Dr. Fernando Garcia Vargas
Dr. Fernando Garcia Vargas, Endometriosis Specialist
City: Puebla, Puebla, Mexico
Philosophy of Endometriosis Care: I believe that the theory of celomic metaplasia, as well as retrograde menstruation and altered immunity, can contribute to the development of the disease and its progression through different pathways. Therefore, it is essential to take a multidisciplinary assessment approach, individualizing each case to offer excision surgery when necessary, as cases of deep infiltrative endometriosis can occur, which may involve the rectum, ureters, bladder, etc. In such cases, joint management with coloproctology and urology is required to perform a successful surgery.
What type of surgery do you perform for endometriosis: Excision
Medication: Synthetic progestins such as desogestrel, implant, injections or levonorgestrel-releasing intrauterine systems, which may help reduce the recurrence of the disease after excision surgery, and the time you use it depends on the option you decide
Approach to Persistent Pain After Surgery: I always recommend a complementary treatment such as synthetic progestins after excision surgery, and in case of symptom persistence, I refer my patients for evaluation by a neuropelveologist.
Dr. Victor J. Carrasco Urrutia
Dr. Victor J. Carrasco Urrutia, Endometriosis Specialist
City: Juárez, Chihuahua, Mexico
Philosophy of Endometriosis Care: A Molecular Disease Driven by microRNA Dysregulation, Sublethal Ferroptosis, and Iron-Induced Cellular Reprogramming. (Epigentic and Genetic).
- Introduction: Rethinking the Origins of Endometriosis– Endometriosis has traditionally been explained by the theory of retrograde menstruation and ectopic implantation of endometrial tissue. However, this paradigm fails to account for the heterogeneity of lesion types, their variable behavior, resistance to hormone therapy, and their presence in distant organs, including in individuals without a uterus. Emerging molecular insights support a paradigm shift: endometriosis is not simply a disorder of misplaced cells but rather a disease of epigenetic reprogramming, sustained by microRNA (miRNA) dysregulation, oxidative damage, and sublethal ferroptosis, all of which collectively transform the phenotype of endometrial cells into persistent, invasive, and inflammatory clones.
- The Molecular Drivers of Endometriosis – At the core of this transformation is a sustained dysregulation of microRNAs, small non-coding RNAs that regulate gene expression post-transcriptionally. These molecules act as master regulators of apoptosis, inflammation, angiogenesis, immune evasion, and cellular differentiation. In endometriosis, an aberrant expression profile of miRNAs alters the fate of eutopic endometrial cells, making them resistant to apoptosis, responsive to local estrogen production, and capable of invading ectopic environments. This altered transcriptomic and epigenetic landscape allows cells to survive retrograde migration and promotes colonization in ectopic locations. However, survival alone does not explain lesion persistence or progression. A critical second hit occurs through exposure to iron-rich microenvironments, particularly in hemorrhagic lesions and repeated retrograde bleeding, which leads to ferroptosis sublethal stress: a state of iron-driven oxidative damage that damages but does not destroy cells, selecting for those with adaptive survival advantages. This interplay between miRNA-driven transformation and environmental oxidative stress is central to the pathogenesis of all lesion types, yet manifests differently depending on the anatomic and physiological context.
- Subtype-Specific Pathogenesis – A. Superficial Peritoneal Endometriosis Superficial lesions are typically small (1–5 mm), found on peritoneal surfaces, and historically considered the “earliest” or “mildest” form of the disease. However, from a molecular standpoint, they represent localized populations of reprogrammed endometrial-like cells that have adhered to the mesothelial surface but not yet established a fibrotic niche or deep invasion. • miRNA profile: These lesions show altered miRNA expression consistent with early evasion of apoptosis and enhanced angiogenesis. • Immune environment: Poor immunosurveillance allows their persistence. • Iron exposure: Low to moderate, driven by cyclic retrograde bleeding. Sublethal ferroptosis here may act as a selective pressure for early clonal expansion. These lesions may remain quiescent or evolve depending on iron burden, oxidative stress, and hormonal responsiveness. B. Ovarian Endometriosis (Endometriomas) Ovarian endometriosis is characterized by the formation of chocolate cysts, or endometriomas, which are hemorrhagic cystic structures resulting from repeated bleeding of ectopic endometrial tissue within the ovary. • Iron microenvironment: Endometriomas are iron-saturated niches due to blood accumulation and hemolysis. This creates a sustained ferroptotic microenvironment with massive lipid peroxidation and reactive oxygen species. • Cellular fate: Sublethal ferroptosis in ovarian lesions promotes selection of molecularly damaged but viable cells with enhanced estrogen biosynthesis, progesterone resistance, and immunoevasive behavior. • Epigenetic profile: Extensive methylation changes and miRNA deregulation in endometriomas render these lesions bioactive, hormone-autonomous, and often refractory to standard hormonal suppression. Thus, endometriomas are not passive collections of blood but dynamic bioactive lesions that perpetuate molecular damage and foster disease progression. C. Deep Infiltrating Endometriosis (DIE) Deep lesions extend more than 5 mm below the peritoneal surface and often involve the bowel, bladder, ureters, and pelvic nerves. These are associated with severe pain and significant morbidity. • Molecular profile: These lesions exhibit the highest degree of cellular reprogramming, with profound miRNA dysregulation, immune suppression, neuroangiogenesis, and resistance to apoptosis. • Stromal remodeling: Chronic trauma, bleeding, and local inflammation stimulate fibrosis, nerve infiltration, and neuroinflammation, explaining the severe pain profile. • Oxidative stress: Iron deposition and recurrent hemorrhage promote sustained oxidative stress, contributing to irreversible structural and functional alterations. • Heterogeneity: Each DIE lesion can be genetically and epigenetically distinct, with varying hormonal sensitivity and miRNA signatures. Deep endometriosis may arise from superficial or ovarian lesions subjected to prolonged inflammatory and oxidative stress, leading to a fibrotic, invasive, and neurotrophic phenotype.
- Endometriosis Beyond the Pelvis- Extrauterine Manifestations Endometriosis has been documented in distant sites including the lungs, diaphragm, kidneys, liver, brain, and even in men. These rare presentations challenge the traditional implantation theory and are better explained through molecular migration hypotheses: • Stem/progenitor cell migration: Endometrial progenitor cells with reprogrammed miRNA profiles may disseminate via lymphovascular routes. • Systemic epigenetic predisposition: The same molecular drivers active in pelvic lesions may operate in ectopic stem niches, particularly under chronic inflammation or hormonal influence. • Iron-independent transformation: In distant sites, local factors (e.g., tissue injury, hormonal crosstalk) may mimic the oxidative and immune environments found in pelvic lesions, allowing ectopic lesions to form without retrograde menstruation. The finding of clonal, progesterone-resistant, estrogen-producing lesions in distant organs supports the notion of systemic disease with localized molecular expressions, not simple mechanical spread.
- Clinical and Research Implications – This molecular redefinition of endometriosis holds several implications: • Diagnosis: Circulating miRNA panels and iron-sensitive imaging may aid in earlier, non-invasive detection. • Treatment: Approaches should target not only estrogen suppression but also iron metabolism, oxidative stress, and epigenetic reprogramming (e.g., miRNA modulation, ferroptosis regulation). • Phenotype-tailored therapy: Understanding the dominant molecular drivers of each lesion type (e.g., ferroptosis in endometriomas, neuroinflammation in DIE) can guide personalized treatment. Endometriosis is a molecularly dynamic disease that begins with epigenetic and post-transcriptional reprogramming of endometrial cells via microRNA dysregulation. Survival and proliferation of these altered cells are supported by iron-induced sublethal ferroptosis, which perpetuates oxidative stress and drives progressive transformation. Each subtype of endometriosis—superficial, ovarian, and deep—inherits this molecular foundation but diverges based on location-specific environmental conditions. Endometriosis should thus be considered a systemic, clonal, and inflammatory disease, rooted in molecular errors and sustained by a hostile microenvironment that the lesions themselves help to create. This framework provides a unified, mechanistically grounded explanation for the diversity, chronicity, and therapeutic resistance observed in clinical practice. VJCU
What type of surgery do you perform for endometriosis: Excision
Medication: OCPs, Progestins (dianogest)(including LNG-IUD) – Used for suppression of hormonally responsive lesions, especially after excision. Less effective in progesterone-resistant or estrogen-autonomous lesions like endometriomas. Antioxidants (e.g., N-acetylcysteine,)– Reduce ROS and lipid peroxidation; support ferroptosis modulation and lesion stabilization. Gabapentin, Pregabalin (Lyrica) – Used for central pain desensitization in deep endometriosis and neuroinflammation. Especially useful pre- and post-surgery in patients with chronic pelvic pain or neuropathic pain. Anti-inflammatory & immunomodulators – Target low-grade chronic inflammation and immune dysregulation associated with lesion survival.
Approach to Persistent Pain After Surgery:
Persistent symptoms after surgery do not always indicate surgical failure or disease recurrence. Instead, they often reflect the complex nature of endometriosis, including residual lesions, nerve involvement, fibrosis, or central sensitization.
- Postoperative Evaluation • Perform a full clinical reassessment (pain type, localization, quality of life). • Imaging (TVUS or MRI) only if recurrence is suspected. • Evaluate for neuropathic pain or central sensitization.
- Common Causes • Residual or missed deep lesions. • Fibrotic entrapment of pelvic nerves. • Central sensitization and amplified pain response. • Myofascial pain or visceral dysfunction. • Adhesions or abnormal scarring.
- Multidisciplinary Management • Neuropathic pain: gabapentin, pregabalin, duloxetine, pelvic floor physiotherapy. • Functional symptoms: gut-directed therapy, microbiota modulation, visceral rehab. • Psychological support: CBT, mindfulness, trauma-focused therapy.
- Hormonal Suppression • Maintenance therapy with continuous OCPs, progestins, or LNG-IUD. • Antioxidants (e.g., NAC) to reduce oxidative stress.
- Reoperation: Reserved for patients with confirmed residual deep lesions, obstructive disease, or failed conservative management. The persistence of symptoms after surgery does not always indicate surgical failure, but rather reflects the multifactorial and neuroinflammatory nature of endometriosis. Management should be: • Individualized and multidisciplinary. • Based on the type of pain (somatic, visceral, or neuropathic). • Supported by continuous follow-up, functional imaging, and comprehensive care.
Dr. Carlos Linder Efter
Dr. Carlos Linder Efter, Endometriosis Specialist
City: Mexico City, Mexico
Philosophy of Endometriosis Care: Celomic metaplasia
What type of surgery do you perform for endometriosis: Excision
Medication: I include progestins (Mirena) in my practice to assess the response to medication. In some special cases, I like to include GnRH analogs.
Approach to Persistent Pain After Surgery: Physical therapy and nutritional changes
Dr. Alberto Maya Epelstein
Dr. Alberto Maya Epelstein, Endometriosis Specialist
City: San Nicolás de los Garza, Mexico
Dr. Marco Guzman
Dr. Marco Guzman
Dr Marco Guzman – Endometriosis Specialist
Summary: Dr Marco Guzman is a dedicated endometriosis specialist based at Hospital Angeles Juarez in Juarez, Chihuahua, Mexico. With a strong foundation in embryology, Dr Marco Guzman focuses on precise excision surgery to effectively treat endometriosis and improve patient outcomes. At Hospital Angeles Juarez, he combines surgical expertise with hormonal and anti-inflammatory therapies during the early stages of treatment and post-surgery care. Dr Guzman emphasizes a personalized approach, using progestins for managing persistent pain after surgery, ensuring patients receive comprehensive care tailored to their needs. His commitment to a holistic and patient-centered approach makes Dr. Marco Guzman a trusted choice for those seeking specialized endometriosis treatment in Juarez. Patients can expect compassionate support and advanced medical care at Hospital Angeles Juarez under his expert guidance.
City: Juarez, Chihuahua, Mexico
Philosophy of Endometriosis Care: Embryology
What type of surgery do you perform for endometriosis: Excision
Medication: Hormonal, anti-inflammatory therapy, in early stages, and after surgery
Approach to Persistent Pain After Surgery: Hormonal therapy (Progestines )
Dr. Gina Ranieri
Dr. Gina Ranieri
Gina Ranieri – Endometriosis Specialist
Summary: Dr Gina Ranieri is an experienced endometriosis specialist based in Princeton, New Jersey. Gina Ranieri’s approach to endometriosis care is rooted in the belief that the condition often originates during embryologic development, involving coelomic metaplasia or embryonic cell remnants. This perspective helps explain endometriosis in patients without menstruation and in unusual locations. Dr Gina Ranieri performs precise excision surgery to remove endometriosis lesions while prioritizing patient well-being. For those not pursuing surgery or to prevent recurrence, she prescribes hormonal treatments such as the levonorgestrel IUD and combined oral contraceptives. Post-surgery, Gina Ranieri carefully evaluates persistent pain by considering other causes, referring patients to pelvic floor physical therapy, and administering trigger point or Botox injections. She also uses non-opioid pain medications and advanced imaging to guide further treatment, always focusing on personalized, compassionate care.
City: Princeton, New Jersey, USA
Philosophy of Endometriosis Care: The theory of endometriosis that I believe makes the most sense is that endometriosis likely originates during embryologic development either through coelomic metaplasia or embryonic cell remnants. This explains how endometriosis can be seen in non-menstruating patients and areas outside the abdominopelvic cavity.
What type of surgery do you perform for endometriosis: Excision
Medication: I will use hormonal medications such as the levonorgestrel IUD, combined oral contraceptive pills, Depo-Provera, or norethindrone for patients who are not interested in surgical treatment or to prevent recurrence after surgical excision in select patients.
Approach to Persistent Pain After Surgery: For patients who have undergone complete surgical excision of endometriosis and continue to report symptoms, I will often explore other pain generators. I do refer patients to pelvic floor physical therapy and perform pelvic floor trigger point and Botox injections, as well as abdominal wall injections to treat myofascial pain. I will also prescribe non-opioid, centrally acting pain medications for patients with very challenging-to-treat pain. If I suspect that the patient’s endometriosis has returned, I will often order imaging in the form of an MRI and potentially offer repeat surgery in appropriate and select patients.
Dr. Gabriel Corona
Dr. Gabriel Corona, Endometriosis Specialist
City:León, Guanajuato, Mexico
Philosophy of Endometriosis Care: Multifactorial, Chelomic Methaplasia, Mullerianosis, Embrionary remanins
What type of surgery do you perform for endometriosis: Excision
Medication: Dinogest, Levonogestrel IUD, Omega 3, Magnesium, Vit. E and D, Vitamins/Folic Acid
Approach to Persistent Pain After Surgery: Pelvic Floor Physiotherapy, Amitriptyline, Gabapentin
Dr. Carlos Eduardo Alcivia Smith
Dr. Carlos Eduardo Alcivia Smith
Dr Carlos Alcivia – Endometriosis Specialist
Summary: Dr Carlos Alcivia, is a dedicated endometriosis specialist based in Querétaro, Mexico. With a deep understanding of the embryological and metaplastic origins of endometriosis, he prioritizes thorough excision surgery to address the root of the disease. His patient-centered approach combines evidence-based medical treatments, such as Dinogest, Levonorgestrel IUDs, and targeted supplements—with holistic strategies for long-term relief. Dr Carlos Eduardo Alcivia Smith also addresses persistent pain post-surgery through a tailored plan that includes physiotherapy, anti-inflammatory nutrition, and high-dose omega-3, magnesium, and vitamins D and E. He collaborates with pain and mental health specialists to ensure patients receive comprehensive care. Known for his compassionate and informed care, Dr Carlos Alcivia empowers each patient on their path to better health and quality of life.
City: Querétaro, Mexico
Philosophy of Endometriosis Care: Embryological and Metaplasia.
What type of surgery do you perform for endometriosis: Excision
Medication: Dinogest, Levonogestrel IUD, Omega 3, Magnesium, Vit. E and D, Vitamins/Folic Acid
Approach to Persistent Pain After Surgery: 6 Months of Dinogest, Physiotherapy, Nutritional Interventions with an Anti-Inflammatory Diet, and Management with Megadoses of Omega-3 Acids, Magnesium, Vitamin D, and Vitamin E. As well as inter-consultations with an Algology specialist and a psychiatrist.
Dr. Alan Alejandro Garza Cantú
Dr. Alan Alejandro Garza Cantú, Endometriosis Specialist
City: Monterrey, Mexico
Jennifer Mier-Cabrera
Jennifer Mier-Cabrera, Dietitian
City: Mexico City, Mexico
Dr. Sergio Villalobos Acosta
Dr. Sergio Villalobos Acosta, Endometriosis Specialist
City: Mexico City, Mexico
Dr. Marco Antonio Lopez Zepeda
Dr. Marco Antonio Lopez Zepeda
Doctor Zepeda – Endometriosis Specialist
Summary: Dr Zepeda, is a highly regarded endometriosis specialist based in Guadalajara, Jalisco, Mexico. With extensive expertise in excision surgery, Dr Zepeda is committed to providing personalized care rooted in leading theories of endometriosis, including retrograde menstruation and coelomic metaplasia. Doctor Zepeda tailors treatment plans based on each patient’s symptoms, fertility goals, and IDEA Protocol results, ensuring thoughtful, patient-centered solutions. He utilizes a range of medical therapies such as Dienogest, GnRH analogs, anovulatory agents, and progestins to support healing and pain management. For those experiencing persistent pain after surgery, Dr Zepeda focuses on individualized care strategies that consider long-term health and well-being. With a warm, professional approach and a deep understanding of endometriosis, Dr Zepeda offers trusted expertise to patients seeking relief and improved quality of life.
City: Guadalajara, Jalisco, Mexico
Philosophy of Endometriosis Care: Retrograde Menstruation (Sampson Theory), Celomic Metaplasie (Iwanoff and Meyer Theory), Linfatic or Vascular Dissemination, and Embryonic Remains Theory.
What type of surgery do you perform for endometriosis?: Excision
Medication: Dianogest, GnRh Analogs, Anovulatories, Progestins
Approach to Persistent Pain After Surgery: Depends on the patient´s symptoms, desire for childbearing, and the results of the IDEA Protocol.
