What Causes Bowel Endometriosis After a Hysterectomy?

Endometriosis is when tissue similar to the lining of the uterus, also called the endometrium, grows outside the uterus. This tissue can grow anywhere in the abdomen and pelvis. About 3 to 37 percent of all cases affect the bowels.

Hysterectomy is the surgical removal of the uterus. This is sometimes done at the same time as oophorectomy, which is surgical removal of the ovaries.

When it comes to endometriosis, these surgeries are considered a treatment of last resort. They can help relieve chronic pelvic pain but aren’t a cure. The condition can return after hysterectomy, particularly in the bowels.

Sometimes, the first symptoms of bowel endometriosis occur after a hysterectomy. But it’s likely that the condition was already present in the bowels, just undiagnosed. Hysterectomy doesn’t cause endometriosis.

Let’s look at some causes for bowel endometriosis after hysterectomy, potential complications, and what you should know about treatment.

What causes bowel endometriosis after hysterectomy?

It’s not clear how the condition progresses. It’s not clear why endometrial tissue grows on the bowels, either. But after the genital organs, it’s the most common place for it to occur.

At the time of your hysterectomy, it’s possible that there were small lesions in the bowels that hadn’t been detected.

Here are some potential causes of bowel endometriosis.

1. Microscopic tissue

Endometriosis is a progressive disease. Removing the uterus can solve part of the problem. But even a tiny amount of endometrial tissue left behind can cause a recurrence.

The large and small bowels are the most common sites of recurrent disease after removal of the uterus and ovaries.

2. Ovarian preservation

When planning for a hysterectomy, some people opt to preserve one or both ovaries. This can help you avoid early menopause and the need for hormone replacement therapy (HRT).

There’s a higher risk of endometriosis coming back if you keep one or both ovaries versus removing them both.

3. Ovarian remnant syndrome

When removing the ovaries, a bit of ovarian tissue can be left behind. This is linked to recurrent endometriosis. It’s possible that hormone secretions from this tissue get the disease process going again.

4. Hormone replacement therapy

The risk of recurrence is higher if you start hormone replacement therapy (HRT) after hysterectomy.

There are case reports of the condition developing after hysterectomy in people with no history of the disease, but who are on HRT. However, this is extremely rare.

It’s also rare for symptoms to develop after menopause if you’re not on HRT. There’s a lack of research on postmenopause and endometriosis, so there are many unknowns.

5. Lymphovascular invasion

It’s uncommon, but endometriosis can involve the lymph nodes. That would help it spread after hysterectomy. Despite this, it’s still a noncancerous disease.

What are the symptoms?

Signs and symptoms of bowel endometriosis may include:

• persistent or recurring abdominal pain
• alternating constipation and diarrhea
• bloating
• blood or mucus in the stools
• change in frequency or appearance of stool
• intestinal cramps
• nausea and vomiting
• painful bowel movements
• pelvic or rectal pain

Symptoms can start at any time in the disease process. Some people only have one symptom while others have many. Some people never develop symptoms.

If you still have your ovaries, you might notice that symptoms are cyclical.

The number and severity of symptoms say nothing about the extent of the disease.

Keep in mind the above symptoms can be symptoms for other bowel conditions. Talk with your doctor about what you’re experiencing so you can get the right diagnosis.

How is it treated?

Your treatment will depend on:

• symptom severity
• extent of disease
• your age and overall health
• previous treatments
• your preferences

Pain medication

You can try taking over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil) and naproxen (Aleve). These may offer some relief from pain and inflammation. They won’t affect disease severity or progression.

Hormone therapy

Your doctor may prescribe hormone therapy. It’s used to reduce chronic inflammation and affect fibrotic tissue formation. Hormone therapy may include hormonal contraceptives, even though you no longer need birth control.

There are many pros and cons to hormone therapy. Your doctor will assess your health history to help you make a decision that’s right for you.

Surgery

Surgery is usually considered a last resort. Your doctor will determine which surgical approach and technique is best for you.

Before the surgery, your doctor will explain the process, so you’ll have some idea of what to expect. However, your surgeon may need to make some decisions during the procedure once they can get the complete picture.

Laparoscopic excision vs. laparotomy

Laparoscopic excision is minimally invasive. The surgery involves making several small abdominal incisions. Your surgeon will be able to see and remove small lesions while preserving healthy tissue.

Laparotomy is open abdominal surgery, and may be done if endometriosis is severe and cannot be treated with laparoscopic surgery.

Rectal shaving

Rectal shaving is a minimally invasive procedure that’s used when lesions are small and low in the rectum.

To do this, your surgeon uses a sharp instrument to “shave” endometrial tissue. This allows the intestines to remain intact.

Compared to other types of surgery, rectal shaving has lower rates of complications and likelihood of long-term bladder and bowel issues after surgery.

Disc resection

In a procedure called disc resection, your surgeon removes very small areas of endometriosis-affected tissue in the bowels. Your surgeon then repairs the opening.

Segmental bowel resection

Segmental bowel resection is used for larger areas of endometriosis. In this procedure, your surgeon removes the entire section of affected intestine. The remaining sections are then joined together.

Recovery time

Your recovery time will depend on:

• the type of surgery
• your age and overall health
• whether there were complications

These surgeries don’t eliminate the possibility of developing an endometriosis recurrence in the bowels.

What are the potential complications?

Superficial endometriosis occurs on the surface of the bowels. One potential complication is deep endometriosis, or deep infiltrating endometriosis. That means that growth has reached vital structures, such as the ureters, bladder, or bowels.

It’s rare, but scarring can lead to acute bowel obstruction. Symptoms may include:

• nausea
• stomach pain
• trouble going to the bathroom

Without treatment, this is a potentially life threatening complication.

Surgery can involve significant complications as well. Any surgery involves the risks of:

• a negative reaction to anesthesia
• infection
• bleeding
• injury to nearby tissue or blood vessels

Risks of bowel surgery may also include bowel perforation or the need for a stoma. This happens in 10 to 14 percent of bowel resections for deep infiltrating bowel endometriosis.

A stoma is an opening in the abdomen through which waste can exit your body. A pouch on the outside of the body collects waste. It needs to get emptied several times a day and changed frequently.

A stoma may be temporary. In some cases, it may be permanent.

When to see a doctor

If you’re not recovering well from your hysterectomy, see your doctor. Whether you’ve ever received a diagnosis of endometriosis or not, bowel problems shouldn’t be ignored.

It’s possible that your symptoms aren’t from endometriosis at all. Symptoms can be similar to those of other bowel conditions, such as inflammatory bowel disease (IBD) or irritable bowel syndrome (IBS).

That’s why it’s so important to mention all your symptoms to your doctor in detail.

Your complete medical history, physical examination, and blood tests can help guide the next steps.

Your doctor may order diagnostic imaging tests, such as:

• barium enema
• colonoscopy
• laparoscopy
MRI
• transvaginal ultrasound
• transrectal ultrasound

These tests will help your doctor figure out what’s going on. Once you have the correct diagnosis, you can start discussing possible treatments.

The bottom line

Endometriosis is a condition in which endometrial-like tissue grows outside the uterus. This tissue can grow anywhere within the abdomen and pelvis.

Hysterectomy doesn’t cause bowel endometriosis. It’s possible that you already had endometrial tissue in the bowels before your hysterectomy, but it hadn’t been detected.

Also, when endometriosis does recur after hysterectomy, it tends to be in the bowels.

If you have symptoms of bowel endometriosis after hysterectomy, it’s vital that you talk with your doctor. Diagnostic testing can help determine whether you have bowel endometriosis or another condition, such as IBD or IBS.

Although there’s no current cure, treatments can manage and relieve symptoms. If these treatments stop working, there are several surgical procedures that may help too.

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