Why Endometriosis Surgery Needs More Than a Surgeon
I have always believed that a good operation is only half the job. As a gynaecologist who performs laparoscopic surgery for endometriosis, I care deeply about what happens inside the operating theatre. The excision, the technique, the attention to detail, but what I've come to understand over years in practice is that the outcome a patient experiences, the pain they wake up to, the recovery they navigate, the life they return to, is shaped by far more than what I do on the day of surgery. It is shaped by the months before and the months after.
Surgery is one day, recovery is months.
When a patient comes to me for a laparoscopy, surgery is often the thing they have been waiting for, and sometimes this wait may have been for years. They have likely pushed through pain, cycled through treatments, and finally arrived at a decision for surgery with enormous hope attached to it, which is understandable. And surgery can absolutely make a meaningful difference. Studies consistently show significant improvements in pain and quality of life following laparoscopic excision of endometriosis, but it is not a complete solution for everyone.
Research tells us that a meaningful proportion of women do not experience lasting pain relief from laparoscopy alone. Recurrence of symptoms is common, with rates of reoperation reaching 25 percent within two years and 40 to 50 percent within five years, which are not small numbers.
What this data reflects is not surgical failure, but the complexity of endometriosis as a condition, and specifically the way that chronic pain changes the nervous system over time. Surgery can remove the disease, but it cannot always undo what chronic pain has done to the body.
This is why the perioperative window, the weeks and/or months before and the months after surgery, matters so much. And why I know I am only one part of the team that my patient needs.
Why pain before surgery matters for pain after surgery:
One of the most important things I want my patients to understand is that endometriosis pain is not just about the lesions itself. When someone has been living with significant pelvic pain for months or years, the nervous system adapts. Pain pathways become sensitised, and the brain and body start to process pain differently. What begins as a signal from a specific source, the pelvis, the bowel, the bladder, can spread and become more complex over time, involving the muscles, the nervous system, the gut, and the brain.
This is a physical change, not a psychological one, but it does have psychological implications, and implications for surgery. A sensitised nervous system does not simply reset at the moment of excision of disease. Patients who arrive at surgery in a high-pain state, with disrupted sleep, elevated anxiety, and a body that has been guarding against pain for a long time, tend to have harder recoveries. They need more analgesia, take longer to mobilise, and their pain experience post-operatively is often more intense and more prolonged.
The RANZCOG living evidence guideline on endometriosis, which is one of the most comprehensive clinical documents we have in this space, is explicit on this point.
The evidence now supports a biopsychosocial approach to managing endometriosis pain, one that addresses the body, the mind, and the social context of the person in front of you. Not as an alternative to surgery where surgery is indicated, but alongside it. For me, this changed the way I prepare my patients for surgery, and the months that follow.
What a multidisciplinary approach actually involves:
When I talk about multidisciplinary care, I am not talking about referrals that tick a box, but coordinated support that addresses the parts of a
patients experience that surgery alone cannot reach. In practice, this looks like a few key things.
Before surgery, I want to know that my patients pain is as well-managed as possible, that their sleep is addressed, and their pelvic floor and musculoskeletal system have been assessed, because patients with chronic pelvic pain frequently develop secondary muscle dysfunction that will still be there after the endometriosis is removed. I want them to understand what surgery can and cannot do, and to try approach the day of her operation with as little anxiety as possible. The evidence on this is clear: lower pre-operative anxiety is associated with better post-operative pain outcomes. I also want their gut health and bowel function addressed before surgery, particularly given how commonly bowel symptoms feature in endometriosis presentations. Arriving at a laparoscopy with unmanaged constipation or bowel irritability adds unnecessary complexity to recovery. Physiotherapy has a formal evidence base in the RANZCOG guidelines now, which is an exciting development. A pelvic health physiotherapist brings pain neuroscience education, assessment of bladder and bowel function, and the ability to address the muscle-level changes that come with chronic pelvic pain. This is part of preparing a patients body to recover well.
Psychology has a key role too, and I want to be careful about how I frame this because I am aware of how it can be interpreted. Pelvic pain and mental health have a bidirectional relationship: pain makes mental illness worse, and mental illness makes pain worse. But even for patients without a diagnosed mental health condition, there are specific psychological treatments for pain that have a strong evidence base. Cognitive behavioural therapy, mindfulness, hypnosis, and pain neuroscience education all show meaningful benefit, and are active treatments. Nutrition, sleep, and movement round out this picture. Exercise has evidence for reducing period pain and is broadly beneficial for chronic pain conditions, when dosed and supported correctly (this may be in the format of seeing an Exercise Physiologist). Sleep disruption drives pain sensitisation, and basic sleep hygiene can make a big difference. Diet influences gut health and inflammation, and simple, but sustainable dietary changes can help support whole-body inflammation, but also help with healing after surgery, and common post-op symptoms (nausea and fatigue).
Each of these individual interventions play a role in patient care, and when done well together, help form the tools in a patient toolbox for before and after surgery.
A patient who arrives at surgery with her body genuinely prepared is in a different physiological state to one who has not had that support.
The rehab side: what I tell patients in the weeks after surgery:
Surgery creates a window for behaviour change. In the early weeks after a laparoscopy, when a patients acute symptoms are reduced, there is an opportunity to change patterns that have been entrenched for a long time.
The research supports structured recovery after surgery, and we are all familiar with this in other surgical disciplines such as orthopaedics. Addressing any residual pelvic floor dysfunction, bladder and bowel symptoms, and pain sensitivity in the post-operative period can significantly influence long-term outcomes, and patients who do this work tend to maintain their gains better over time.
What I tell my patients is this: the surgery removes the disease. The recovery work is what helps your body learn to feel different.
This is also where I am honest about expectations. Surgery is not the finish line, but ideally, a turning point. What comes next, the rehab, the support, the gradual return to full function, is where the real work of recovery happens.
Why I refer, and what that looks like now:
I have always known that my patients needed more than I could give them in a surgical consultation. What has changed is that there is now a structure for providing it.
Earlier this year, my practice Womens Obstetrics and Gynaecology became a partner with Matilda Health, a digital prehabilitation and rehabilitation platform built specifically for people navigating endometriosis-related surgery. Matilda was designed by practitioners who understand the perioperative window and what evidence-based support in that window can do, and people who have walked the
surgery journey themselves. For my patients, this means they now have access to a structured program from the moment surgery is planned. It is not a replacement for the clinical team around them, but it gives them the guidance, the education, and the support to prepare their body and their mind before surgery, and to recover with intention after it. This is the kind of care I want to be able to offer.
