Diagnostic Laparoscopy is the first line of diagnosis in chronic pelvic pain with, or without, endometriosis. The surgeon introduces a telescope at the umbilicus under general anaesthesia to inspect the pelvic organs. It is a significant procedure with risks of anesthesia, perforation of bwoel or blood vessels.
(1) Ablation of endometriosis lesions using laser, ultrasound, cautery, etc.At present if you have clear deposits of endometriosis then many colleagues will offer you this surgery. As you now know the relationship between bleeding from these deposits and clinical symptoms is not entirely clear. If they do contribute to clinical symptoms then it is likely that the pain occurs during, and after, your period. They do NOT contribute to pain in the week before your period which is more likely to result from irritation of abnormal pelvic nerves from increases in pelvic blood flow.
(2) Laser ablation of uterosacral ligaments and presacral nerves
The logic behind these operations is that if you cannot deal with the abnormal nerves in the lower pelvis then it should be possible to cut the nerve pathways from the uterus to the spinal cord and brain. It is technically possible to do so – but there are many pathways for these pain signals and the results of these operations are disappointing.
(3) Hysterectomy (removal of uterus)
Removing the uterus, cervix, uterosacral ligaments and upper vagina removes the bulk of abnormal nerves and the ability of increases in pelvic blood flow to cause pain. It may give clear respite for a period of years. However any injury to pelvic nerves lays down memories in your spinal cord and brain that may “reactivate” in later years. Rates of chronic, recurrent pelvic pain range from 10-50% at five years though the pain may be substantially less in these circumstances.
(4) Oophorectomy (removal of ovaries)
Standard gynaecological teaching is that advanced endometriosis requires hysterectomy and removal of your ovaries. Permanent removal of your ovaries is a drastic step. You can get some idea of what it feels like if you receive a six months trial of GnRH agonists (injections) before taking on this surgery. The injections make you menopausal and shut down your pelvic blood flow so that irritation of abnormal nerves is avoided and bleeding no longer takes place from pelvic deposits of endometriosis.
You will eventually go through a natural menopause (average age is 51) that has the same effect.