In 1996 I was diagnosed with endometriosis. I had surgery to remove adhesions and then was on Lupron for nine months. I became pregnant in 1997 and again in 1999. After I delivered my son in February 2000 I was told that the endometriosis should not have grown back yet because of the Lupron followed by two consecutive pregnancies. Four months later, I went back to the doctor because of extreme mood swings and night sweats. I was told that the endometriosis was back and not allowing my ovaries to produce estrogen. I was given a choice to take hormones or have surgery again. How fast does endometriosis usually grow back? Would having tubal ligation delay the growth?

M.B.

Recurrence of endometriosis is not all that rare, particularly if endometriosis is inadequately treated at surgery -- either by failing to identify the extent of the disease or by limiting treatment to superficial destruction with a laser rather than excising both superficial and deep endometriosis. Lupron only works while you are taking it. As soon as the medication is stopped, endometriosis will begin to regrow. The effect of pregnancy is similar. Often as soon regular menstrual cycles resume, the endometriosis will begin to regrow.

Endometriosis would probably not affect hormonal levels or the ability of your ovaries to produce estrogen unless a large endometrioma (cyst of endometriosis) is present in the ovary. I can't be certain that your physician suspects recurrence of endometriosis because a cyst was seen on ultrasound, but if that is the case, hormonal treatment is rarely effective. Treatment with a GnRH-agonist such as Lupron can relieve many of the symptoms associated with endometriosis, yet it is rarely helpful in managing ovarian endometriomas.

The role of tubal ligation in preventing endometriosis is not clear. One theory suggests that endometriosis results from endometrial (uterine lining) tissue flowing out "backwards" through the fallopian tubes at the time of menses. Presumably this misplaced tissue then takes root in the pelvic cavity, forming endometriosis implants. It would make sense, then, that tying the fallopian tube would block recurrence of endometriosis by preventing this backflow of endometrial tissue. Yet data from women who have undergone hysterectomy suggest that this is not the case. In fact, if the ovaries remain after hysterectomy or if post-hysterectomy hormonal replacement includes only estrogen, a significant percentage of endometriosis patients will experience recurrence of their symptoms, even without a uterus to supply new endometrial tissue. One study even suggests an increase in endometriosis after tubal sterilization. So I do not recommend tubal ligation as an endometriosis treatment.