Why some doctors think condition is being treated with unnecessary surgery

A Melbourne gynaecologist has surrendered his medical registration after being accused of performing unnecessary endometriosis surgeries, fuelling broader concerns about ineffective treatments for the painful condition.

The allegations coincide with new data showing the Australian Health Practitioner Regulation Agency (AHPRA) has received about 225 complaints about medical practitioners who treated and managed endometriosis between 2021-22 and 2023-24.

Top medical leaders are warning that after decades of underdiagnosing endometriosis and ignoring women’s pain, the media spotlight on the disease has led to too many women having surgery that is not backed by robust evidence.

The number of surgeries to treat endometriosis almost doubled between 2016 and 2023, according to government data.

Dr Simon Gordon is being investigated by AHPRA over allegations he performed surgery on women to treat endometriosis, including removing their ovaries, despite no clinical evidence justifying these procedures.

Gordon, who abruptly closed his East Melbourne clinic late last year, told this masthead he decided to retire in November for personal reasons and had always acted ethically and responsibly.

He denies the allegations and said he only performed surgery to treat endometriosis when he was “absolutely convinced” it was in a patient’s best interests.

“For generations the pain suffered by women was ignored, downplayed and untreated,” he told this masthead. “My concern was to try and alleviate pain and restore quality of life for female patients, a cohort once neglected and dismissed.”

He said the overwhelming majority of his patients were referred to him following initial care with a primary gynaecologist and most of them already had a suspected or confirmed diagnosis of endometriosis or adenomyosis (a condition in which tissue that normally lines the uterus grows into the muscular outer wall of the uterus).

Gordon, who worked at public and private hospitals including the Epworth, said the vast majority of the surgeries he performed were successful in relieving or eliminating patients’ pain.

“No surgeon can ever guarantee that every surgery performed will be totally successful or that there’s not a genuine risk of recurrence.”

Maurice Blackburn principal lawyer Tom Ballantyne said he had received 15 inquiries from women who were concerned about the treatment provided by Gordon.

“It has invariably involved issuing very aggressive treatment for endometriosis, including the removal of ovaries and in a few extreme cases, hysterectomy,” he said.

“Some of these patients are concerned that the treatment was unnecessary and they may not have even had endometriosis. You are dealing with patients with very debilitating symptoms; they want answers.”

This masthead does not suggest the complaints are true, only that they have been made.

From underdiagnosis to overtreatment?

Endometriosis is a painful, inflammatory condition characterised by tissue similar to the lining of the womb growing outside it.

Since 2011, the proportion of women diagnosed with endometriosis by GPs almost doubled, while the rate of women under 44 attending hospital for endometriosis procedures is up 47 per cent over a similar time frame.

Many celebrate this as a rightful correction. But some researchers and pain specialists argue the publicity has led women in pain to become too focused on endometriosis diagnosis and treatment – despite only a proportion of pelvic pain being attributable to endometriosis.

Many women have clinical endometriosis but no symptoms or pain. The rate of asymptomatic endometriosis is as high as 44 per cent in some studies.

“We’re under-acknowledging period pelvic pain, and trying to attribute it all to endometriosis,” said Professor Sonia Grover, a gynaecologist and pain medicine specialist at the Royal Children’s Hospital, who has led trials of endometriosis interventions. “The correlation between pain and endometriosis is unclear.

“Why call it endometriosis when you can just call it shocking period pain – and get on and treat the period pain? Why pathologise her with a label? It’s obviously painful, but it does not mean it’s endometriosis.”

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) released guidelines on diagnosing and treating endometriosis in May. The College of Anaesthetists Faculty of Pain Medicine was consulted in the writing of those guidelines, but grew so concerned they placed “too big an emphasis” on surgery, it put out its own position statement, said Associate Professor Michael Vagg, director of professional affairs at the Faculty of Pain Medicine.

“The long-held paradigm that endometriosis lesions are a direct cause of persistent pelvic pain is no longer tenable,” the statement reads. “Surgical treatment of lesions has not been shown to reliably improve pain and disability outcomes. Some evidence suggests that ill-advised surgery may in fact worsen outcomes for some women.”

RANZCOG president Dr Nisha Khot said that while surgery was vital for removing endometriotic cysts – which can cause pain by rupturing or twisting – there was weak evidence supporting improvements in pain or quality of life following the surgical removal of other types of endometriosis lesions.

She expressed concern about repeat operations.

“If women are needing more than two surgeries, then that needs to be carefully considered within a team of experts,” she said. “As a clinician … if I’d done a couple of surgeries and the patient’s symptoms were still there, I would be questioning myself: ‘Am I helping this person?’”

She said ultrasound, rather than a laparoscopy, should be used to diagnose endometriosis. Oral contraceptives, according to Khot, are often an effective first-line treatment for managing the symptoms.

“We are still learning what the evidence is for and against surgery,” she said. “If you look, especially at some of the older studies, you’ll find evidence on both sides, and that makes it difficult to make decisions and counsel women.”

A diagnosis of endometriosis can be helpful for many women, according to Khot.

“Pain is a diagnosis. Saying that you have pain and validating that you have pain is not a failure of diagnosis. It is a diagnosis.”

The laparoscopy dilemma

Laparoscopy is a form of keyhole surgery that allows a surgeon to access pelvic and abdominal cavities via the abdomen. Surgeons can use it to visualise and cut out endometrial tissue.

The number of women with endometriosis undergoing surgery to cut out the tissue has risen dramatically, from about 10,800 in 2016-17 to about 19,700 in 2022-23, government data shows.

“If you raise awareness, the corollary of that is lots of people think they have got something,” said Professor Martha Hickey, director of the Women’s Gynaecology Research Centre. “The reality is pelvic pain is very common in women, and a lot of the time it’s not endometriosis.”

Yet the evidence for laparoscopy remains deeply controversial. A 2021 Cochrane review of laparoscopic removal of endometriosis – considered gold-standard evidence – concluded it was uncertain if it provided effective pain relief, but likely improved fertility.

‘It’s obviously painful, but it does not mean it’s endometriosis.’

Professor Sonia Grover

Abbott, who is also chair of the National Endometriosis Clinical and Scientific Trials Network, disagreed with that assessment. He authored a small 2004 clinical trial that found 80 per cent of women undergoing a laparoscopic excision improved their symptoms – beating a placebo. “Further work is, of course, needed, but ignoring the current high-quality evidence is regressive,” he said.

Diagnosis also remains controversial.

The College of Obstetricians and Gynaecologists’ guidelines recommend using ultrasound and MRI to diagnose endometriosis.

But a 2016 Cochrane review concluded imaging was not accurate enough to replace diagnostic surgery.

Professor Sonia Grover led a 2021 study that randomised 471 women presenting at Mercy Hospital with chronic pelvic pain to two gynaecology units, one specialising in surgery and the other in pain management.

The women randomised to the surgical unit were 65 per cent more likely to have surgery. Yet, they were no more likely to be diagnosed with endometriosis.

An AHPRA spokesman said of the steady stream of complaints the watchdog had received about practitioners linked to endometriosis, about half were related to clinical care and about 20 per cent raised concerns about communication.

He said six practitioners working in the endometriosis space had conditions placed on their registration and five practitioners were issued cautions.

“We are unable to comment on any individual or matter outside information published on the register or in a tribunal decision,” he said when asked about Gordon.

A spokeswoman for Epworth HealthCare said Gordon had notified the hospital of his retirement in October last year.

“AHPRA does not routinely notify hospitals when it commences investigations into current or former visiting medical officers,” she said.

“From time to time, AHPRA may request patient records from a hospital. Those requests are typically framed around specific matters and do not identify an individual practitioner.”

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