Excision vs Ablation for Endometriosis: What Studies Show

In endometriosis surgery, excision cuts a lesion out and ablation destroys it, for example by burning. For mild endometriosis on the surface, trials have found no clear difference in pain between the two, but excision may give more relief from deep pain during sex over time.

This page sets out what the trials show on pain, on endometriosis coming back and on repeat surgery. It also shows where the evidence is still unsure, so you can talk it through with your surgeon.

What excision and ablation are

Both methods are done during a laparoscopy, the keyhole operation in which a surgeon looks inside your tummy with a camera and can remove areas of endometriosis. If you have not had one yet, our laparoscopy preparation and recovery guide covers the day itself and the weeks after it.

• Excision means cutting a lesion out. The tissue that comes out can go to a lab, and a lab check is how lesions seen in surgery are confirmed as endometriosis.
• Ablation means destroying a lesion in place, for example by burning it. No tissue comes out to test.

Surgery for endometriosis can also remove ovarian cysts caused by endometriosis, or part of the bladder or bowel when endometriosis affects them.

Pain: what the trials show

The trials that compare the two methods are small, and most of them included people with minimal to mild endometriosis.

• Pain in the first year. A review of 4 randomised trials with 346 people could pool the data from 3 of them. In those pooled trials, excision and ablation gave no significant difference in period pain, pain with bowel movements or pain during sex at 12 months. There was no difference after 12 months either. Larger trials with longer follow-up are still needed.
• Overall pain at 12 months. There is too little evidence to tell whether overall pain differs between ablation and excision. That result rests on one trial of 103 people, and the evidence is rated very low quality.
• Pain over 5 years. In one double-blind trial, all pain scores fell over 5 years with either method. At 5 years, pain during sex had dropped more in the excision group. More people in the ablation group were still taking hormone treatment for endometriosis at 5 years.

Put together, the evidence leans a little toward excision. In the European endometriosis guideline from ESHRE, surgeons may consider excision instead of ablation to reduce endometriosis pain. The guideline grades this as a weak recommendation, which means the evidence behind it is limited.

There is one more uncertainty to know. Compared with a laparoscopy that only looks, it is uncertain whether surgery to treat endometriosis reduces overall pain. Pain scores fell after either method in the 5-year trial. The trials are too small to say how much of that comes from the surgery itself.

Deep endometriosis

Deep endometriosis can affect organs such as the bowel and bladder, and surgery may then remove part of the bladder or bowel. The pooled trials above studied minimal to mild endometriosis.

For deep endometriosis, surgery to remove it may reduce pain and improve quality of life. The same guideline recommends that people with deep endometriosis are referred to a centre of expertise. It makes no recommendation on which surgical technique to use for deep endometriosis, because the evidence does not settle it.

Painful bowel movements, deep pain during sex and pain when you pee are symptoms that should make doctors think of endometriosis. Tell your surgeon about them before the operation so they can plan for them.

Will endometriosis come back after surgery?

It can, after either method, and it can even continue after a hysterectomy. In a review of published studies, the reported rate of endometriosis coming back after surgery was about 21.5% at 2 years and 40 to 50% at 5 years. That review covers surgery in general. It does not split the rates by excision and ablation.

Some things can lower the chance that period pain returns. After surgery, the guideline advises doctors to consider a hormonal IUD (52 mg levonorgestrel) or a combined hormonal contraceptive for at least 18 to 24 months. Ask your doctor whether this suits you, especially if you want to get pregnant soon.

Repeat surgery: the least clear part

You may need more surgery if your symptoms come back, or if surgery causes scar tissue that makes organs stick together (adhesions).

Whether excision lowers the chance of a second operation is not clear. The 5-year trial tracked repeat surgery, but its reported differences were in pain during sex and in hormone use. The trials also had limited reporting of side effects, with too little evidence to draw conclusions on safety. Claims that one method "always" prevents repeat surgery go further than the trials do.

Questions to ask your surgeon

These questions help you learn what the surgeon plans and how they decide.

• Do you usually excise, ablate or use both? How do you decide during the operation?
• Will the tissue you remove go to a lab for testing?
• Do my symptoms suggest deep endometriosis? If so, do you work in or with a specialist endometriosis centre?
• If you find disease on the bowel, bladder or ureters, will you treat it in this operation, or plan a second one with another surgeon?
• What hormone treatment do you suggest after surgery, and for how long?
• What should I expect for recovery, and who do I call if something feels wrong?

Our guide to getting a referral to an endometriosis specialist explains how to ask for one.

What to track before and after surgery

A record from before surgery gives you a baseline, so you can compare it with how you feel in the months after. Note:

• Period pain, pain between periods and pain during sex, each on a 0 to 10 scale
• Pain with bowel movements or when you pee, and the cycle day
• Painkillers and hormone treatment you take
• Days of work, school or plans you miss

Endolog lets you log pain, where it is and what you took, so you can show your surgeon how things change after the operation.

Frequently asked questions

Is excision better than ablation for endometriosis?

For mild endometriosis on the surface, trials have not shown a clear difference in pain. Excision may reduce deep pain during sex more over 5 years, and guidance leans weakly toward excision.

Does endometriosis come back after excision?

It can. Reported rates after surgery are about 21.5% at 2 years and 40 to 50% at 5 years, and those rates are not split by technique.

Can ablation treat deep endometriosis?

The trials that compare the two methods studied minimal to mild endometriosis. For deep endometriosis, the guideline recommends referral to a centre of expertise, where the surgical team decides how to remove it.

This article is for general information. It does not replace advice from your own doctor or surgeon, who decides what treatment is right for you.