As a specialist in gynecological pelvic surgery, practicing for the past 30 years, pelvic pain is one of the most complex and challenging problems I evaluate in my practice. Many of the patients who come to see me have already spent years searching for answers as their symptoms progressively deteriorated. They have seen multiple physicians, undergone imaging that was labeled “normal,” and tried treatments that either failed or made things worse. When endometriosis is suspected or has been mentioned but never fully addressed, the evaluation has to be thoughtful, methodical, and individualized.
Endometriosis is one of the most common causes of pelvic pain, yet it does not always present the same way and at times mimics other conditions. Likely, it’s because endometriosis is not a single, uniform disease. It presents differently from one patient to another, and the severity of symptoms does not always match what we see on imaging or even during surgery. I’ve treated patients with extensive disease who had relatively mild symptoms, or I discovered by accident during surgery, treating another condition, and others with debilitating pain whose disease was subtle but strategically located. This disconnect is one of the main reasons endometriosis is so often overlooked or dismissed.
Before ordering tests or reviewing prior records, I focus on the patient’s history. Most times, patients are able to provide clues to their condition. I want to understand when the pain began, how it has changed over time, and whether it follows a cyclical pattern. Pain that worsens around menstruation raises different concerns than pain that is constant, provoked by movement, random, or triggered by intercourse, bowel movements, or bladder filling.
Equally important is understanding what has already been tried. Hormonal treatments, physical therapy, prior surgeries, and injections. What helped, what didn’t, and what made symptoms worse or was not implemented correctly or long enough to make a difference. Failed treatments, just as successful ones, often provide critical clues about what is really driving the pain.
A pelvic exam in the setting of chronic pelvic pain is very different from a routine gynecologic exam. I assess pelvic floor muscle tone, focal tenderness, uterine mobility, and pain along specific ligaments or nerve pathways. Pain mapping can reveal patterns that suggest deep endometriosis, pelvic floor dysfunction, or nerve involvement. Also, many times in patients with pelvic pain, multiple organ systems are affected, which makes finding evidence for endometriosis challenging.
At the same time, a normal exam does not rule out endometriosis. Some of the most symptomatic patients I see have minimal findings on exam, which is why history, exam, and finally clinical judgment, guide decision-making.
Ultrasound and MRI are useful tools, particularly for identifying ovaries affected with endometriosis or endometrioma, deep infiltrating endometriosis, sometimes bowel adhesions, or associated conditions such as adenomyosis. However, superficial disease and peritoneal implants are frequently invisible on imaging. When I review imaging, I do so in the context of the patient’s symptoms and exam findings. A report that reads “unremarkable” does not mean the pain isn’t real or that endometriosis isn’t present.
RELATED: What Causes Endometriosis?
One of the most important aspects of evaluating pelvic pain is recognizing that endometriosis rarely exists in isolation. Chronic pelvic pain is often multifactorial. Pelvic floor muscle dysfunction, bladder pain syndromes, bowel hypersensitivity, nerve entrapment, and scar tissue from prior surgeries commonly coexist, and endometriosis may have involved many organ systems.
Focusing on endometriosis alone without addressing these overlapping conditions often leads to incomplete or disappointing results. This is why I frequently involve pelvic floor physical therapists and, when appropriate, pain specialists or other subspecialists as part of a comprehensive approach.
Surgery can be both diagnostic and therapeutic, but it should never be automatic. When I recommend surgery, it is because the overall picture of symptoms, exam findings, prior treatment response, and imaging suggests that surgical excision has a reasonable chance of improving quality of life. When surgery is performed, complete excision of the disease is essential. Incomplete treatment or superficial ablation often leads to persistent pain and repeated procedures, which can compound pelvic dysfunction over time.
Just as important is knowing when not to operate. Not every patient benefits from surgery, and honest conversations about expectations and alternatives are a critical part of responsible care. The key is proper diagnosis, honest conversation, and a comprehensive plan that treats the condition, prevents regression, and restores patients’ control over their lives.
Frequently Asked Questions:
How is endometriosis diagnosed?
Endometriosis is diagnosed using a combination of symptom history, physical examination, imaging, and, when appropriate, surgical evaluation. There is no single test that can diagnose all cases.
Can ultrasound or MRI rule out endometriosis?
No. Imaging can identify certain forms of endometriosis, but many patients with significant symptoms have normal imaging studies.
Is surgery required to confirm the diagnosis?
Not always. Surgery is considered when symptoms are severe, progressive, or unresponsive to conservative treatment, or when the diagnosis remains unclear after thorough evaluation.
Why does pelvic pain persist even after treatment?
Pelvic pain is often multifactorial. Endometriosis may be one contributor, but pelvic floor dysfunction, nerve sensitization, bladder or bowel pain, and prior surgical scarring can all play a role.
Does the severity of endometriosis match the severity of pain?
No. The amount of visible disease does not reliably correlate with pain intensity.
Is surgery a cure for endometriosis?
Surgery can significantly improve symptoms for many patients, but endometriosis is a chronic condition that often requires long-term management.
Who should evaluate suspected endometriosis-related pelvic pain?
Patients benefit most from evaluation by a surgeon with specialized training in pelvic pain and endometriosis excision.
If you are experiencing persistent pelvic pain, have been told your tests are “normal,” or feel your symptoms have not been fully explained, a comprehensive evaluation can make a meaningful difference.
To schedule a consultation with Dr. Michael Tahery, please call 310-446-4440 or 818-265-9499 at his offices in Los Angeles and Glendale.