Why Does Endometriosis Come Back After Surgery? The Gut, Estrobolome, and Bioenergetic Mechanism — Why surgery addresses the lesion but not the substrate

Excision surgery, performed by a skilled specialist, achieves a specific clinical goal. It removes the macroscopically visible endometriotic tissue. The procedure is necessary in many cases and provides meaningful relief in many. It addresses the lesion. It does not address the five mechanisms described above. The elevated beta-glucuronidase activity continues. The gut barrier failure continues. The LPS-driven systemic inflammation continues. The mast cell-permissive microenvironment continues. The mitochondrial dysfunction continues. The iron-driven oxidative damage continues with each subsequent menstrual cycle. The substrate that selected for the original disease is fully intact after surgery. This is why recurrence is so common. The body is producing the same physiological state that produced the original disease. Retrograde menstruation continues to seed cells into the peritoneum. The peritoneal environment is the same one that supported lesion development the first time. The result is the same. Lesions reestablish. Often in new locations because the previously affected sites are scarred and less receptive, but the disease itself persists at the systemic level. The implication is not that surgery is the wrong choice. For many patients, surgery is necessary to relieve acute symptoms or to address specific complications (deep infiltrating endometriosis, endometriomas, fertil