Laparoscopic surgery is the best method to treat endometriosis. This chronic inflammatory condition affects 1 in 10 women worldwide.Experts now believe that surgery may not be as effective in relieving symptoms as it was once believed. It could even make things worse for patients who have suffered from other pain conditions due to their endometriosis.According to Andrew Horne, a professor in gynaecology at Edinburgh University's MRC Centre for Reproductive Health and a professor of gynaecology, patients don't always feel better after surgery.Cystic ovarian endometriosis patients are likely to feel significant relief after having surgery to remove the cysts. Photograph by Morsa Images/Getty ImagesEndometriosis, which can be described as tissue similar to the one found within the uterine walls is found in other parts. It was previously thought to be a pelvis-only condition, but now it is found in every organ.Horne believes that endometrium should be divided into three distinct strands: cystic ovarian endometriosis or endometrioma, superficial peritoneal and deep.Horne claims that doctors used the same treatment for all cases of endometriosis until recently. This included surgery. The best treatment for endometrium depends on the type of disease and tissue.The ovarian-strand is a clump of errant tissue that grows in the ovaries. These cysts can burst, causing severe pain and inflammation. This strand is likely to provide significant relief for patients. Horne says that surgery is sometimes necessary as part of the treatment.However, 80% of sufferers of endometriosis have superficial peritoneal diseases. In these cases, it is less likely the diseased tissue is the main cause of the pain and symptoms. The main cause is often the interaction of the diseased tissue with the nerves in the pelvis.These cases could mean that surgery is actually making matters worse.The nerve connectionEndometriosis is most often associated with pain. In a 2021 study, 59% of endometrists reported having suffered from pelvic pain for at least five years. In 2020, 39.9% of patients had experienced severe pain that required them to visit an emergency department.These sensations, like the disease, are all included under the umbrella of pelvic discomfort, despite some important differences.Endometriosis pain can be caused by many mechanisms, according to Katy Vincent, a senior professor and pain fellow at Oxford University's Nuffield Department for Women & Reproductive Health.Endometriosis surgery is an important tool, but it's crucial that we understand when and how to use it as part of a more personalized treatment plan.Nociceptive pain is the most common type of pain. It refers to pain that occurs after an injury, such as a broken arm and a scalding cut. Endometriosis will often cause some of this type of pain. This is due to the presence of diseased tissue.Vincent says that it is not always the primary suspect.Research is showing that many endometriosis patients experience high levels of neuropathic pain. This refers to pain that comes from nerve endings that have been damaged.According to the Oxford team, there are three possible ways nerve pain could develop in patients with endometriosis. The nerves around the disease lesions can become hypersensitive. The second is that certain lesions can compress nerves and cause pain. The third reason is that nerves may be damaged by endometriosis surgery.Endometrial lesions can contain nerves and blood cells, according to Dr Christian Becker (associate professor at Nuffield Department of Women & Reproductive Health). This means that surgeons often need to cut through the nerves in the pelvis to remove diseased tissue. Nerve pain can be worsened by the cutting of nerves.Endometriosis can be treated with analgesics and nonsteroidal painkillers as well as hormone treatments and GnRH injectables. Photograph by milos-kreckovic/Getty ImagesVincent states that patients whose symptoms are primarily caused by neuropathic pain may not be able to benefit from surgery and might experience greater pain after surgery.Horne agrees that repeated surgeries in neuropathic pain cases are unlikely to be beneficial. In these cases, it is important to determine if surgery is beneficial.There are many licensed treatments that can be used to treat nerve pain. These drugs are often successful in treating patients with neuropathic pain. Vincent believes these drugs may be a better option than surgery for severe nerve pain. Endometriosis has yet to approve any of these drugs because no research has been done.The vicious cycle of painEndometriosis patients might also experience pain from the central nervous system. Lydia Coxon is another member of Nuffield Department of Womens & Reproductive Health. After experiencing pain for a prolonged period without any relief, the brain adapts to send severe pain signals, even though the tissue damage isn't severe. This is called central pain sensitisation or turning up the volume on pain, according to the Oxford team.The brain produces all pain sensations. However, endometriosis can cause more pain signals to be sent to the brain by the central nervous system, especially if the patient has overridden any pain warning signs.Katy Vincent: The psychological state that a patient develops as a result of living with the illness can actually make the pain worse.Vincent and Coxon clarified that the condition does not necessarily exist in the head of the sufferer or as a result of anxiety or depression. Many endometriosis sufferers are familiar with the saying, "The causative link is not what it seems."Vincent states that endometriosis is rarely caused by anxiety. Vincent says that patients who have untreated, chronic, and unexplained pain often develop anxiety or depression.An anxious or depressed brain can be more sensitive to pain. This is because the psychological conditions that a patient has developed from living with the illness actually make it worse.Becker states that pain can change your brain, which makes it more susceptible to feeling pain more acutely. This cycle will continue.Pain travels from the injured tissue to the nervous system, spine and brain. It is then felt or interpreted by the body. Endometriosis patients have discovered that anything can go wrong at any point in the process. This causes pain to be amplified. It is therefore important to identify which system is responsible.03:08 How does chronic pain work? Video explanationDue to the fact that surgery is not always successful for some patients because of different diseases and pain mechanisms, doctors will often perform repeat laparoscopic surgeries to try to eliminate more endometrium.Horne states that repeat surgery will not be performed if the patient's pain is chronic or neuropathic. Horne also says repeated surgeries can exacerbate nerve pain and make it more sensitive.Diagnostics need a revolutionAlthough researchers have known about the subtypes of endometriosis since the last decade, the distinction has only been widely accepted and thoroughly researched in the past five.Horne states that laparoscopic surgery is the only way to determine the subtype of a patient. This is because, while ovarian cancer can be detected on ultrasounds or other imaging tests, it's much less likely that either deep or superficial diseases will show up.Analyzing diagnostic laparoscopies shows that approximately 80% of patients have superficial endometriosis. A nonsurgical screening would be a better way to identify which treatment options for these patients.Horne said that endometriosis specialists are currently improving imaging tools like ultrasounds and magnetic resonance imaging (or MRIs) in the hope that these screening tools will be more sensitive to both superficial and deep endometriosis in the future.Experts in endometriosis hope that MRI scans will be more sensitive to detect both superficial and deep levels of the disease. Photograph by dowell/Getty ImagesHorne states that it is important to be able to predict which patients will respond to surgery and which ones won't.Targeted screening could also be used to create a treatment plan that is more specific for each patient. This could include surgery if it is expected to improve symptoms or a combination of other treatments. Analgesics, nonsteroidal painkillers like ibuprofen, hormone treatment such as the combined contraceptive pills and GnRH injections that chemically induce temporary menopause in sufferers, are all possible.Experts say that endometriosis research is still chronically underfunded. This means that we don't yet have the tools to distinguish between the two.Vincent claims that endometriosis is still more well-kept than other diseases. This is partly due to the fact that it is a condition of women and funding and research are just not available.Horne compares the current situation to breast cancer. In the 20th century, there was little research on the disease and patients received the same treatment: chemotherapy and radiotherapy.However, a massive public health push for awareness and funding has led to a better understanding of the condition. Women are now thoroughly screened when they are diagnosed to determine which treatment is best for them.Horne says the same must be done for endometriosis to ensure proper treatment and avoid encouraging repeat surgery that could make patients' pain worse.Chronic pain sufferers have been told for years that it is all in their heads. It is now clear that this is false. The pain that cannot be seen explains why doctors are still playing catch-up with chronic pain conditions such as endometriosis, migraine, and other pain conditions. It also explains what they need to do about long Covid.
