Dr. Carlos Enrique Parraga Sandoval
Dr. Carlos Enrique Parraga Sandoval, Endometriosis Specialist
City: Lima, Lima, Peru
Philosophy of Endometriosis Care: Consider that genetic and epigenetic theory play a crucial role in the pathophysiology of the disease. – Over time, endometriosis has had a wide variety of options as part of its development. However, the lack of a concise and clear definition makes each patient’s management and future treatment completely different. -For example, it is crucial to consider the onset of endometriosis with extensive organic involvement versus endometriosis with isolated nerve involvement. – This makes part of my management personalized. Most of my patients who come for a new medical opinion or surgery have highly relevant medical histories: previous surgeries, family history of endometriosis, and persistent pain.
What type of surgery do you perform for endometriosis: Excision
Medication: The vast majority of my patients receive a combination treatment, which includes hormone suppression therapy, an anti-inflammatory diet, and vitamin supplements. -In some cases, we resort to excisional surgery for endometriosis. Afterward, we continue the treatment, which is discontinued when the patient desires pregnancy or is in menopause. -I also incorporate pain relief, especially for patients with injuries to the pudendal nerve or peripheral branches of the ilioinguinal or iliohypogastric nerve. -I generally recommend treatment independently of surgery. If surgery is required, we continue treatment afterward and evaluate pain improvement over the months.
Approach to Persistent Pain After Surgery: A large number of patients who come for a second opinion because they persist in pain despite undergoing surgery. It is important to mention that patients need:
1) A new evaluation of the type of pain they have and a determination of whether it is due to endometriosis or another pelvic cause. Previous studies and treatments must also be evaluated.
2) A neuropelviological perspective must be considered, not only to view pain as a disease but also as information, and to evaluate the pain pathway, given that a large number of patients have nerve involvement.
3) A coadjuvant treatment must be considered for pain management: pelvic physical therapy, pain therapy, among others.
Dr. Reza Askari
Dr. Reza Askari, Endometriosis Specialist
City: Los Angeles, California, USA
Philosophy of Endometriosis Care: Current scientific evidence most strongly supports the coelomic metaplasia theory as the primary explanation for the development of endometriosis.
Our knowledge of endometriosis is growing every day, and I believe epigenetics and immune system factors will become key areas of focus moving forward.
What type of surgery do you perform for endometriosis: Excision
Medication: Effective care for endometriosis requires a comprehensive view of each patient’s health, recognizing that other conditions may contribute to symptoms. While there is no medical therapy that cures endometriosis, complete surgical excision remains the foundation of treatment. After surgery, when necessary, I often recommend hormonal therapy—typically progestins, either orally or through an intrauterine device (IUD)—to help manage bleeding or adenomyosis-related symptoms when present. I generally avoid GnRH agonists and antagonists, as their risk profiles and clinical outcomes do not, in my experience, offer meaningful advantages over progestin-based
Approach to Persistent Pain After Surgery: My goal is always to walk alongside patients through their recovery, not just for the surgery itself, but until they truly feel better
I believe that recovery does not end in the operating room. I stay closely involved with every patient’s care, providing follow-up and support for as long as needed to help them achieve meaningful, lasting improvement.
Every patient leaves surgery with a personalized recovery plan, shaped by their history, examination, and lab findings, with particular attention to any additional pain contributors. I routinely recommend pelvic physical therapy and collaborate with a trusted network of physiatrists to ensure each patient receives truly comprehensive care throughout their healing journey.
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. Ronald Enrique Delgado Bocanegra
Dr. Ronald Enrique Delgado Bocanegra, Endometriosis Specialist
City: Salvador, Bahia, Brazil
Philosophy of Endometriosis Care: My approach to the treatment of endometriosis is grounded primarily in the embryonic theory of origin, as proposed by Dr. David Redwine. According to this theory, endometriosis results from the aberrant differentiation of embryonic Müllerian remnants, which persist outside the uterine cavity and later develop into endometriotic lesions. This perspective shifts the focus away from retrograde menstruation and toward the concept that endometriosis is a congenital disease — present from birth and not caused by menstrual backflow. It explains cases in premenarchal girls, women with Müllerian anomalies, and the presence of endometriosis in distant locations that retrograde menstruation can’t account for. Clinically, this theory supports a surgical approach that emphasizes complete excision of all visible and suspected disease, rather than ablation or suppression. It also reinforces the idea that endometriosis is not a recurrent disease if completely removed — recurrence is often due to incomplete excision. Therefore, my goal is to perform meticulous, fertility-preserving excision surgery whenever possible, aiming for long-term relief and definitive treatment
What type of surgery do you perform for endometriosis: Excision
Medication: Grounded in the embryonic theory of endometriosis, I view the disease as congenital and not caused by retrograde menstruation. Therefore, my primary treatment is complete surgical excision, aiming for definitive management. Medications are used as supportive tools in two main contexts: before surgery, to manage symptoms temporarily when immediate surgery isn’t feasible. After surgery, in selected cases — like when there’s a residual microscopic disease or when fertility preservation is a priority. I typically use: Continuous combined oral contraceptives, Progestins (like dienogest) GnRH analogues with add-back therapy These options help control symptoms but don’t cure the disease. The focus remains on individualized, surgical-centered care.
Approach to Persistent Pain After Surgery: When patients experience persistent symptoms after surgery for endometriosis, my approach is comprehensive and individualized. First, I assess whether the symptoms are due to residual disease, coexisting conditions, or central sensitization. Persistent pain doesn’t always mean recurrence — it could be related to pelvic floor dysfunction, adenomyosis, irritable bowel syndrome, interstitial cystitis, or neuropathic pain. If I suspect residual or recurrent disease, I review the surgical report and imaging and may repeat diagnostic imaging with an expert. In some cases, reoperation may be necessary, especially if the initial surgery was incomplete. If other causes are identified, I work with a multidisciplinary team — including pelvic physiotherapists, pain specialists, gastroenterologists, and psychologists — to address the symptoms holistically. Medication (like progestins or neuromodulators) can also be used as part of symptom control, but not as the sole strategy. In essence, I treat persistent symptoms not with a one-size-fits-all approach, but through careful reassessment, patient education, and a multidisciplinary plan tailored to each woman’s needs.
Dr. Mohammad Haekal
Dr. Mohammad Haekal, Endometriosis Specialist
City: Jakarta, Indonesia
Philosophy of Endometriosis Care: Retrograde, stem cell, and epigenetic theories.
What type of surgery do you perform for endometriosis: Excision
Medication: Dienogest GnRH Analog injection
Approach to Persistent Pain After Surgery: Medical management first, we only perform a single, complete, comprehensive surgery.
Dr. Mamta Mamik
Dr. Mamta Mamik, Endometriosis Specialist
City: New York City, New York
Philosophy of Endometriosis Care: Embryonic rest theory, coelomic metaplasia, stem cell theory
What type of surgery do you perform for endometriosis: Excision
Medication: Only oral contraceptives and Mirena IUD. I recommend their use after excision surgery to avoid recurrence. I avoid using GnRH agonists, as this makes excision difficult unless the patient really would like to try this.
Approach to Persistent Pain After Surgery: Multi-modality approach is always best. This includes collaboration with physical therapy, nerve blocks in the office, and possible neuromodulator implants depending on the severity of pain.
Dr. Hector Oliva
Dr. Hector Oliva, Endometriosis Specialist
City: Ciudad de Guatemala, Guatemala
Philosophy of Endometriosis Care: Mullerosis Gene Ensemble Genetic
What type of surgery do you perform for endometriosis: Excision
Medication: Dienogest with little symptoms and few diseases through mapping. before surgery pills containing estradiol plus dienogest when the patient needs contraception. AINE´s and antioxidant supplement. Every patient needs nutritional guidance, exercise, and physical therapy
Approach to Persistent Pain After Surgery: Perform lifestyle changes and wait 6 months after the surgery. because this is the time that we can evaluate the benefits of the surgery. Every patient continues with physical rehabilitation.
Dr. Ruy Machado Jr.
Dr. Ruy Machado Jr., Endometriosis Specialist
City: São Paulo, Brazil
Philosophy of Endometriosis Care: Believe mainly in the theory of cellular metaplasia and autoimmune theory.
What type of surgery do you perform for endometriosis: Excision
Medication: I often use medications; I often use dienogest and gossreline acetate. I use dienogest both before and after surgery to control symptoms. Gosserrelin acetate is used exclusively after surgery in cases of grade 4 endometriosis for a period limited to 6 months.
Approach to Persistent Pain After Surgery: I have been treating endometriosis for laparoscopy for 17 years and more recently for robotic surgery. In recent years, we have had very few patients with persistent symptoms after the surgeries we practice using nerve-preserving disease excision techniques. The cases we had improved only with the use of continuous dienogest, anti-inflammatory drugs, or the use of levonorgestrel IUD. Over these years, we re-operated only 2 patients for persistent symptoms.
Dr. Francesco Di Chiara
Dr. Francesco Di Chiara, Endometriosis Specialist
City: Oxford, England
Philosophy of Endometriosis Care: Thoracic endometriosis and diaphragmatic endometriosis
What type of surgery do you perform for endometriosis: Excision
Medication: As a thoracic surgeon, I prefer to consult with Gynae colleagues to adjust hormonal treatments.
Approach to Persistent Pain After Surgery: Re-imaging, multidisciplinary discussion, and re-doing surgery in selected cases.
Dr. Mauricio Abrao
Dr. Mauricio Abrao, Endometriosis Specialist
City: Sao Paulo, Brazil
Philosophy of Endometriosis Care: Immunology
What type of surgery do you perform for endometriosis: Excision
Medication: Oral contraceptives / dienogeste for patients with pain who don’t want surgery and
GnRHa 2m after surgery for patients with adenomyosis wanting to be pregnant
Approach to Persistent Pain After Surgery: US for mapping the disease
Dr. Daniel Santos
Dr. Daniel Santos, Endometriosis Specialist
City: Rio de Janiero, Brazil
Philosophy of Endometriosis Care: I believe in both the theory of retrograde menstruation and the embryonic theory as key explanations for the origin of endometriosis. These perspectives guide my surgical approach, leading me to perform a complete excision of endometriotic lesions and a full peritonectomy of the affected compartments to ensure thorough disease removal.
What type of surgery do you perform for endometriosis:Both excision and ablation. I always perform complete excision of endometriotic lesions, as I believe it is the most effective approach for disease removal. However, I reserve ablation for specific cases where excision is not feasible, such as extensive scattered diaphragmatic lesions and those located on the pericardium. In these situations, ablation is used to manage the disease while minimizing the risks associated with deep excision in anatomically challenging areas.
Medication: In my practice, I incorporate hormonal and non-hormonal medications as part of a comprehensive approach to managing endometriosis. I typically recommend hormonal therapy, such as combined oral contraceptives, progestins, or GnRH analogs, for symptom control in patients who are not candidates for surgery or who prefer a non-surgical approach. These therapies help suppress disease activity and manage pain.
For patients with significant pain, I use nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line symptom relief. Additionally, I may consider neuromodulators in cases of central sensitization and persistent pain syndromes.
However, in cases where surgery is indicated, I prioritize complete excision of endometriotic lesions. Postoperatively, hormonal therapy may be used to prevent recurrence, particularly in patients who are not seeking pregnancy. My treatment recommendations are always tailored to the patient’s symptoms, reproductive goals, and disease severity.
Approach to Persistent Pain After Surgery: This is a significant challenge, and unfortunately, it occurs with some frequency, especially when psychological factors are involved. My approach is always multidisciplinary, involving a pain specialist—my anesthesiologist, who is also a pain specialist and provides care at our clinic—along with pelvic physiotherapy and psychological support. This comprehensive strategy ensures that persistent symptoms are addressed holistically, considering both physical and emotional aspects to optimize patient outcomes.
