Treatment of Cesarean Section Site Endometriosis
Surgical excision is the definitive treatment for cesarean section scar endometriosis, with complete removal of the lesion including surrounding fascia and muscle tissue to ensure adequate margins and prevent recurrence. 1
Diagnostic Confirmation
When a mass appears in a cesarean section scar accompanied by cyclic pain and visible changes with menses, endometriosis should be strongly suspected. 1 The classic triad includes:
- Palpable tumor in the scar
- Periodic pain associated with menstrual cycles
- History of cesarean section 1
The mechanism involves iatrogenic transplantation of endometrial or decidual tissue into the incision during the cesarean delivery. 1
Treatment Algorithm
First-Line: Surgical Excision
Complete surgical excision is the treatment of choice and is typically curative for cesarean section scar endometriosis. 1 The procedure should include:
- Wide local excision of the entire lesion
- Removal of involved fascia and muscle tissue to achieve negative margins
- Histopathologic confirmation of endometrial glands and stroma 1
This approach provides both definitive diagnosis and treatment, with excellent outcomes and minimal recurrence when margins are adequate. 1
Medical Management: Limited Role
While hormonal suppression can be attempted initially, it is generally ineffective for scar endometriosis. 1 If medical therapy is considered before surgery:
- Combined oral contraceptives or progestins may be tried but typically fail to resolve the mass 1, 2
- NSAIDs can provide temporary symptomatic relief 3, 4
- GnRH agonists for at least 3 months may reduce pain but will not eliminate the lesion 3, 2
However, medical therapy alone is insufficient because it does not eradicate the ectopic endometrial tissue embedded in the scar. 1, 2
Critical Clinical Pitfalls
Do not delay surgical excision in favor of prolonged medical management. The lesion will not resolve with hormones alone, and the patient will continue experiencing cyclic symptoms. 1
Ensure adequate surgical margins. Incomplete excision leads to recurrence, requiring repeat surgery. 1
Always send tissue for histopathologic examination to confirm the diagnosis and exclude other pathology such as malignancy, though this is rare. 1
Post-Surgical Management
Following complete excision, patients typically experience complete resolution of symptoms with no need for additional hormonal therapy. 1 Long-term follow-up shows excellent outcomes with minimal recurrence when adequate margins are achieved. 1
If symptoms recur after surgery, consider:
- Incomplete excision requiring re-operation
- Separate endometriotic lesions elsewhere in the pelvis 2
- Alternative diagnoses