area near the injury is the site for the next ovulation (for example, ovulating from the right ovary when the right ovary had an endometrioma removed from it), tissue changes occur in an already injured area. The result of these dynamic changes in an extremely sensitive area can be unusual pain. While this may be a totally self-limiting process, the pain can be severe and slow to subside. It is terribly frightening particularly when it seems to be similar to events you have always been associated with endo. In fact, there is no sure-fire way for us to tell instantaneously the difference in the sources for your pain. Because of this, I now suppress ovulation for a three-month interval post-op. Unfortunately, even women on this regimen can still have an ovarian event. For more information about post-op ovarian suppression, please see the article I wrote on that topic. Ovarian Cysts Post-operative ovarian cysts (after LAPEX of ovarian endo) are not common. However, they can and do occur. After ovarian LAPEX, the same factors that can make ovulation unusually painful are also responsible for an increase in the frequency of ovarian cysts. Some of these cysts form because of adhesions around the ovary. Others form because of bleeding within the ovary. A surgically treated ovary has a higher chance of some bleeding within the ovary during a natural event such as ovulation, or corpus luteum formation after ovulation, than a normal ovary does. If the bleeding is confined within the ovary and is not released into the abdomen, a hemorrhagic cyst will form. This is simply a pocket of blood. A hemorrhagic cyst can require 8-16 weeks to resolve, but it usually will. In the absence of signs of an acute problem, such as active bleeding into the abdominal cavity, most ovarian cysts in the post-op period should be treated patiently. Recommendations include activity limitation (avoid prolonged sitting and standing, no lifting or straining until the pain has been substantially relieved for at least three days) and close observation by knowledgeable physicians. If you have just been through surgery to deal with endometriosis and the cysts so commonly associated with it, a new cyst is a scary thought. Added to your fear can be a visit with a physician who will automatically tell you that a new cyst is "new endo". All too often, this results in patients being wrongly told their endo has come back! Then they are usually offered one of the stronger suppressive drugs. Now in addition to hurting, these women are confused, angry, and afraid that their disease has not been treated effectively, or that it has come back already. Cysts that form within the first six months after LAPEX are almost never endometriosis. In fact, in more than 650 patients I have treated with LAPEX, we are aware of fewer than one dozen recurrent ovarian endometriomas. The average length of time post-op for patients in this series is almost four years, and 95 patents more than seven years past surgery. [Continued in post below]

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