Overview

A substantial component of Dr. Kruger's clinical practice is dedicated to endometriosis care. Endometriosis is a chronic, varied condition: the location and amount of disease do not always match the severity of pain or its effect on fertility and quality of life. Care is individualized and may include education, pain treatment, hormonal therapy, pelvic floor physiotherapy, fertility care, surgery, or a combination of these approaches.

What is Endometriosis?

Endometriosis occurs when tissue similar to the lining of the uterus is found outside the uterus. It may contribute to inflammation, scarring, adhesions, and pain. Endometriosis most commonly affects the pelvis, including the ovaries, peritoneum, uterosacral ligaments, and the space between the uterus and rectum.

Symptoms

Chronic pelvic pain, often worsening during menstruation
Painful intercourse (dyspareunia)
Heavy or irregular menstrual bleeding
Pain with bowel movements or urination, particularly during menstruation
Infertility
Fatigue and general malaise

How Endometriosis Is Diagnosed

Endometriosis can often be diagnosed from symptoms and examination, supported by expert ultrasound or MRI when indicated. A normal scan does not exclude superficial endometriosis. Laparoscopy is not routinely required simply to make the diagnosis.

Laparoscopy may be considered when imaging is negative and empirical treatment has not helped, is unsuitable, or is not desired; when deep disease or another surgical condition is suspected; or when surgery is otherwise being considered. If surgery is performed, tissue may be sent to pathology, although a negative biopsy does not always exclude endometriosis.

Role of Surgery in Endometriosis Care

Surgery is one option for selected patients. It is most often considered when there are:

Persistent symptoms despite optimized medical therapy
Intolerance or contraindications to hormonal treatment
Suspected deep infiltrating disease
Fertility goals that may be affected by anatomy or disease location
Endometriomas, suspected deep disease, or organ involvement that warrants surgical assessment

The decision is shared and should consider symptoms, imaging, prior treatment, fertility goals, ovarian reserve, other pain contributors, and the benefits and risks of surgery. Surgery can treat visible disease and obtain tissue for confirmation, but it cannot guarantee that all microscopic disease is removed, that pain will resolve, that fertility will improve, or that disease will not recur.

Surgical Techniques

Excision of Endometriosis

Depending on disease location, depth, safety, and patient goals, visible lesions may be excised or ablated. Excision provides tissue for pathology and may be preferred for some deep lesions, but no technique can guarantee lasting symptom relief or prevent recurrence.

Disease may involve the peritoneum, ovaries, uterosacral ligaments, rectovaginal septum, bladder, ureters, or bowel. Surgical complexity is dictated by disease location and depth.

Management of Deep Infiltrating Endometriosis (DIE)

Deep endometriosis may affect pelvic nerves, the urinary tract, or the gastrointestinal system and often presents with complex pain syndromes or organ-specific symptoms. Surgical management may include:

Ureterolysis
Bladder dissection
Rectovaginal or bowel shaving
Segmental bowel resection in selected cases

Ovarian Endometriomas

When surgery is chosen, cystectomy may reduce recurrence and pain more than drainage alone, but it can also reduce ovarian reserve. The plan should balance symptom control, recurrence risk, ovarian tissue preservation, prior ovarian surgery, and fertility goals.

Hysterectomy in Endometriosis

In selected patients who have completed childbearing and have refractory symptoms, hysterectomy may be considered, particularly when adenomyosis or uterine pain is also suspected. Hysterectomy is not a guaranteed cure and does not treat endometriosis outside the uterus. Whether visible extra-uterine disease can be safely treated, and whether the ovaries should be conserved, requires individualized discussion.

Preoperative Evaluation

Detailed symptom assessment including pain phenotype and organ-specific symptoms
Review of prior medical and surgical treatments
Targeted imaging (ultrasound and/or MRI) for suspected deep disease
Consideration of fertility goals and long-term management planning

Integration with Medical Therapy

Surgery is integrated into a longer-term care plan. Post-operative hormonal treatment may be offered to reduce recurrence of symptoms or disease when pregnancy is not being pursued immediately. Pelvic floor physiotherapy, pain-focused treatment, and fertility support may also be appropriate.

Outcomes

Endometriosis surgery is most effective when:

Guided by realistic expectations and shared decision-making
Performed by surgeons with advanced training in minimally invasive surgery
Embedded within a multidisciplinary care framework

The goals are meaningful symptom improvement, preservation of organ function and fertility where possible, and better quality of life. Some patients continue to need medical or multidisciplinary care after surgery.

Sources

Clinical content updated July 2026. Sources: ESHRE Guideline: Endometriosis (2022) and SOGC Guideline No. 449: Diagnosis and Impact of Endometriosis.