Why Does Endometriosis Come Back After Surgery? The Gut, Estrobolome, and Bioenergetic Mechanism — Selected primary research

The mechanisms described in this article are drawn from primary research published over the past two decades. Key references include: Plottel CS, Blaser MJ. Microbiome and malignancy. Cell Host Microbe. 2011;10(4):324-335. Baker JM, Al-Nakkash L, Herbst-Kralovetz MM. Estrogen-gut microbiome axis: Physiological and clinical implications. Maturitas. 2017;103:45-53. Khan KN, Kitajima M, Hiraki K, et al. Toll-like receptors in innate immunity: role of bacterial endotoxin and toll-like receptor 4 in endometrium and endometriosis. Gynecol Obstet Invest. 2009;68(1):40-52. Ata B, Yildiz S, Turkgeldi E, et al. The endobiota study: comparison of vaginal, cervical and gut microbiota between women with stage 3/4 endometriosis and healthy controls. Sci Rep. 2019;9(1):2204. Salliss ME, Farland LV, Mahnert ND, Herbst-Kralovetz MM. The role of gut and genital microbiota and the estrobolome in endometriosis, infertility and chronic pelvic pain. Hum Reprod Update. 2021;28(1):92-131. Leonardi M, Hicks C, El-Assaad F, et al. Endometriosis and the microbiome: a systematic review. BJOG. 2020;127(2):239-249. These references are starting points. The endometriosis-microbiome literature has expanded substantially in the past five years. The framework described in this article synthesizes findings across this literature into a clinical interpretation that has not yet been formalized in mainstream gyneco