Why Imaging, Mapping, and Complete Excision Matter (From an Endo Specialist)
Hi everyone,
I’m Dr. JM, a surgeon specializing in Complex Benign Gynecology and Minimally Invasive Surgery in Phoenix, AZ. My practice, Lumina Surgical Gynecology, focuses heavily on endometriosis, adenomyosis, fibroids, and complex cases.
I read through this subreddit often and see so many of the same questions and frustrations—especially around getting a proper diagnosis, the confusion between ablation and excision, and whether imaging is actually “worth it.” I wanted to share some insights from the surgical side on why imaging, pre-surgical mapping, and complete excision are so critical for long-term relief.
- The Myth That “Imaging Can’t Show Endo”
You’ve probably heard (maybe even from a doctor) that endometriosis can only be diagnosed through surgery. While a laparoscopy with pathology is the gold standard for definitive diagnosis, the idea that imaging is useless is outdated.
Expert-guided imaging—specifically a dedicated pelvic MRI or advanced transvaginal ultrasound done by someone trained to look for endo—can be incredibly valuable. While superficial endo might not always show up, imaging is excellent at detecting:
• Deep Infiltrating Endometriosis (DIE): Nodules on the bowel, bladder, or uterosacral ligaments.
• Endometriomas: “Chocolate cysts” on the ovaries.
• Adenomyosis: Often the culprit behind heavy bleeding and a “boggy” uterus, which frequently co-occurs with endo.
If your imaging comes back “clear,” it does not mean you don’t have endo. But if it does show disease, it completely changes the surgical approach.
- Why Pre-Surgical Mapping is Crucial
Imagine trying to navigate a complex road trip without a map. That’s what surgery without proper pre-operative imaging can be like.
When we do advanced imaging beforehand, we are “mapping” the disease. If we know ahead of time that there is bowel involvement, we can ensure a colorectal surgeon is on standby. If there is ureter involvement, we might need a urologist.
Mapping prevents the heartbreaking scenario where a patient wakes up from surgery only to be told, “We found endo on your bowel, but we couldn’t remove it because we weren’t prepared.” It allows us to plan for a single, comprehensive surgery rather than multiple incomplete ones.
Ablation vs. Complete Excision
This is one of the most important topics in endo care.• Ablation (Burning): This technique burns the surface of the endometriosis lesion. The problem? Endo is like an iceberg. Burning the top leaves the root behind, which means the disease (and the pain) often comes right back.
• Excision (Cutting out): This involves cutting around and completely removing the diseased tissue from the root, preserving the healthy tissue underneath.
Complete excision is technically much more difficult and requires specialized training, which is why many general OBGYNs default to ablation. However, excision is widely considered the gold standard because it offers the best chance at long-term symptom relief and lower recurrence rates.
Advocating for Yourself
If you are considering surgery, here are a few questions you have every right to ask your surgeon:
1. Do you perform excision or ablation? (Look for excision).
2. Do you order specialized imaging (like an MRI with endo protocol) prior to surgery to map the disease?
3. What happens if you find endo on my bowel or bladder? Are you equipped to remove it, or will you leave it behind?
You know your body best. If your pain is being dismissed, or if you are being pushed toward treatments that don’t align with your goals, keep seeking second opinions.
I hope this helps clarify some of the confusing aspects of endo care. I’m happy to answer general questions in the comments (though please remember I can’t give specific medical advice over Reddit!).
Sending strength to everyone navigating this disease. 💛