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BackTable / OBGYN / Article
Rethinking Hysterectomy for Endometriosis: Is it Really the Best Solution?
Sam Strauss • Updated Apr 7, 2025 • 34 hits
Endometriosis is a chronic, often painful condition in which tissue similar to the uterine lining grows outside the uterus, affecting the ovaries, fallopian tubes, and other organs within the pelvis. This condition can lead to severe symptoms such as pelvic pain, dysmenorrhea, dyspareunia, and infertility. Despite being a common diagnosis, treatment options remain a significant challenge for clinicians. Hysterectomy, a surgical procedure involving the removal of the uterus, has often been considered a potential solution for endometriosis, especially in patients with persistent pelvic pain. However, this approach does not always result in symptom relief, particularly in cases where endometriosis extends beyond the uterus.
In this article, Dr. Emad Mikhail, an expert in minimally invasive gynecologic surgery (MIGS), explains the myths and realities surrounding hysterectomy as a treatment for endometriosis. He highlights the importance of thorough preoperative imaging and surgical decision-making, the complexities of ovarian conservation versus oophorectomy, and the challenges of managing deep endometriosis.
This article features excerpts from the BackTable OBGYN Podcast. You can listen to the full episode below.
The BackTable OBGYN Brief
• Hysterectomy is not a cure for endometriosis, especially when the disease extends outside the uterus; it can be beneficial for adenomyosis or cyclic pelvic pain but does not address endometriosis outside the uterus.
• Ovarian conservation should be considered for premenopausal patients, as removing the ovaries (oophorectomy) can lead to significant long-term health risks, such as bone loss and cardiovascular issues, without necessarily solving the endometriosis symptoms.
• Deep endometriosis, which affects organs such as the bladder, bowel, and vaginal cuff, requires specialized imaging (ultrasound or MRI) to properly diagnose and guide treatment, as it is often missed during routine evaluations.
• Preoperative workups, including detailed history-taking and imaging, are critical for identifying deep endometriosis before surgery, especially in post-hysterectomy patients with lesions. Undiagnosed lesions can lead to severe surgical complications.
Table of Contents
(1) Hysterectomy for Endometriosis: Myths & Realities
(2) Oophorectomy vs Ovarian Conservation: Benefits & Risks
(3) Ovarian Suspension: Minimizing the Risk of Retroperitonealization
(4) Deep Endometriosis: The Importance of Thorough Imaging
Hysterectomy for Endometriosis: Myths & Realities
Hysterectomy is often mistakenly viewed as the best solution for endometriosis, particularly by patients desperately seeking relief from chronic pelvic pain. However, while hysterectomy can be effective for conditions like adenomyosis or significant cyclic pain, it does not address endometriosis outside the uterus. The key to successful treatment lies in excising visible endometriotic lesions and ensuring that other potential pain generators, such as interstitial cystitis or myofascial pelvic pain, are addressed. Hysterectomy should be considered as part of a comprehensive approach, rather than the end-all cure for endometriosis.
[Dr. Mark Hoffman]
…I think when we think about some of the most challenging cases in our MIGS world and GYN surgery, I think of the repeat surgery, right? Once you've gone into a space, operated and come back, that's a big part of how we counsel patients. It's a big part of how we address potential complications is, if we're going to operate, remember if it doesn't provide the results that you want and we have to go back, that next surgery certainly can be very challenging. Before we get into the second surgery, talk to us about the role of hysterectomy and endometriosis. I think it's something that certainly a lot of our patients think about as being curative in that sense. Talk to us about what we understand about hysterectomy as a treatment for endometriosis.
[Dr. Emad Mikhail]
Thank you, Mark, for this question. This is a very important topic is that when to do a hysterectomy in patients with endometriosis from the patient perspective as well as from the surgeon perspective. Some patients come and say, if I do a hysterectomy, I'm going to get cured from endometriosis, get cured from pelvic pain, and I'm good to go for life. This is very rarely the case. Actually, hysterectomy, when you think about endometriosis, it is basically an X-ray trial disease because endometriosis of the uterus is actually called adenomyosis. Doing a hysterectomy does not necessarily treat endometriosis. It is a great step to do if you are treating adenomyosis or if you are treating very significant cyclic pelvic pain and dyspareunia.
For endometriosis, hysterectomy usually does not cut it. You have to many things, number one, make sure that you excise endometriosis that's present outside the uterus, and then do a hysterectomy as a complementary treatment in cases that the hysterectomy is indicated. Also make sure that the patient does not have a concomitant- other pain generators that would come as a result of residual symptoms or recurrent symptoms.
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Oophorectomy vs Ovarian Conservation: Benefits & Risks
The decision between performing an oophorectomy or conserving the ovaries during endometriosis surgery is a critical one, especially in premenopausal patients. The goal of the removal of the ovaries is to reduce estrogen levels. This is because high levels of estrogen can stimulate the growth of endometriosis tissue. However, removing the ovaries comes with its own risks.
Oophorectomy leads to surgical menopause, which can cause long-term health consequences such as bone density loss, cardiovascular risks, and other hormone-related issues, especially if the patient is under 50. It also eliminates all possibilities of the patient becoming pregnant for the rest of their lives, which may not be a desirable outcome.. Dr. Mikhail stresses that if the ovaries are healthy, preserving them is often the best option for maintaining hormonal balance and preventing the premature onset of menopause. Ovarian conservation offers the benefit of maintaining estrogen production, which has protective effects on bone and cardiovascular health.
[Dr. Mark Hoffman]
…I think when we talk about hysterectomy, we're talking about uterus and cervix traditionally, but we have to counsel about whether or not to leave the ovaries. Many women who are suffering from endometriosis are of reproductive age, right? Younger, premenopausal, oftentimes remote from menopause. The decision to take out ovaries is not a small decision. Clearly, if they're getting a hysterectomy, they've made the decision that they're not interested in future childbearing, but potential impact on bone, heart, other systems that are not small deals and how we counsel on that. I think historically, the thinking was, make it menopausal, problem solved, right?
They don't have hormones, but that's number one. It's a big decision and we have to think about, is it worth it? Number two, is that going to solve the problem? Talk to us about hysterectomy with BSO, without BSO, as it relates to endometriosis, and what you understand about the likelihood that patients still have symptoms post-op.
[Dr. Emad Mikhail]
One important point that I have to emphasize is that deep endometriosis nodules secrete their own estrogen as a mechanism of self-survival. Removing the ovaries of the patient and push them into surgical menopause, specifically when the ovaries are normal, not diseased, I believe that this is not the right decision. Removing the ovary as a source of estrogen does not cure the endometriosis. Actually, the endometriosis will still be there, will still profilate, and will still cause symptoms. ACOG, in the last practice bulletin, reports about if the patient is elderly, 60 or older or 65 or older, they can offer them an ophorectomy with potentially no harm. If you have a premenopausal patient, taking out the ovaries has a huge implication on the patient health. If the ovaries are normal, an ophorectomy is not indicated. Excision of endometriosis is the way to go.
One caveat that I have to emphasize is that if you do a lot of pelvic dissection, opening the pelvic spaces, specifically complete peritonectomy of the ovarian fossa or the patient has deep endo and you're treating that and you open all the retroperitoneal spaces and you leave the ovaries, there is a likelihood of the ovaries getting really retroperitonealized. Become underneath the peritoneum. Then this actually by itself causes pain, and if for any reason a repeat surgery is indicated, the surgery becomes significantly harder. Ways to prevent that scarring has to be thought about ovarian suspension, something like that, until the space heals off and the ovary does not become retroperitonealized.
Ovarian Suspension: Minimizing the Risk of Retroperitonealization
Ovarian suspension is a technique used during endometriosis surgery to prevent retroperitonealization, which can occur if the ovaries become trapped beneath the peritoneum due to extensive pelvic dissection. It can lead to extensive amounts of scarring, making future surgeries more difficult and increasing the risk of complications.
Dr. Mikhail prefaces his introduction to this concept by admitting that there is limited amounts of large-scale data supporting the effectiveness of ovarian suspension. The limited data is due to the fact that in order to actually have conclusive data, there would need to be a second laparoscopy, and this would be unethical to perform without medical cause. However, Dr. Mikhail also confirms that it has been widely adopted based on clinical experience and expert opinion. He emphasizes the importance of temporarily suspending the ovaries, particularly in cases where the ovarian tissue is healthy and being preserved. By attaching the ovary to the ipsilateral round ligament or the abdominal wall, the ovary is kept above the peritoneal space, allowing the peritoneum time and space to heal without trapping the ovary. The suspension is done using an absorbent stitch. If done with proper technique, there is essentially no downside to this strategy.
[Dr. Emad Mikhail]
If you end up doing a peritonectomy or open the parietal space specifically and the ovary is normal and you are keeping it, I usually suspend the ovary to the ipsilateral round ligament. It keeps it above the space until the space is retroperitonealized. I know other surgeons who suspend the ovary to the abdominal wall with a temporary stitch that can be removed in two days after. Different ways people are doing to prevent that falling of the ovary into the dissected space, and then it becomes retroperitonealized.
[Dr. Mark Hoffman]
If you're sewing it to the round ligament, are you using just a Vicryl? Are you using something permanent?
[Dr. Emad Mikhail]
Yes, no, I don't use something permanent. I use absorbent stitch, that I- get absorbed in a week or two. By that time, the peritoneum regrows and the ovaries will not be retroperitonealized.
[Dr. Mark Hoffman]
Now, I think this is one of those areas where we just don't have a lot of data or is there data on that? From the last time I looked, I don't know of any.
[Dr. Emad Mikhail]
No, actually, there is very scarce data about this, and the main reason is that we cannot do just repeat laparoscopy just to find out if what we did last time worked or not. This is unethical. Any surgical randomized trial will not ever be done, because we cannot do a second look laparoscopy anymore.
Deep Endometriosis: The Importance of Thorough Imaging
Sometimes, patients may have a more severe form of endometriosis called “deep endometriosis”. This is defined by the severity of overgrowth of endometrial tissue. Deep endometriosis presents significant diagnostic and treatment challenges. The deep lesions commonly associated with deep endometriosis are often missed during routine examinations, making accurate preoperative imaging essential for effective surgical planning. To detect these lesions, standard imaging may not always suffice. Specialized techniques, such as using vaginal and rectal dyes during MRI, help highlight deep lesions that are otherwise difficult to visualize. By utilizing specialized imaging, clinicians can better visualize the extent of the disease and avoid missing critical areas during surgery.
A comprehensive preoperative workup also involves detailed history-taking, physical examinations, and collaboration with a multidisciplinary team—including radiologists trained in endometriosis imaging and colorectal specialists. This integrated approach enhances the chances of successful outcomes and ensures more accurate treatment strategies.
[Dr. Mark Hoffman]
How do you evaluate for deep disease? What's your workup?
[Dr. Emad Mikhail]
First thing is I listen to your show, and I remember your conversation with Dr. Ted Lee about the value of history taking. I still remember that. I cannot emphasize this very well that how much you listen to the symptoms and try to think about which symptom can be translated in what anatomical location. By listening to the patient, you almost are painting a mental model of the anatomy, where is the location of the disease. Then you can- examination, this is something that we all have been trained during our training about, but utilizing expert imaging, and I cannot emphasize this enough, ultrasounds are not created equal. MRIs are not created equal. If you are a GYN surgeon who decides that you're going to treat patients with deep endometriosis, you have to have access to expert imaging. Either you learn how to do ultrasound for endometriosis yourself or you have a partner or somebody you can access who knows how to do, deep endometriosis ultrasound examinations, and you have also a radiologist who is trained and is interested to develop MRI experience in deep endometriosis.
We have great radiologists, but some of them, they really want to excel in imaging of endometriosis and some not so much, which is okay. But if you are going to tackle deep disease, you have to have those two team members, an expert sonologist and an expert radiologist.
[Dr. Mark Hoffman]
Do you read your own ultrasounds?
[Dr. Emad Mikhail]
I have a partner who is a GYN sonologist and she does all my ultrasounds.
[Dr. Mark Hoffman]
That's great.
[Dr. Emad Mikhail]
She does deep endometriosis ultrasounds. Actually, I ask myself every time, do I really need to get an MRI after her scan?
[Dr. Mark Hoffman]
Oh, wow.
[Dr. Emad Mikhail]
Well, sometimes we still do.
[Dr. Mark Hoffman]
Then you have, I'm assuming, a close relationship with your radiologists and do you have a special pre procedure set up that you do?
[Dr. Emad Mikhail]
We actually have a multi-disciplinary team meeting for pre-op and post op patients. In this meeting we have mixed surgeons. We have RDI specialists, we have the GYN sonologists, we have the radiologists who are the team who are interested in endometriosis imaging. We have our colorectal surgeon. We do this, maybe, every other month and then we go over cases and for surgical planning. Actually, we come back and present the cases post operatively, showing them the laparoscopy or the robotic images. Actually, everybody learns. We learn together and get better together.
Podcast Contributors
Dr. Emad Mikhail
Dr. Emad Mikhail is a gynecologic surgeon at Tampa General Hospital in Tampa, Florida.
Dr. Mark Hoffman
Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.
Cite This Podcast
BackTable, LLC (Producer). (2025, January 14). Ep. 76 – Clinical Pearls: Managing Endometriosis Post-Hysterectomy [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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