I have stage II–III endometriosis treated with excision surgery and adenomyosis; I now have constant pelvic pain that worsens between regular menstrual cycles without spotting—what is the most likely cause and what are the next management steps?

Worsening Pelvic Pain After Endometriosis Surgery with Mirena IUD and Adenomyosis

Your worsening inter-menstrual pain despite previous excision surgery and Mirena IUD most likely indicates persistent deep infiltrating endometriosis, adenomyosis progression, or both—and you need immediate escalation to GnRH agonist therapy with add-back hormones while pursuing repeat imaging to guide definitive management.

Most Likely Causes of Your Worsening Pain

Adenomyosis as Primary Driver

• Adenomyosis is strongly associated with persistent pelvic pain after endometriosis surgery, particularly when pain continues or worsens despite optimal surgical excision 1
• Women with uterine junctional zone (JZ) thickness ≥11 mm on MRI show minimal improvement in dysmenorrhea after endometriosis surgery, and those with JZ ≥8 mm show minimal improvement in non-menstrual pain 1
• The Mirena IUD provides incomplete relief for adenomyosis in many patients, and your worsening inter-menstrual pain suggests the progestin dose is insufficient 2

Recurrent or Residual Deep Infiltrating Endometriosis

• Deep infiltrating endometriosis (not superficial lesions) is the primary cause of pelvic pain in endometriosis patients, and incomplete excision leads to persistent symptoms 3
• Recurrence rates after conservative surgery are substantial: 20-40% experience pain recurrence and 15-20% require reoperation within several years 4
• Deep endometriosis typically involves the posterior vagina, cervix, pouch of Douglas, rectovaginal septum, and uterosacral ligaments—areas that may have been incompletely excised 3

Immediate Next Steps

Step 1: Obtain MRI Pelvis Without and With Contrast

• MRI is essential to map disease extent, measure junctional zone thickness, and identify deep infiltrating lesions that will guide your treatment decisions 2
• This imaging will differentiate between adenomyosis progression (JZ thickness) versus recurrent endometriosis versus both 1
• MRI reduces morbidity by decreasing incomplete surgeries and need for repeat procedures 2

Step 2: Initiate GnRH Agonist Therapy Immediately

• Start leuprolide acetate 3.75 mg intramuscularly monthly or 11.25 mg every 3 months, as GnRH agonists provide the most robust pain relief for severe endometriosis and are appropriate even without surgical confirmation 2, 5
• Simultaneously prescribe add-back therapy with norethindrone acetate 5 mg daily to prevent bone mineral loss without reducing pain relief efficacy 2, 5
• GnRH agonists for at least 3 months provide significant pain relief superior to other medical options 2, 5

Step 3: Bridge Pain Control

• Use NSAIDs (naproxen 550 mg twice daily or ibuprofen 600-800 mg three times daily) for immediate pain relief 2, 5
• Consider tramadol 50-100 mg every 6 hours if NSAIDs are insufficient, as it shows superior efficacy to naproxen for endometriosis pain 5

Definitive Management Based on MRI Findings

If MRI Shows Predominantly Adenomyosis (JZ ≥11 mm)

• Medical therapy alone will likely be insufficient for long-term control 1
• Hysterectomy with or without bilateral salpingo-oophorectomy is the definitive treatment, with medium-term satisfaction rates around 85% 2, 4
• If you preserve ovaries, you may need ongoing medical suppression as residual ovarian function can stimulate remaining endometriotic tissue 2
• Bilateral oophorectomy reduces reoperation risk by six-fold but causes premature menopause—this decision depends on your age and whether you're willing to use hormone replacement 4, 6

If MRI Shows Recurrent Deep Infiltrating Endometriosis

• Repeat excision surgery by an experienced endometriosis specialist is indicated, as deep endometriosis surgery is among the most difficult gynecologic operations and should only be performed by surgeons with oncological dissection skills 3
• Complete excision of deep infiltrating lesions provides significant pain reduction in the first 6 months 5
• Bowel resection may be necessary if disease involves the rectovaginal septum or bowel serosa 2
• After repeat surgery, continue GnRH agonist therapy or switch to continuous oral contraceptives to prolong symptom-free intervals 6

If MRI Shows Both Conditions

• Consider hysterectomy with complete excision of all visible endometriosis as the most definitive approach 2, 6
• Hysterectomy combined with endometriosis excision provides better outcomes than hysterectomy alone 6

Critical Pitfalls to Avoid

• Do not continue with Mirena alone—it has already failed to control your symptoms and escalation is mandatory 2
• Do not assume superficial endometriosis or adhesions are causing your pain—these do not correlate with pain severity in multivariate analysis 3
• Do not delay imaging—proceeding to repeat surgery without MRI mapping increases risk of incomplete excision and need for third surgery 2
• Do not use GnRH agonists long-term without add-back therapy—bone mineral loss occurs without reducing pain relief efficacy 2, 5
• If you ultimately choose hysterectomy without oophorectomy and symptoms persist, you may still need ongoing hormonal suppression 2

Expected Outcomes

• With appropriate GnRH agonist therapy, you should experience significant pain relief within 3 months 2, 5
• If definitive surgery is performed, approximately 85% of patients report satisfaction, though 15% have persistent symptoms and 3-5% experience worsening 4
• Recurrence remains possible even after optimal treatment—endometriosis is a chronic disease requiring long-term management 7, 4