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Definitions and pathophysiology

endometriosis general
Endometrium is the tissue lining the inside of the uterus.
Endometriosis is defined as endometrial stroma and glands outside the uterus, but this definition needs revision.
Adenomyosis is endometrial stroma and glands in the myometrium of the uterus

Endometriosis is caused by genetic-epigenetic changes (see our recent publications , caused by oxidative stress and infection.

Observations on endometriosis

Pathophysiology of endometriosis: The genetic epigenetic theory

Growth of endometriosis lesions starts after G-E incidents and varies with the G-E changes and with the environment as immunology and peritoneal cavity

Consequences of the genetic-epigenetic theory

  • We understand the problems during pregnancy
  • Endometriosis lesions are clonal and thus small benign tumors
  • The different types of lesions have different genetic-epigenetic incidents. Even similar looking lesions can be different e.g. progesterone resistance and thus react very differently to hormonal treatment
  • at the moment of diagnosis most lesions are no longer progressive
  • no recurrences after complete excision


Surgical treatment

advanced laparoscopic surgery


Only surgical excision can cure endometriosis, if the surgeon has the skills to recognize all endometriosis and the expertise.

Better no surgery than incomplete, excessive or bad surgery. The first surgery should be the last

Video-registration is needed to judge quality of surgery


Medical treatment

Medical treatment decreases pain but not in all women.

Side effects are weight gain by progestagens or osteoporosis secondary to GNRH.

Some lesions continue to grow during medical treatment (see heterogeneity of lesions)

Deep endometriosis can cause bowel occlusion or bowel or bladder perforation  during pregnancy

Symtoms and diagnosis

endometriosis check-list

endometriosis check-list




  1. Suspicion because of  symptoms, clinical exam or ultrasound:   50% of women with pain or infertility have endometriosis.
  2. The decision to perform a laparoscopy, is based on the suspicion and imaging and other exams.
  3. The Diagnostic Laparoscopy requires a surgeon who recognizes all forms of endometriosis. Surgery is performed if the surgeon has the skills, otherwise the patient is referred, as explained in the informed consent .
  4. Medical treatment can be useful following a laparoscopy and surgery as a prevention or recurrences.

Wrong concepts and Common mistakes

Wrong concepts start with the  Sampson implantation theory.

  • Endometriosis is not progressive or recurrent.
  • Lesions are heterogeneous and thus different from the endometriuml.
  • Hysterectomy and ovariectomy without complete removal of the endometriosis is a mistake

Inadequate diagnosis and referral

  • Diagnosis of superficial endometriosis requires a laparoscopy
  • Medical treatment without a diagnosis is wrong
  • IVF without a laparoscopy
  • Surgery is avoided by those without the skills
  • resulting in a mean delay in diagnosis of 7-8 years

Why ?

  • Surgery without skills has more complications, incomplete surgery and a high recurrence rate
  • Less skilled surgeon fear the quality control  by video-registration  .
  • The low reimbursement of endometriosis surgery  favors bowel resections.
  • Infertility surgery Microsurgery was performed in specialized centers, but today fertility centers became IVF centers with less focus on fertility surgery by laparoscopy
  • Medical therapy of endometriosis is a ‘billion dollar business’ .
  • The gynecologists-Pelvic Surgeons are a small group and they do not fit with the classic sub-specialties .
    • Too many bowel resections  since bowel resections can be done in every hospital by the bowel surgeon
    • The Infertility lobby. Good surgery is a prevention of IVF, which is expensive for society.
    • Oncologist do not like the concept of the pelvic surgeon for endometriosis who could do oncology.


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