{"paper_id":"2896c23d-e0bb-4832-8977-da6f07a0011f","body_text":"International Journal of Science and Research (IJSR)\n \nISSN: 2319\n-\n7064\n \nImpact Factor 2024: 7.101\n \nVolume 14 Issue 7, July 2025\n \nFully Refereed | Open Access | Double Blind Peer \nReviewed Journal\n \nwww.ijsr.net\n \nRelief \no\nf Pain in Scar Endometriosis\n \n-\n \nMedical Vs \nSurgical Treatment\n \n \nDr. Nivedha Joseph\n1\n, Dr. Anushree S\n2\n, Dr. Harshitha K M\n3\n, Dr. Anju Arpana\n4\n, Dr. Rekha N\n5\n \n \n1\nMBBS, Junior Resident, BGS Global Institute of Medical Sciences, \nBangalore\n \nEmail: \ndrnivedhajoseph[at]gmail.com\n \n \n2\nMS, Assistant Professor, BGS Global Institute of Medical Sciences, Bangalore\n \nEmail: \nanushreeshashikumar[at]gmail.com\n \n \n3\nMS, Senior Resident, BGS Global Institute of Medical Sciences, Bangalore\n \nEmail: \nharshithakm1996[at]gmail.com\n \n \n4\nDGO, Professor, BGS Global Institute of Medical Sciences, Bangalore\n \nEmail: \nmeetyourdoctor01[at]gmail.com\n \n \n5\nMS, Professor and HOD, BGS Global Institute of Medical Sciences, Bangalore\n \nEmail: \nkarthikmana[at]gmail.com\n \n \n \nAbstract:\n \nBackground\n: Scar endometriosis is a rare form of extra pelvic endometriosis characterized by the ectopic implantation of \nendometrial tissue in surgical scars, typically following obstetric or gynaecological procedures such as caesarean section or\n \nhysterectomy. \nThis \ntissue remains hormonally responsive, leading to cyclical pain, swelling, or bleeding at the scar site. The most widely accep\nted \npathogenesis is iatrogenic transplantation during surgery.\n \nEndometriosis \naffects 5\n–\n10% of women of reproductive age worldwide and is \noften associated with chronic pain and infertility. Scar endometriosis, though uncommon and difficult to diagnose, may clinic\nally mimic \nconditions such as hernia, lipoma, or hematoma. Common sympt\noms include a palpable mass and cyclical pain at the scar site. Other sites \nof extrapelvic endometriosis include the bladder, bowel, omentum, lungs, umbilicus, and abdominal wall.\n \nResults\n: The mean age of the \npatients was 32.41 ± 4.71 years, with an age ra\nnge of 25 to 39 years. The most common presenting symptoms were a palpable mass and \ncyclical abdominal pain. All 12 cases were confirmed as scar endometriosis through histopathological examination.\n \nAmong the \nparticipants, 58.3% underwent surgical excision of the lesion, while 41.7% received medical therapy with various hormonal age\nnts. Post\n-\ntreatment analysis revealed a significant reduction in pain scores, with the mean VAS score decreasing from 7.4\n2 ± 1.08 to 3.00 ± 0.85 (p \n= 0.000). However, no statistic\nally significant difference in pain reduction was found between the surgical and medical treatment groups \n(p = 0.613).\n \nThe average duration of hospital stay was 2.53 ± 1.2 days. Additionally, there was no significant correlation between the siz\ne \nof the lesion and either patient age or the number of previous cesarean sections.\n \nConclusion\n: Scar endometriosis, though uncommon, is \na notable cause of chronic cyclical abdominal pain in women with a history of pelvic or abdominal surgeries. In this study, t\nhe most\n \nfrequently observed clinical features included a palpable abdominal mass, cyclical pain, and dysmenorrhea. All cases were con\nfirmed by \nhistopathological examination, highlighting the critical role of tissue diagnosis in establishing a definitive diagnosis\n \nand guiding \nappropriate management.\n \nBoth surgical and medical treatments proved effective in alleviating pain, with a statistically significant \nreduction in mean VAS pain scores observed following intervention.\n \n \nKeywords\n:\n \nScar Endometriosis, Pain Management, Surgical Excision, Hormonal Therapy, Visual Analogue Scale (V AS)\n \n \n1.\n \nIntroduction\n \n \nScar endometriosis is a rare form of extrapelvic endometriosis \nwherein endometrial tissue is ectopically \nimplanted in \nsurgical scars, most commonly following obstetric or \ngynecological procedures such as cesarean sections or \nhysterectomies¹. This ectopic endometrial tissue responds \ncyclically to hormonal changes, leading to localized pain, \nswelling, and often\n \ncyclical bleeding at the scar site². Though \nthe exact pathogenesis is not fully understood, the most \naccepted theory is iatrogenic transplantation of endometrial \ncells during surgery³.\n \n \nThe clinical presentation of scar endometriosis is often \ndelayed and may mimic other differential diagnoses such as \nhernias, abscesses, or lipomas, leading to misdiagnosis or \ndelayed treatment⁴. The mainstay of therapy has traditionally \nbeen surgical excis\nion, which offers definitive symptom \nrelief⁵. However, medical management using hormonal \nsuppression (e.g., oral contraceptives, progestins, or GnRH \nanalogs) has also shown some benefit in alleviating \nsymptoms⁶. There remains ongoing debate about the most \neffective and sustainable treatment modality, especially with \nregard to recurrence, cost, patient preference, and quality of \nlife outcomes⁷.\n \n \n2.\n \nNeed for the Study\n \n \nGiven the increasing incidence of cesarean deliveries and \nother abdominal surgeries, the prevalence of scar \nendometriosis may be rising, although it remains \nunderreported due to diagnostic challenges⁸. There is limited \nhigh\n-\nquality comparative evidence eva\nluating the \neffectiveness of medical versus surgical treatment for scar \nendometriosis in terms of long\n-\nterm pain relief and \nrecurrence⁹. Furthermore, current literature largely comprises \ncase reports or small retrospective series, highlighting the \nneed for\n \nprospective studies and direct comparisons¹⁰.\n \n \nThis study aims to evaluate and compare the outcomes of \nmedical versus surgical treatment specifically in patients \npresenting with painful scar endometriosis, with the goal of \nPaper ID: MR25629111614\nDOI: https://dx.doi.org/10.21275/MR25629111614\n15 \n\nInternational Journal of Science and Research (IJSR)\n \nISSN: 2319\n-\n7064\n \nImpact Factor 2024: 7.101\n \nVolume 14 Issue 7, July 2025\n \nFully Refereed | Open Access | Double Blind Peer \nReviewed Journal\n \nwww.ijsr.net\n \nguiding evidence\n-\nbased clinical decision\n-\nmaking and \nimproving patient care.\n \nCases \n \n \n3.\n \nCase Description of Selected Cases\n \n \nCase 1\n \nA 33\n-\nyear\n-\nold woman, P2L2, with a history of lower segment \ncesarean section (LSCS), presented with complaints of right\n-\nsided abdominal pain over the scar site during menstrual \ncycles for the past 4\n–\n5 months. Ultrasonography revealed an \nirregular, heterogen\neously hypoechoic area measuring 10 × \n20 × 15 mm located in the subcutaneous plane superior to the \nright rectus abdominis muscle, with loss of intervening fat \nplanes and internal vascularity on color Doppler, suggestive \nof scar endometriosis. The patient w\nas managed medically \nwith oral \ndienogest 2 mg\n \ndaily. On follow\n-\nup, she reported \nsymptomatic relief.\n \n \nCase 2\n \nA 28\n-\nyear\n-\nold woman, P2L2, with two previous LSCS, \npresented with cyclical pain over the scar site for the past 6 \nmonths. Ultrasonography revealed a well\n-\ndefined hypoechoic \nlesion with mixed echogenicity and cystic areas measuring \n3.6 × 3.0 × 1.5 cm in the\n \nmuscular plane of the LSCS scar. \nThe lesion showed increased vascularity and abutted the \nanterior myometrium; its posterior extent could not be clearly \ndelineated. Findings were suggestive of scar endometriosis. \nShe was initially treated with \nregesterone \n10 mg\n \nand later \nunderwent \nhernioplasty with mesh repair and excision\n \nof \nthe lesion.\n \n \nHistopathological examination showed fibrocollagenous and \nfibroadipose tissue infiltrated with endometrial glands of \nvarying sizes, some cystically dilated with luminal secretion, \nand surrounded by endometrial stroma. Hemosiderin\n-\nladen \nmacrophages were pre\nsent. No atypia or malignancy was \nobserved. The features confirmed a diagnosis of scar \nendometriosis. On follow\n-\nup, the patient reported \nsymptomatic improvement.\n \n \nCase 3\n \nA 25\n-\nyear\n-\nold woman, P2L2A2, with a history of two LSCS, \npresented with complaints of cyclical pain at the operative site \nfor the past 3 years. Ultrasonography showed an irregular, \nheterogeneously hypoechoic lesion measuring 17.4 × 8.6 × \n11.2 mm in the sub\ncutaneous plane superior to the right rectus \nabdominis muscle with associated loss of fat planes and \ninternal vascularity, indicative of scar endometriosis. The \npatient was treated with \ninjection DMPA 150 mg \nintramuscularly every 12 weeks for 4 cycles\n, fol\nlowed by \nsurgical wide excision\n \nof the lesion.\n \n \nHistopathology revealed fibrocollagenous and fibroadipose \ntissue containing endometrial glands \nsurrounded by \nendometrial stroma. The glands were tubular, some \npseudostratified, and few were cystically dilated with \nsecretions. The stroma exhibited edema and myxoid changes \nwith hemorrhage and lymphocytic infiltration. No evidence \nof malignancy or atyp\nia was found. Histopathological \nfindings were consistent with scar endometriosis. The patient \nshowed significant clinical improvement on follow\n-\nup.\n \n \nCase 4\n \nA 31\n-\nyear\n-\nold woman, P2L2, with two prior LSCS, presented \nwith complaints of cyclical abdominal pain and heavy \nmenstrual bleeding for one year. Ultrasonography revealed a \nsmall, irregular heterogeneously hypoechoic lesion \nmeasuring 0.9 × 1.2 × 1.2 mm locat\ned in the subcutaneous \nplane superior to the right rectus abdominis muscle overlying \nthe LSCS scar, with loss of fat planes and internal vascularity \nnoted on color Doppler, suggestive of scar endometriosis. She \nwas managed medically with \nTab Delsy\n, and sho\nwed \nsymptomatic improvement during follow\n-\nup.\n \n \n \nFig\nure \n1\n \n \nThe ultrasound image demonstrates an \nill\n-\ndefined, \nheterogeneously hypoechoic lesion\n \nlocated in the \nsubcutaneous plane\n, consistent with the typical sonographic \nappearance of \nscar endometriosis\n. The lesion appears to \ndisrupt the normal fat planes and is situated over the \nanterior \nabdominal wall\n, likely corresponding to a previous \nLSCS \n(lower segment cesarean section) scar\n \nsite.\n \n \nThere is evidence of \ninternal vascularity\n \n(as seen on Doppler \nmode), which further supports the diagnosis, as endometriotic \ntissue is hormonally active and often displays \nvascular \nproliferation\n. The echotexture is mixed, possibly reflecting \nfibrosis, hemorrhagic areas\n, or \ncystic degeneration\n—\nhallmarks of ectopic endometrial implants.\n \n \nThis imaging finding is \nhighly suggestive of scar \nendometriosis\n, particularly in a patient presenting with \ncyclical pain at the surgical scar site.\n \n \n \nFig\nure \n2\n \n \nPaper ID: MR25629111614\nDOI: https://dx.doi.org/10.21275/MR25629111614\n16 \n\nInternational Journal of Science and Research (IJSR)\n \nISSN: 2319\n-\n7064\n \nImpact Factor 2024: 7.101\n \nVolume 14 Issue 7, July 2025\n \nFully Refereed | Open Access | Double Blind Peer \nReviewed Journal\n \nwww.ijsr.net\n \nFigure 2: Ultrasound Image Depicting Abdominal Wall \nLesion Suggestive of Scar Endometriosis\n \n \nThis ultrasound image shows a \nwell\n-\ncircumscribed, \nheterogeneously hypoechoic lesion\n \nlocated in the \nanterior \nabdominal wall\n, in close proximity to the \nrectus muscle\n, \nconsistent with the typical features of \nscar endometriosis\n. \nThe lesion appears embedded within the muscular or \nsubmuscular plane, showing \nmixed internal echogenicity\n, \nlikely representing \nfibrotic tissue, cystic changes\n, or \nhemorrhagic components\n.\n \n \nGiven the patient history and the location of the lesion near a \nlikely cesarean section scar, this sonographic appearance\n—\nalong with clinical correlation of \ncyclical pain and swelling \nat the scar site\n—\nis strongly indicative of \nscar \nendometriosis\n.\n \n \n \nFig\nure \n3\n \nFigure 3: Ultrasound Image Showing Abdominal Wall Lesion Consistent with Scar Endometriosis\n \n \nThis grayscale ultrasound image demonstrates a \nwell\n-\ndefined \nhypoechoic lesion\n \nlocated in the \nanterior abdominal wall\n, \nsuperficial to the rectus sheath, in the region of a previous \ncesarean section scar\n. The lesion appears rounded with a \nrelatively homogeneous hypoechoic center and peripheral \nacoustic shadowing. Its location and morphology are \nconsistent with \nscar endometriosis\n.\n \n \nThe sonographic findings are supported by the clinical \ncontext (patient history of LSCS and cyclical scar pain), and \nthe lesion’s appearance is characteristic of \nectopic \nendometrial tissue with possible internal hemorrhagic or \ncystic components\n.\n \n \n \nTable\n \n1:\n \nClinical Profile of Patients with Scar Endometriosis Cases Based on Treatment Modality\n \nCase\n \nAge \n(Years)\n \nChief Complaint\n \nObstetric/Surgical History\n \nMedication\n \nManagement Type\n \n1\n \n33\n \nPain at scar site during menses (4\n–\n5 \nmonths)\n \nP2L2, previous 2 LSCS\n \nTab \nDienogest 2 mg\n \nMedical\n \n2\n \n39\n \nBrownish discharge at scar site (4 months)\n \nP2L2, post\n-\nlaparotomy for \ntubo\n-\novarian mass\n \nTab Danazol 200 mg\n \nMedical\n \n3\n \n38\n \nPain at operated site during menses (3 \nyears)\n \nP2L2, laparoscopic hernia \nrepair with scar \nendometriosis\n \nTab Dienogest 2 mg\n \nSurgical (Wide \nexcision)\n \n4\n \n31\n \nPain abdomen and heavy bleeding during \nmenses (1 year)\n \nP2L2, previous 2 LSCS\n \nTab Delsy\n \nMedical\n \n5\n \n28\n \nPain and mass at scar site during menses (6 \nmonths)\n \nP2L2, laparoscopy for ectopic \npregnancy\n \n–\n \nSurgical (Excision)\n \n6\n \n35\n \nPain at scar site during menses (3 years)\n \nP2L2A2, previous 2 LSCS\n \nInj. DMPA 150 mg \n×4\n \nSurgical (Wide \nexcision)\n \n7\n \n30\n \nBrownish discharge from scar during \nmenses (2 months)\n \nP3L2, laparotomy for ovarian \ncyst\n \n–\n \nSurgical (Wide \nexcision)\n \n8\n \n25\n \nPainful menstrual cycles (3 months)\n \nP1L1, previous LSCS\n \nTab Danazol 200 mg\n \nMedical\n \n9\n \n36\n \nPainful mass at scar site during menses (4 \nmonths)\n \nP3L2, post\n-\nlaparotomy for \nmyomectomy\n \nInj. DMPA 150 mg \n×4\n \nMedical\n \n10\n \n34\n \nHeavy \nbleeding and painful cycles (8 \nmonths)\n \nP2L2, post\n-\nlaparoscopic \nappendicectomy\n \n–\n \nSurgical (Wide \nexcision)\n \n11\n \n32\n \nPain abdomen during menses (4 months)\n \nP3L3, post\n-\nlaparotomy for \novarian cyst\n \n–\n \nSurgical (Wide \nexcision)\n \n12\n \n28\n \nPain at scar site during \nmenses (6 months)\n \nP2L2, previous 2 LSCS\n \nTab Regesterone 10 \nmg\n \nSurgical (Hernioplasty \nwith excision)\n \n \n \n \nPaper ID: MR25629111614\nDOI: https://dx.doi.org/10.21275/MR25629111614\n17 \n\nInternational Journal of Science and Research (IJSR)\n \nISSN: 2319\n-\n7064\n \nImpact Factor 2024: 7.101\n \nVolume 14 Issue 7, July 2025\n \nFully Refereed | Open Access | Double Blind Peer \nReviewed Journal\n \nwww.ijsr.net\n \nTable 2:\n \nOutcome Summary\n \nManagement Type\n \nNo. of Patients\n \nSymptomatically Improved\n \n% Improved\n \nMedical Only\n \n5 (excluding Case 12)\n \n5\n \n100%\n \nSurgical (± Medical)\n \n7 (including Case 12)\n \n7\n \n100%\n \n \n4.\n \nResults\n \n \nThe \nmean age\n \nof the patients was \n32.41 ± 4.71 years\n, with an \nage range of \n25 to 39 years\n. The \nmost common presenting \ncomplaints\n \nincluded \npalpable mass\n, \ncyclical \nabdominal \npain\n, and \npainful menstrual cycles\n.\n \n \nRegarding \nsurgical history\n, \n5 patients (41.7%)\n \nhad \nundergone \nprevious lower segment cesarean section \n(LSCS)\n. Additionally, \n1 patient each (8.3%)\n \nhad a history of \nlaparotomy for tubo\n-\novarian mass\n, \novarian cyst\n, and \nmyomectomy\n, while another \n1 patient each (8.3%)\n \nhad \nundergone \nlaparoscopy for hernia repair with scar \nendometriosis\n, \nlaparoscopy for ectopic pregnancy\n, and \nlaparoscopic appendicectomy\n.\n \n \nHistopathological confirmation\n \nof scar endometriosis was \nachieved in \nall 12 cases (100%)\n, with microscopy revealing \nthe presence of \nendometrial glands and stroma\n \n(refer to \nFigure 1).\n \n \nTreatment distribution showed that \n7 patients (58.3%)\n \nunderwent \nsurgical excision\n \nof the endometriotic lesion \nalong with a margin of approximately \n1 cm of surrounding \ntissue\n. The remaining \n5 patients (41.7%)\n \nwere managed \nmedically\n \nwith hormonal therapy.\n \n \nThe \nmean hospitalization duration\n \nwas \n2.53 ± 1.2 days\n, \nranging from \n2 to 5 days\n.\n \n \nPostoperative evaluation of excised lesions revealed a \nmean \nendometrioma size\n \nof \n21.53 ± 5.93 mm\n, with sizes ranging \nbetween \n10 mm and 34 mm\n.\n \n \nFollow\n-\nup medical therapy\n \nincluded:\n \n•\n \nInjection DMPA 150 mg every 12 weeks for 2 patients\n \n•\n \nTablet Danazol 200 mg for 2 patients\n \n•\n \nTablet Dienogest 2 mg for 2 patients\n \n•\n \nTablet Regesterone 10 mg for 1 patient\n \n•\n \nTablet Delsy for 1 patient\n \n \nStatistical analysis revealed \nno significant correlation\n \nbetween the \nsize of the lesion\n \nand \npatient age\n \nor the \nnumber \nof previous LSCS procedures\n \n(\nP > 0.05\n).\n \n \nTable 2: \nComparison of pain score between pre\n-\ntreatment (Surgery or medical management) with post\n-\ntreatment\n \nTreatment \n \nNumber of patients \n \nV AS pain score \n \nPaired t\n-\ntest value and p\n-\nvalue \n \nMean ± SD\n \nPre\n-\nTreatment (Surgical or medical management)\n \n12\n \n7.42 ± 1.08\n \nt = 22.885, P = 0.000, HS \n \nPost\n-\nTreatment (Surgical or medical management)\n \n12\n \n3.00 ± 0.85\n \nUn\n-\npaired t\n-\ntest and        P\n-\nValue \n \nt = 0.712,  P = 0.613,     NS\n \n \nTable 2\n \npresents the comparison of pain scores before and \nafter treatment, encompassing both surgical and medical \nmanagement modalities. A statistically significant reduction \nin pain was observed following treatment. The mean Visual \nAnalogue Scale (V AS) pain scor\ne decreased substantially \nfrom \n7.42 ± 1.08\n \nin the pre\n-\ntreatment phase to \n3.00 ± 0.85\n \npost\n-\ntreatment among the 12 patients evaluated. This \nreduction was highly significant, as indicated by a \npaired t\n-\ntest value of 22.885\n \nand a \np\n-\nvalue of 0.000\n, confi\nrming the \neffectiveness of the interventions in pain alleviation.\n \n \nAdditionally, the comparison between the two treatment \ngroups using the \nunpaired t\n-\ntest\n \nyielded a \nt\n-\nvalue of 0.712\n \nand a \np\n-\nvalue of 0.613\n, which was not statistically significant. \nThis suggests that there was no meaningful difference in pain \nreduction between patients managed surgically and those \nmanaged medically. These results collectively highlight the \nclinical efficacy of both treatment\n \nmodalities in significantly \nreducing pain, reinforcing their roles in the management \nstrategy for the condition under \ninvestigation.\n \n \n5.\n \nDiscussion \n \n \nEndometriosis occurring within a postoperative scar is a rare \nclinical entity. Most reported cases have been identified in or \nadjacent to surgical scars, particularly following \ncaesarean \nsections\n, \nhysterectomy\n, and \nhysterotomy\n. Less commonly, \nscar endometriosis has also been documented after \nprocedures involving the \nfallopian tubes\n, \nappendectomy\n, \namniocentesis\n, and even \nepisiotomy.\n11\n \n \nThe incidence of endometriosis developing within a surgical \nscar varies depending on the indication for the original \nprocedure. It has been reported to be approximately \n1.08% \nfollowing mid\n-\ntrimester abortions\n, compared to \n0.03\n–\n0.4% \nafter caesarean sections\n \n.\n11\n-\n12\n \nThe higher incidence \nassociated with mid\n-\ntrimester abortions may be attributed to \nthe \npluripotent nature of early decidual tissue\n, which \npossesses greater potential for \ncellular replication\n, thereby \nincreasing the likelihood of endometrioma formati\non.\n \n \nA large review by \nHorton et al.\n \n4\n, analyzing \n445 cases\n \nof \nabdominal wall endometriosis, found that \n57%\n \noccurred in \ncaesarean section scars\n, \n11%\n \nin \nhysterectomy scars\n, and \n12%\n \nin \nscars from other surgical procedures\n. Interestingly, \n20%\n \nof cases were located outside surgical scars, such as in \nthe \numbilicus\n \nand \ngroin\n \nregions.\n \n \nThe pathogenesis of scar endometriosis remains a topic of \ninvestigation, with two main theories proposed. The most \nwidely accepted is the \nmetastatic theory\n, which suggests that \nendometrial cells are transplanted to ectopic locations\n \nthrough \ndirect surgical manipulation\n, or via \nhematogenous\n \nor \nlymphatic spread\n. Alternatively, the \nmetaplastic theory\n \nposits that \nprimitive pluripotent mesenchymal cells\n \nundergo \ndifferentiation into endometrial tissue\n, possibly \nPaper ID: MR25629111614\nDOI: https://dx.doi.org/10.21275/MR25629111614\n18 \n\nInternational Journal of Science and Research (IJSR)\n \nISSN: 2319\n-\n7064\n \nImpact Factor 2024: 7.101\n \nVolume 14 Issue 7, July 2025\n \nFully Refereed | Open Access | Double Blind Peer \nReviewed Journal\n \nwww.ijsr.net\n \ntriggered by hormonal or environmental stimuli .\n13\n \n \nEndometriosis\n \nis a chronic gynecological condition \ncharacterized by the presence of endometrial\n-\nlike tissue \noutside the uterine cavity, often resulting in significant pelvic \npain, infertility, and a decreased quality of life. Its \nmanagement generally includes either me\ndical therapy\n—\nprimarily hormonal suppression\n—\nor surgical excision, with \neach modality offering specific benefits and limitations \ndepending on the clinical scenario.\n \n \nScar endometriosis\n, a rare form of extrapelvic \nendometriosis, occurs when endometrial tissue is implanted \nin surgical scars, typically following obstetric or \ngynecological procedures. It commonly presents as a painful, \npalpable mass at the site of a previous incision and is\n \noften \ncyclic in nature. Due to its rarity and diagnostic challenges, \ntreatment strategies vary, with both medical and surgical \noptions being employed.\n \n \nThe present study was undertaken to compare the \neffectiveness of surgical and medical management in \nreducing pain and improving clinical \noutcomes in a cohort of \n12 women diagnosed with scar endometriosis.\n \n \nDemographic and Clinical Characteristics:\n \nOur study population consisted of women with scar \nendometriosis, with a mean age of 32.41 ± 4.71 years, ranging \nfrom 25 to 39 years. These demographics align with the \ntypical presentation of scar endometriosis in women of \nreproductive age. The most common \npresenting complaints in \nour study were palpable mass, cyclical abdominal pain, and \npainful menstrual cycles, which are consistent with \npreviously documented symptoms. Notably, a significant \nproportion (41.7%) of our patients had a history of lower \nsegment\n \ncesarean section (LSCS), reinforcing the established \nassociation between obstetric surgeries, particularly Cesarean \nsection, and the development of scar endometriosis. Other \nreported surgical histories, such as laparotomy, ovarian cyst \nremoval, myomectomy\n, hernia repair, ectopic pregnancy, and \nappendicectomy, while less frequent, are also recognized as \npotential contributing factors. Histopathological confirmation \nof scar endometriosis was achieved in all cases (100%), \nconfirming the presence of endometria\nl glands and stroma, \nwhich is the definitive diagnostic method.\n \n \nTreatment Approaches and Outcomes:\n \nOur study observed a distribution of treatment strategies, with \n58.3% of patients undergoing surgical excision and 41.7% \nreceiving medical management with hormonal therapy. \nSurgical excision, which involves removing the \nendometriotic lesion along with a ma\nrgin of surrounding \ntissue, is widely considered the definitive treatment for scar \nendometriosis. This is because medical therapies, while \noffering symptomatic relief, often provide only temporary \nalleviation of symptoms, with recurrence frequently \noccurri\nng after treatment cessation. In line with this, surgical \nexcision aims to achieve complete removal of the endometrial \ntissue, thus minimizing the risk of recurrence.\n \n \nComparison with Published Literature:\n \nOur findings regarding the effectiveness of surgical versus \nmedical management for scar endometriosis align with \nseveral published studies.\n \n \nIn a study done by \nMalutan AM et al \n14\n \nthe demographic and \nclinical characteristics of the study population. The median \nage of the patients was \n34 years\n, with a range spanning from \n26 to 55 years\n \nand a standard deviation of \n±6.50 years\n. The \naverage parity among the patients was \n1.5\n, ranging from \n1 to \n3\n.\n \n \nAll patients (\n100%\n) had a history of previous abdominal \nsurgery. Among them, \n11 patients (78.57%)\n \nhad undergone \na cesarean section (CS), indicating a strong association \nbetween prior obstetric surgery and the condition under \ninvestigation.\n \n \nSimilarly, in a study conducted by Sultana N et al. \n15\n, the \nbaseline characteristics of 76 participants\n—\ndivided equally \ninto surgical (n=38) and medical (n=38) treatment groups\n—\nwere reported to be comparable. The mean age in the surgical \ngroup was 32.4 years (SD ±6.1), while it was 31.8 years (SD \n±5.9) in the\n \nmedical group, with no statistically significant \ndifference (p=0.625). Body mass index (BMI) was also \nsimilar between the groups, with averages of 24.6 kg/m² (SD \n±3.4) in the surgical group and 24.9 kg\n/m² (SD ±3.2) in the \nmedical group (p=0.712). Additionally, no significant \ndifferences were observed in the duration of symptoms \n(p=0.762), severity of pain as measured by the Visual Analog \nScale (V AS) (p=0.553), history of infertility (p=0.640), or \nprior \ntreatments undertaken by the participants (p=0.646). \nThese findings underscore the homogeneity of the study \npopulation at baseline, thereby strengthening the internal \nvalidity of the comparative outcomes reported.\n \n \nOur study demonstrated a significant reduction in pain scores \nfollowing treatment, which included both surgical and \nmedical management modalities. The mean Visual Analogue \nScale (V AS) pain score decreased substantially from 7.42 ± \n1.08 in the pre\n-\ntreatment\n \nphase to 3.00 ± 0.85 post\n-\ntreatment \namong the 12 patients evaluated. This improvement was \nstatistically significant, as evidenced by a paired t\n-\ntest value \nof 22.885 and a p\n-\nvalue of 0.000, thereby confirming the \neffectiveness of both interventions in alle\nviating pain.\n \n \nIn comparison, another study evaluated long\n-\nterm pain relief \noutcomes at 6 and 12 months among patients undergoing \nsurgical or medical treatment. At the 6\n-\nmonth follow\n-\nup, the \nmean V AS pain score in the surgical group was 3.2 ± 1.5, \nsignificantly lower tha\nn the 4.6 ± 1.8 recorded in the medical \ngroup (p = 0.004). This trend persisted at 12 months, where \nthe surgical group showed a further reduction in the mean \nV AS score to 2.8 ± 1.4, compared to 5.2 ± 2.0 in the medical \ngroup, with the difference remaining \nhighly significant (p < \n0.001).\n \n \nThe same study also assessed the proportion of patients \nachieving clinically meaningful pain relief, defined as a ≥50% \nreduction in V AS score at 12 months. A significantly higher \npercentage of patients in the surgical group (78.9%) \nexperienced substantial \npain relief, in contrast to 47.4% in the \nmedical group (p = 0.003).\n \n \nFurthermore, the study reported differences in recurrence \nrates and treatment\n-\nrelated side effects. Pain recurrence was \nPaper ID: MR25629111614\nDOI: https://dx.doi.org/10.21275/MR25629111614\n19 \n\nInternational Journal of Science and Research (IJSR)\n \nISSN: 2319\n-\n7064\n \nImpact Factor 2024: 7.101\n \nVolume 14 Issue 7, July 2025\n \nFully Refereed | Open Access | Double Blind Peer \nReviewed Journal\n \nwww.ijsr.net\n \nsignificantly lower in the surgical group (21.1%) compared to \nthe medical group (52.6%, p = 0.003). Surgical complications \nwere observed in 7.9% of patients in the surgical group, while \nno surgical complications were applicable to the medical \ngroup. Conver\nsely, hormonal side effects were reported in \n36.8% of participants receiving medical treatment, a factor \nnot relevant in the surgical group.\n \n \nThe study also examined fertility outcomes in patients \ndesiring conception. Pregnancy was achieved in 50.0% of \npatients in the surgical group and 31.3% in the medical group; \nhowever, this difference did not reach statistical significance \n(p = 0.262). The m\nean time to conception was slightly shorter \nin the surgical group (9.2 ± 3.1 months) compared to the \nmedical group (11.4 ± 3.6 months), though the difference was \nalso not statistically significant (p = 0.127).\n15\n \n \nPain relief is a primary treatment goal for endometriosis. \nIn \nthis\n \nstudy\n, the surgical group exhibited\n \nsignificantly greater \npain reduction compared to the medical group. At 12 months, \n78.9% of patients in the surgical group reported a significant \nreduction in pain (≥50% reduction in V AS score) versus \n47.4% in the medical group (p=0.003). These findings   \nalign   \nwith prior research, which\n \ngenerally\n \nsupports the superiority   \nof surgical\n \nmanagement for sustained pain relief. A systematic \nreview by \nAbbott et al.,\n16\n \ndemonstrated that laparoscopic \nexcision of endometriotic lesions resulted in a  65%  reduction \nin pain at 6 months, and 50% at 12 months, compared to a \n33% reduction in the hormonal therapy group.21Similarly, \nSutton et al., \n17\nreported that 65% of women undergoing \nlaparoscopic excision experienced significant pain relief at 12 \nmonths compared\n \nto 42%  in  the  medical  group.\n \nThis \nsuggests that while medical therapy, such as GnRH agonists, \nis effective during   treatment, pain recurrence is c\nommon   \nafter cessation, unlike in surgical treatment where pain relief \ntends to be more durable.\n \n \nThe recurrence of pain remains a significant challenge in the \nlong\n-\nterm management of endometriosis. In the present study, \nthe recurrence rate was notably lower in the surgical group \n(\n21.1%\n) compared to the medical group (\n52.6%\n), and this \ndifference was statistically significant (\np = 0.003\n). Elevated \nrecurrence rates associated with medical therapy have been \nconsistently reported in the literature. For example, Vercellini \net al. observed pain recurrence in \n45%\n \nof patients receiving \nmedical treatment within \n12 months, as opposed to only \n15%\n \nin those who underwent surgical intervention .\n18\n \nThis \ndisparity is largely attributed to the temporary symptom \nsuppression provided by medical therapy, which reduces \nendometriotic activity but does not eliminate the underlying \nlesions.\n \n \nSimilarly, the ENZIAN study (2020) reported a recurrence \nrate of \n30%\n \nin patients treated surgically, compared to \n60%\n \nin those managed medically .\n19\n \nThese findings reinforce the \nadvantage of surgical intervention in providing more \nsustained pain relief, likely due to the direct excision of \nendometriotic tissue\n—\nan outcome that medical therapy alone \ncannot achieve. Consequently, surgical management may \nbe \nmore favorable for patients requiring long\n-\nterm symptom \ncontrol and recurrence prevention.\n \n \nAlthough surgical treatment offers substantial benefits in \nterms of symptom relief and reduced recurrence, it is not \nwithout risk. In the present study, \n7.9%\n \nof patients in the \nsurgical group experienced complications, including \ninfections and bleeding. These findings are consistent with \nthose reported by Chapron et al.,\n20\n \nwho documented a \ncomplication rate of \n6\n–\n8%\n \nfor laparoscopic excision, with \nbowel injury\n \nand \nintraoperative bleeding\n \nbeing among the \nmost common adverse events. These risks highlight the \nnecessity of expert surgical technique and thoughtful patient \nselection to minimize procedural complications.\n \n \nOn the other hand, while medical management circumvents \nsurgical risks, it is often associated with significant systemic \nside effects. In this study, \n36.8%\n \nof patients receiving medical \ntherapy reported adverse effects such as \nweight gain\n \nand \nmood disturbances\n. Surrey and Hornstein et al. similarly \nreported that \n35\n–\n40%\n \nof women treated with \nGnRH agonists\n \nexperienced notable side effects, particularly \nbone mineral \ndensity loss\n, which is a major concern with prolonged use .\n21\n \nThese limitations restrict the lo\nng\n-\nterm applicability of \nhormonal therapy and may lead to treatment discontinuation, \nrecurrence of symptoms, or a shift toward surgical options \nwhen side effects become intolerable.\n \n \nWhile our study, like many others, suggests surgical excision \nas the primary treatment for scar endometriosis, it's important \nto acknowledge that some individuals may experience limited \nor intermittent benefits from treatment, regardless of the \napproach. T\nhis could be due to various factors, including the \nseverity and extent of the disease at the time of treatment, the \ncompleteness of lesion removal, and the presence of \nunderlying or associated endometriosis. Furthermore, the lack \nof standardized classifica\ntion systems and inconsistencies in \nreporting outcomes across studies make direct comparisons \nchallenging. \n \n \n6.\n \nConclusion\n \n \nScar endometriosis, although rare, remains a significant cause \nof chronic cyclical abdominal pain in women with a history \nof pelvic or abdominal surgeries. In this study, the most \ncommon clinical features were a palpable abdominal mass, \ncyclical pain, and \ndysmenorrhea. Histopathological \nconfirmation was achieved in all cases, underscoring the \nimportance of tissue diagnosis in guiding treatment.\n \n \nBoth surgical and medical treatments were found to be \neffective in relieving pain. The mean V AS pain score showed \na statistically significant reduction post\n-\ntreatment, regardless \nof the modality used. While surgical excision led to a slightly \ngreater reduc\ntion in pain, the difference between surgical and \nmedical groups was not statistically significant. This suggests \nthat both approaches can be considered viable options, with \ntreatment individualized based on patient preference, clinical \npresentation, repro\nductive goals, and tolerance to hormonal \ntherapy.\n \n \n7.\n \nLimitation\n \n \nThe study has several limitations. The small sample size (n = \n12) \nlimits the generalizability of the findings, and larger \nmulticentric studies are needed to validate these results. The \nshort follow\n-\nup duration prevented the assessment of long\n-\nPaper ID: MR25629111614\nDOI: https://dx.doi.org/10.21275/MR25629111614\n20 \n\nInternational Journal of Science and Research (IJSR)\n \nISSN: 2319\n-\n7064\n \nImpact Factor 2024: 7.101\n \nVolume 14 Issue 7, July 2025\n \nFully Refereed | Open Access | Double Blind Peer \nReviewed Journal\n \nwww.ijsr.net\n \nterm recurrence and the sustainability of pain relief. The non\n-\nrandomized design, where patients were not randomly \nassigned to treatment groups, introduces potential selection \nbias. The subjective measurement of pain using the V AS score \nmay not fully captu\nre the multidimensional impact of pain \nand its effect on quality of life. Additionally, the \nheterogeneous medical therapy, with patients receiving \ndifferent hormonal agents, may have influenced individual \noutcomes and reduced comparability.\n \n \nFunding: \nThis research did not receive grant from any \nfunding agency.\n \n \nConflicts \no\nf Interest: \nNone\n \n \nReferences\n \n \n[1]\n \nSteck WD, Helwig EB. Cutaneous endometriosis. \nClin \nObstet Gynecol\n. 1966;9(2):373\n-\n383.\n \n[2]\n \nLeite GK, Carvalho LF, Korkes H, Guazzelli TF, Kenj \nG, Viana Ade T. Scar endometrioma following \nobstetric surgical incisions: retrospective study on 33 \ncases and review of the literature. \nSão Paulo Med J\n. \n2009;127(5):270\n-\n277.\n \n[3]\n \nVictory R, Diamond MP, Johns DA. Villar’s nodule: a \ncase report and systematic literature review of \nendometriosis externa of the umbilicus. \nJ Minim \nInvasive Gynecol\n. 2007;14(1):23\n-\n27.\n \n[4]\n \nHorton JD, Dezee KJ, Ahnfeldt EP, Wagner M. \nAbdominal wall endometriosis: a surgeon's \nperspective and review of 445 cases. \nAm J Surg\n. \n2008;196(2):207\n-\n212.\n \n[5]\n \nBumpers HL, Butler KL, Best IM, Siram SM. \nEndometriosis of the abdominal wall. \nAm J Surg\n. \n2009;198(2):e111\n-\n113.\n \n[6]\n \nNominato NS, Prates LF, Lauar I, Morais J, Maia L, \nGeber S. Scar endometrioma: a retrospective study of \n12 cases and review of the literature. \nInt J Surg\n. \n2011;9(6):318\n-\n323.\n \n[7]\n \nZhang J, Liu X, Li F, Zhou J. Diagnosis and treatment \nof abdominal wall endometriosis: a retrospective \nstudy. \nMedicine (Baltimore)\n. 2018;97(39):\n \ne12250.\n \n[8]\n \nSengul I, Sengul D, Kahyaoglu S. Incisional \nendometriosis: a report of 3 cases and a review of the \nliterature. \nCase Rep Obstet Gynecol\n. 2012;\n \n2012:741320.\n \n[9]\n \nBektaş H, Bilsel Y , Sari YS, Ersöz F, Koç O, Deniz M, \net al. Abdominal wall endometrioma; a 10\n-\nyear \nexperience and brief review of the literature. \nJ Surg \nRes\n. 2010;164(1):\n \ne77\n-\n81.\n \n[10]\n \nVellido\n-\nCotelo R, Muñoz\n-\nGonzález JL, Oliver\n-\nPérez \nMR, et al. Endometriosis node in gynaecologic scars: \na study of 17 patients and the diagnostic considerations \nin clinical experience in tertiary care center. \nBMC \nWomen's Health\n. 2015;\n \n15:13.\n \n[11]\n \nGoel P, Sood SS, Romilla, Dalal A. Cesarean section \nendometriosis Report of two cases. Indian J Med Sci \n2005;\n \n59:495\n-\n8.\n \n[12]\n \nBlanco RG, Parithivel VS, Shah AK, Gumbs MA, \nSchein M, Gerst PH. Abdominal wall endometriomas. \nAm J Surg 2003;\n \n185:\n \n596\n-\n8. \n \n[13]\n \nCatalina\n-\nFernández I, López\n-\nPresa D, Sáenz\n-\nSantamaria J. Fine needle aspiration cytology in \ncutaneous and subcutaneous endometriosis. Acta Cytol \n2007;\n \n51:380\n-\n4.\n \n[14]\n \nMalutan AM, Simon I, Ciortea R, Mocan\n-\nHognogi RF, \nDudea M, Mihu D. Surgical scar endometriosis: a \nseries of 14 patients and brief review of literature. \nClujul Med. 2017;90(4):411\n-\n415. doi: \n10.15386/cjmed\n-\n743. Epub 2017 Oct 20. PMID: \n29151790; PMCID: PMC568\n3831.\n \n[15]\n \nSultana N, Zabin F, Begum KF, Parveen M, Fatema K, \nNoor F, et al.Comparative analysis of surgical versus \nmedical management in alleviating pain in \nendometriosis patients. Int J Reprod Contracept Obstet \nGynecol 2024;\n \n13:2649\n-\n54\n \n[16]\n \nAbbott J, Hawe J, Hunter D, Holmes M, Finn P, Garry \nR.    Laparoscopic    excision    of    endometriosis: \nA \nrandomized, placebo\n-\ncontrolled   trial.   Fertil   Steril. \n2004;82(4):878\n-\n84.\n \n[17]\n \nSutton CJ, Pooley AS, Ewen SP, Haines P. Follow\n-\nup \nreport   on   a   randomized   controlled   trial   of   laser \nlaparoscopy in the treatment of pelvic pain associated \nwith minimal, mild, and moderate endometriosis. \nFertil Steril. 1997;68(6):1070\n-\n4\n \n[18]\n \nVercellini P, Somigliana E, Viganò P, Abbiati A, \nDaguati R, Crosignani PG. The effect of surgery for\n \nsymptomatic\n \nendometriosis: \nT\nhe other side of the \nstory. Hum Reprod Update. 2009;15(2):177\n-\n88.\n \n[19]\n \nENZIAN Study Group. Surgical treatment of deep\n \ninfiltrating endometriosis: \nA\n \n10\n-\n \nyear cohort analysis. \nGynecol Obstet Invest. 2020;85(1):49\n-\n54.\n \n[20]\n \nChapron C, Dubuisson JB, Fritel X, Rambaud D, Jacob \nS, Fauconnier A. Operative complications of \nlaparoscopic    surgery in gynecology: \nA\n \nFrench \nmulticenter collaborative study. Obstet Gynecol.\n \n1999;\n \n94(4):489\n-\n94.\n \n[21]\n \nSurrey ES, Hornstein MD. Prolonged GnRH agonist \nand add\n-\nback therapy for symptomatic endometriosis: \nlong\n-\nterm follow\n-\nup. Obstet Gynecol. 2002;99(5):709\n-\n19\n \nPaper ID: MR25629111614\nDOI: https://dx.doi.org/10.21275/MR25629111614\n21","source_license":"CC0","license_restricted":false}