You may also be offered a laparoscopy, particularly if Mr Chattopadhyay thinks you may have endometriosis, adhesions or pelvic infection.
Diagnostic laparoscopy has been regarded in the past as the ‘gold standard’ in the diagnosis of chronic pelvic pain. It may be better seen as a second-line investigation if other therapeutic interventions fail. Diagnostic laparoscopy may have a role in developing your beliefs about your pain. Diagnostic laparoscopy is the only test capable of reliably diagnosing peritoneal endometriosis and adhesions, it is therefore seen as an essential tool in the assessment of women with chronic pelvic pain. However, it carries significant risks: an estimated risk of death of approximately 1 in 10 000, and a risk of injury to bowel, bladder or blood vessel of approx- imately 2.4 in 1000, of whom two-thirds will require laparotomy.
Clearly, conditions such as IBS and adenomyosis are not visible at laparoscopy, but there is also a risk that some forms of endometriosis will be missed. Endometriosis is a disease with a large variety of appearances and many authorities consider that it is significantly underdiagnosed at laparoscopy. Some recommend that all suspicious areas should be biopsied. It is well known that the existing scoring systems do not correlate with severity of pain and that deeply infiltrating endometriosis, which is strongly correlated with pain, may be misinterpreted as minimal disease. One-third to one-half of diagnostic laparoscopies will be negative and much of the pathology identified is not necessarily the cause of pain.
The risks and benefits of diagnostic laparoscopy and the possibility of negative findings should be discussed before the decision is made to perform a laparoscopy. Perhaps it should be performed only when the index of suspicion of adhesive disease or endometriosis requiring surgical intervention is high, or when you have specific concerns which could be addressed by diagnostic laparoscopy such as the existence of endometriosis or adhesions potentially affecting your fertility.
What treatment may help?
If Mr Chattopadhyay thinks that your pain is due to a particular cause then you should be offered treatment for that condition:
- irritable bowel syndrome (IBS) – medication and changes to your diet may help
- infections should be treated (usually with antibiotics)
- if your pain is related to your periods, you may be offered hormone treatment, for example the pill, injections or the Mirena IUS (hormone coil) to stop your periods for 3–6 months, instead of having a laparoscopy – these treatments may also be worth trying even if there is no pattern to your pain
- surgery for mild adhesions does not appear to help pelvic pain – however, it may be considered in cases of severe adhesions caused by endometriosis or previous surgery.
Many women find that they can cope better with the pain if they have been listened to, taken seriously, have a full explanation of their test results and agree a plan of action. You may be reassured by finding that nothing is seriously wrong and the pain may get better with time. Some women find acupuncture or complementary therapies, or changing diet, helpful. Whatever your situation, you should be offered pain relief. If this does not help, you may be referred to a pain management team or a specialist pain clinic.
Chronic pelvic pain can be very difficult to live with and can cause emotional, social and economic difficulties. You may experience depression, difficulty sleeping and disruption to your daily routine. Talk to your GP if this is the case. The support of other women who also experience pelvic pain may also help: see below for information about support groups.
Further information and support groups: