title: Recurrence of endometriosis after hysterectomy.
abstract: OBJECTIVE
  Persistent or recurrent pain after hysterectomy is one of the most frustrating clinical scenarios in benign gynaecology. We attempt to review the current evidence regarding the recurrence of pelvic pain after hysterectomy for endometriosis. The impact of ovarian conservation, type of hysterectomy and the extent of surgical excision were analysed.
  
  
  METHODS
  Peer reviewed published manuscripts in the English language in the period between 1980 and 2014 were reviewed using Pubmed and science direct regarding the incidence, causes and recurrence of endometriosis.
  
  
  RESULTS
  Sixty-seven articles were identified. Incomplete excision of endometriosis is the most predominant reason in the literature for the recurrence of endometriosis, and the type of Hysterectomy affects the recurrent symptoms mainly by impacting the extent of excision of the lesion. Ovarian cyst drainage is associated with the highest rate of ovarian cyst reformation within three to six months after surgery. The use of hormone replacement therapy is associated with recurrence of pelvic pain in 3.5% of cases. No studies addressed the recurrence of endometriosis after standard vs robotic assisted hysterectomy.
  
  
  CONCLUSIONS
  A high recurrence rate of 62% is reported in advanced stages of endometriosis in which the ovaries were conserved. Ovarian conservation carries a 6 fold risk of recurrent pain and 8 folds risk of reoperation. The decision has to be weighed taking into consideration the patient's age and the impact of early menopause on her life style. The recurrence of endometriosis symptoms and pelvic pain are directly correlated to the surgical precision and removal of peritoneal and deeply infiltrated disease. Surgical effort should always aim to eradicate the endometriotic lesions completely to keep the risk of recurrence as low as possible.
authors.affiliation: Division of Reproductive Medicine, Department of Obstetrics and Gynecology, University of South Alabama College of Medicine, Mobile, Alabama, USA.
authors.forename: B
authors.initials: B
authors.lastname: Rizk
authors.affiliation: Baylor College of Medicine, Houston, Texas, USA.
authors.forename: A S
authors.initials: AS
authors.lastname: Fischer
authors.affiliation: Division of Reproductive Medicine, Department of Obstetrics and Gynecology, University of South Alabama College of Medicine, Mobile, Alabama, USA. ; Department of Obstetrics and Gynecology, Tanta University, Egypt.
authors.forename: H A
authors.initials: HA
authors.lastname: Lotfy
authors.affiliation: Division of Reproductive Medicine, Department of Obstetrics and Gynecology, University of South Alabama College of Medicine, Mobile, Alabama, USA. ; Department of Obstetrics and Gynecology, King Abdulaziz University, Jeddah, Saudi Arabia.
authors.forename: R
authors.initials: R
authors.lastname: Turki
authors.affiliation: Department of Obstetrics and Gynecology, King Abdulaziz University, Jeddah, Saudi Arabia.
authors.forename: H A
authors.initials: HA
authors.lastname: Zahed
authors.affiliation: Department of Obstetrics and Gynecology, Indiana University, Indianapolis, USA.
authors.forename: R
authors.initials: R
authors.lastname: Malik
authors.affiliation: Division of Reproductive Medicine, Department of Obstetrics and Gynecology, University of South Alabama College of Medicine, Mobile, Alabama, USA.
authors.forename: C P
authors.initials: CP
authors.lastname: Holliday
authors.affiliation: Division of Reproductive Medicine, Department of Obstetrics and Gynecology, University of South Alabama College of Medicine, Mobile, Alabama, USA.
authors.forename: A
authors.initials: A
authors.lastname: Glass
authors.affiliation: Division of Reproductive Medicine, Department of Obstetrics and Gynecology, University of South Alabama College of Medicine, Mobile, Alabama, USA.
authors.forename: H
authors.initials: H
authors.lastname: Fishel
authors.affiliation: Division of Reproductive Medicine, Department of Obstetrics and Gynecology, University of South Alabama College of Medicine, Mobile, Alabama, USA.
authors.forename: M Y
authors.initials: MY
authors.lastname: Soliman
authors.affiliation: Springhill Memorial Hospital, Mobile, Alabama, USA.
authors.forename: D
authors.initials: D
authors.lastname: Herrera
keywords: Endometriosis; hysterectomy; pelvic pain; recurrence; reoperation