Women with disabling pain that is premenstrual and or menstrual and that does not respond to NSAIDs or hormonal contraceptives should be considered for laparoscopic evaluation. Diagnostic laparoscopy is a standard procedure in the evaluation of patients with chronic noncyclic pelvic pain; however, laparoscopy is generally withheld until other nongynecologic somatic or visceral causes of pain are excluded. Nonrandomized retrospective and prospective studies suggest that diagnostic laparoscopy provides a positive psychological effect on the treatment of chronic pelvic pain, but this should not be the main goal of laparoscopy (142). During diagnostic laparoscopy, endometriotic lesions should be excised for biopsy, and if infection is suspected, cultures should be performed. The laparoscopy is essentially a debulking procedure, and all visible endometriosis may not be able to be removed safely; but if possible the implants should be excised or electrocoagulated.
Presacral neurectomy and laparoscopic uterosacral nerve ablation (LUNA) are techniques to interrupt the nerve supply to the uterus. A large study showed that LUNA was no more effective for chronic pelvic pain than laparoscopy alone (143). A Cochrane database review revealed that there is insufficient evidence to recommend pelvic nerve disruption for the treatment of dysmenorrhea (45).
The role of pelvic adhesions in pain is unclear, and the efficacy of lysis of adhesions is even more in doubt. Adhesiolysis, even via laparoscopy, is frequently complicated by adhesion reformation and may not be effective for relief of pain in controlled trials (90,144). Other causes must be treated first, and psychological consultation and management should precede or accompany the lysis of adhesions.
Although 19% of hysterectomies are performed to cure pelvic pain, 30% of patients presenting to pain clinics have already undergone hysterectomy without experiencing pain relief. A multidisciplinary approach including a gynecologist, physical therapist, and a psychologist decreased the frequency of hysterectomy in one study from 16.3% of patients with chronic pelvic pain to 5.8% (145).
Hysterectomy is particularly useful for women who have completed childbearing and have secondary dysmenorrhea or chronic pain related to endometriosis, to uterine pathology, such as adenomyosis, or to pelvic congestion. Before recommending hysterectomy for pain or unilateral adnexectomy for unilateral pain, it is useful to apply the PREPARE mnemonic in discussions with the patient (146): the Procedure that is being done, Reason or indication, Expectation or desired outcome of the procedure, Probability that the outcome will be achieved, Alternatives and nonsurgical options, and Risks as well as Expense (see Chapter 3). Hysterectomy for central pelvic pain in women with dysmenorrhea, dyspareunia, and uterine tenderness provided relief of pain in 77% of women in one retrospective study and in 74% of women in one prospective cohort study (147,148). Nevertheless, 25% of women in the retrospective study noted that pain persisted or worsened at 1-year follow-up (147). Persistent pain in the prospective study was associated with multiparity, prior history of PID, absence of pathology, and Medicaid payer status (148). The Maine Women’s Health Study, a prospective cohort study, studied outcomes of 199 women with frequent pain at baseline who underwent hysterectomy. In this cohort, only 11% reported persistent symptoms after their surgery (149).