Why Does Endometriosis Come Back After Surgery? The Gut, Estrobolome, and Bioenergetic Mechanism — The clinical pattern that defines recurrent endometriosis

A patient presents with severe dysmenorrhea, often beginning shortly after menarche but typically dismissed for years as "bad periods." Pelvic pain extends beyond the menstrual window. Pain with intercourse develops. Bowel symptoms emerge, often misdiagnosed as IBS. Fatigue is severe and disproportionate to the visible illness. The patient sees three to seven physicians over six to ten years before receiving an endometriosis diagnosis. The diagnosis is confirmed by laparoscopy. Excision surgery is performed. For some patients, surgery produces substantial and durable relief. For many, the relief is partial. For a substantial fraction, the symptoms return within months to a few years, often with new lesion locations identified at subsequent imaging or surgery. The recurrence is sometimes attributed to incomplete excision at the original surgery, sometimes to "aggressive disease," sometimes to inadequate hormonal suppression in the post-operative period. The patient is offered another surgery, often with the addition of continuous oral contraceptives, GnRH agonists (Lupron, Orilissa), or progestins (Visanne, Mirena IUD) to suppress the disease. The medications reduce symptom severity in some patients. They produce significant side effects in many. They are not curative. The disease persists at the underlying tissue level even when symptoms are suppressed. When the medication is d