Can You Still Have Endometriosis After Total Hysterectomy and Fibroids: What to Know

September 13, 2025

Can You Still Have Endometriosis After Total Hysterectomy and Fibroids: What to Know

Many people undergo hysterectomy to relieve heavy bleeding and pressure from uterine fibroids. But if pelvic pain continues—or returns—after surgery, you may wonder whether endometriosis could still be the cause. The short answer: yes. Endometriosis can persist or recur after a total hysterectomy, particularly if the ovaries are retained, and less commonly even if they are removed. Here’s what to know, how to recognize symptoms, and which treatments are available.

First, a quick definition: what does a “total” hysterectomy remove?

A total hysterectomy removes the uterus and cervix. The ovaries and fallopian tubes may or may not be removed at the same time. When both ovaries and tubes are removed, it is called a bilateral salpingo-oophorectomy (BSO). The American College of Obstetricians and Gynecologists (ACOG) notes that hysterectomy addresses conditions of the uterus (like fibroids or adenomyosis), but endometriosis lesions can exist outside the uterus and therefore may not be eliminated by hysterectomy alone.^ACOG

Can endometriosis persist after hysterectomy?

Yes. Endometriosis is driven by tissue similar to the uterine lining growing outside the uterus—on the ovaries, pelvic peritoneum, bladder, bowel, or even beyond the pelvis. Removing the uterus does not automatically remove these implants. Authoritative sources, including ACOG and the National Institutes of Health (NIH), emphasize that endometriosis can continue or recur after hysterectomy, particularly if ovarian function remains to stimulate residual lesions.^ACOG^,^NIH/NICHD

When the ovaries are preserved, estrogen production continues and can fuel remaining endometriosis implants. Even when both ovaries are removed, a small percentage of people may have persistent disease due to residual microscopic implants, deeply infiltrating lesions, or estrogen produced in other tissues through aromatization. A peer-reviewed review available through the NIH’s PubMed Central notes that recurrence is more likely with ovarian conservation and when endometriosis lesions were not thoroughly excised at the original surgery.^{PMC review}

Why symptoms may continue after a hysterectomy done for fibroids

Overlapping conditions are common

Fibroids and endometriosis can co-exist. Fibroids typically cause heavy or prolonged bleeding and bulk symptoms (pelvic pressure, urinary frequency), while endometriosis is more associated with pain (period pain, pain with sex, bowel or bladder pain). If a hysterectomy was performed primarily for fibroids, undiagnosed endometriosis may persist after the operation.

Residual or deep lesions

Endometriosis may be located on the bowel, bladder, uterosacral ligaments, or nerves. If not identified and removed at surgery, these lesions can continue to cause pain. Deeply infiltrating endometriosis often requires targeted excision by surgeons experienced in complex endometriosis care.

Hormonal stimulation

If the ovaries remain, cyclical or fluctuating symptoms may persist as hormones stimulate any remaining implants. Even without ovaries, small amounts of estrogen from other tissues can sometimes maintain symptoms.

Symptoms to watch for after hysterectomy

Pelvic pain or cramping that is cyclical or persistent
Pain with intercourse (dyspareunia)
Bowel symptoms (pain with bowel movements, constipation/diarrhea, rectal pain)
Bladder symptoms (urgency, frequency, pain with filling)
Low back, hip, or leg pain linked to pelvic triggers
Bloating and fatigue associated with flares

Seek urgent care for fever, severe or escalating pain, vomiting, inability to pass stool or gas, or heavy vaginal bleeding after surgery.

How clinicians evaluate pain after hysterectomy

History and exam: Character, timing, and triggers of pain; review of surgical findings/pathology.
Imaging: Transvaginal ultrasound to assess ovaries and pelvic structures; MRI if deep infiltrating endometriosis is suspected.
Diagnostic laparoscopy: In selected cases, minimally invasive surgery allows direct visualization and removal of residual lesions.

ACOG and NIH resources emphasize that while imaging can suggest endometriosis, laparoscopy remains the gold standard for definitive diagnosis and treatment.^ACOG^,^MedlinePlus

Treatment options if endometriosis persists

Medical therapy

NSAIDs and supportive care: For pain relief and inflammation control.
Hormonal suppression (if ovaries are present): Continuous combined hormonal contraceptives or progestin-only therapies (e.g., norethindrone acetate, depot medroxyprogesterone) can suppress ovulation and reduce lesion activity.^ACOG
GnRH agonists or antagonists: Leuprolide (GnRH agonist) and elagolix (a GnRH antagonist, FDA-approved for moderate-to-severe endometriosis pain) reduce estrogen to control symptoms; add-back therapy helps protect bone and reduce side effects.^{FDA on elagolix}
Relugolix combination therapy: The FDA has approved relugolix/estradiol/norethindrone acetate (Myfembree) for moderate-to-severe pain associated with endometriosis; it uses built-in add-back to balance efficacy with bone health.^{FDA label: Myfembree}

Medication choices depend on your surgical status (ovaries present or removed), medical history, and goals for symptom control.

Surgical management

When pain is driven by discrete residual lesions, expert laparoscopic excision can be effective. If the ovaries were retained and are major symptom drivers, removal may be considered after a thorough discussion of benefits, risks, and the implications of surgical menopause. A systematic review on NIH’s PubMed Central highlights that complete excision of visible disease and thoughtful ovarian management reduce recurrence risk.^{PMC review}

Multidisciplinary pain care

A comprehensive plan often includes pelvic floor physical therapy, bowel/bladder optimization, nutrition strategies for symptom flares, and, when appropriate, neuropathic pain medications. This approach addresses central and peripheral contributors to chronic pelvic pain alongside endometriosis-directed care.

Hormone therapy after BSO for endometriosis

If both ovaries were removed, you may discuss menopausal hormone therapy (MHT) to manage surgical menopause symptoms and protect bone and heart health. Because residual endometriosis could theoretically be stimulated by estrogen, ACOG notes that hormone therapy should be individualized; some clinicians add a progestin or use combined therapy rather than unopposed estrogen in patients with a history of significant endometriosis.^ACOG Decisions should weigh symptom relief, quality of life, and recurrence risk.

What to ask your clinician

Were endometriosis lesions seen or removed during my hysterectomy? What did the pathology show?
Could my current symptoms be from residual endometriosis, pelvic floor dysfunction, or another condition?
Which imaging or diagnostic steps do you recommend next?
What are my medical and surgical treatment options now that I’ve had a hysterectomy?
How will we monitor bone health if we use medicines that lower estrogen?

Key takeaways

Yes—endometriosis can persist or recur after total hysterectomy, especially if ovaries remain, and less commonly even after ovary removal.
Persistent pelvic pain after hysterectomy is not “in your head” and deserves a thorough evaluation.
Effective options exist, from hormonal suppression and FDA-approved therapies to expert excision surgery and multidisciplinary pain care.

This article is informational and not a substitute for personal medical advice. If you have ongoing pain after hysterectomy, talk with a clinician experienced in endometriosis care.