I had a C-section 13 years ago and surgery for endometriosis three years after that. The endometriosis was outside the uterus, in the pelvic area. I believe it is back and growing. I have horrible pain during ovulation, after sex, and sometimes during bowel movements. At times, I can actually GRAB a huge knot in my lower pelvic area! I have been to my OB-GYN twice for this, and he says he feels nothing! I had a pulmonary embolism 25 years ago, so I have been advised not to use hormonal medication. I am lost, discouraged, and in pain. Please give me some guidance.

S.T.

Rarely is a physical exam or ultrasound helpful in actually "feeling" or seeing endometriosis. The diagnosis is best made at the time oflaparoscopic surgery, a procedure that involves inserting a miniature viewing device through a tiny slit in the abdomen. This should be carried out by a skilled endometriosis surgeon who is able to excise, rather than burn or laser ALL the involved tissue. During the surgery, air-filled, rotating compression stockings can massage your legs and reduce the risk of blood-clot formation.

Alternatively, your physician may consult with hematologist (a specialist in blood disorders) to get more information about your history of thromboembolic (abnormal blood clotting) complications with low-dose hormone replacement therapy. The hematologist will want to review your family history and will ask you questions. For example, were you were pregnant or taking birth control pills at the time? Have you had genetic tests for clotting disorders such as factor V Leiden, protein S & C, antithrombin III, and prothrombin gene mutation, and are the results normal? If so, your physician may consider the use of a GnRH-agonist hormonal treatment along with minimal replacement levels of estrogen and progesterone.

Your situation is obviously quite complicated. Significant risks may be involved with either surgical or medical treatment. Careful evaluation of your history, consultation with other medical specialists, making sure you fully understand your options and risks and a bit of outside-the-box thinking are required. Based on your description, it sounds like your physician is either unskilled or unwilling to take the necessary steps to address your medical needs.