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Pain after Surgery: What You Can Expect

by Robert B. Albee, Jr., MD FACOG ACGE FOUNDER

Just as each woman with endometriosis has a case like no one else's, so, too, can she expect her recovery to be as individual as she is. In other words, there is a very wide range of "normal" recovery after laparoscopic excision of endometriosis.

For some women, some of the pain they had been experiencing before their operation will disappear immediately. Such cases are explained more fully below. For other women, their pain decreases at a steady rate over a few to many days or weeks. For still others, pain relief seems as though it will never happen, then a very dramatic corner is turned. Often, the older a woman is and the longer she's been sick, the longer her recovery may take. Of course, there are many exceptions.

Are there any guidelines as to what to expect?

First, let's discuss situations in which a patient might experience significant pain relief almost immediately.

Internal Pressure is Relieved

In the course of excision of endometriosis, it is common to encounter areas where a build up of fluid or edematous (swollen) tissues occupy a confined space. For example, an endometrioma within the capsule of the ovary will create increasing pressure as it enlarges. Some women have areas of endometriosis that are encapsulated by adhesions (internal scar tissue). This can result in swollen tissue that has no place into which to expand.

These areas of pressure exert a stretching effect on the local nerve endings. This can result in intense pain. When we release this pressure by excising the endometriosis and removing the adhesions the pain may disappear immediately.

Some women wake up after surgery and can tell instantly that some pain has been relieved.

Adhesions are the Bind that Ties

It is quite common for a woman with endometriosis to have adhesions holding together two structures that need to move separately. For example, a woman's ovary moves in various ways throughout her menstrual cycle. If the ovary is stuck down with adhesions, these attempts at movement can cause great pain. If the ovary is attached to the bowel, for example, movement of either structure is going to trigger pain.

When the adhesions that are preventing independent movement of bodily structures are removed, the pain relief is often intense and immediate. You can read more about adhesions here.

Lingering Pain

We are frequently asked why the pain doesn't go away in the first few days after surgery. After all, the reasoning goes, the endometriosis is gone, so why should I have any pain?

Each area of endometriosis that is excised leaves behind a base of normal tissue, which has been uncovered of its normal peritoneal surface. This is essentially a raw tissue, which immediately becomes swollen with the body's natural response to injury. This also involves an increase in the local blood supply, and an infusion of defense cells such as plasma calls and white blood cells.

This surgical "injury" requires a significant amount of time to heal. New peritoneum must be generated to cover the raw area. The swelling must have time to subside. The patient's nerve endings can't tell the difference between endometriosis and the surgery to excise it: all they know is that something is causing them to fire, and the result can be pain.

Local Anesthesia

I now routinely leave a long-acting local anesthesia in the abdomen/pelvis. Sometimes a patient will notice an increase in pain when this medicine wears off, usually in one to three days after surgery. Overall, however, I have found that this technique reduces significantly the amount of pain medication a patient needs.

Post-Op Menses

Frequently, the patient's next ovulation and/or menstrual period occur during the early stages of healing. These processes can add to the factors that create irritation of already swollen tissues. It is not uncommon, therefore, for the first ovulation and period after surgery to be quite painful. Also, the first period after surgery is often heavy, cramp, clotty, and long. Succeeding periods should be much more normal. 

For more information on ovulation after excision surgery for endometriosis, please see Dr. Albee's article on the topic.

Take Heart

Although the tissue healing can take up to twelve weeks and seem as though it will never happen, there is much to look forward to. It is important to remember that while surgery is an event, healing is a process.

Most women find that they are doing quite well by their third menstrual period after surgery. However, we have had many women report that they felt their healing took even longer.

By ninety days post-op, virtually all patients have resumed normal activities. Significant numbers, however, report ongoing improvement, in very small increments, for up to one full year after surgery.

The key point to remember is that until all the swelling is resolved on the inside where the endometriosis was excised, there is still a source of pain in exactly the same area previously affected by endometriosis.

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