Endometriosis Excision Surgery Worked—So Why Am I Still in Pain?

You did the hard thing: you found a surgeon, went through the work-up, arranged time off, and had endometriosis removed. Maybe you were even told the surgery was “successful.” And yet—weeks or months later—you still hurt, or the pain is back in less than a year or so.

If that’s you, it doesn’t mean you imagined it, failed recovery, or that surgery was pointless. Persistent pain after endometriosis surgery is a real, recognized problem, and multiple lines of research help explain why it happens. Some reasons are “local” (in the pelvis), like adhesions or fibrosis, suboptimal excision, or recurrence. Others involve a hyper-sensitized peripheral and/or central nervous system and that way pain can become amplified over time. And for many people, endometriosis isn’t the only pain condition in the picture—overlapping pain disorders can raise the overall pain burden even when pelvic disease is treated.

This article (the first in our “Why Do I Still Hurt?” series) focuses on the big-picture, most common explanations—especially recurrence and adhesions/scar tissue—and how to talk with your care team about next steps.

First: “The surgery worked” can mean different things

Surgery can be medically successful in several ways: lesions were removed safely, organs were protected, anatomy was restored, and no major complications occurred. But pain relief isn’t guaranteed to match what was seen—or removed—during surgery.

A 2025 review on endometriosis pain mechanisms describes a key reason: pain isn’t only a direct readout of visible lesions. Chronic inflammation around endometriosis can stimulate nerves and contribute to sensitization, where the nervous system becomes more reactive over time. In that situation, removing lesions may reduce one driver of pain, but the “alarm system” can stay turned up.

That doesn’t mean surgery was the wrong choice. It means pain after surgery often needs a broader, stepwise plan—starting with the most common pelvic causes.

Reason #1: Endometriosis can return—or persist in ways imaging can’t easily show

One straightforward explanation for ongoing pain is persistent disease (not everything could be safely removed or it was burned/fulgurated), or recurrence (new or returning lesions over time). This is especially relevant when endometriosis is deep or involves sensitive structures like bowel, bladder, or ureters.

A 2024 review comparing robotic-assisted laparoscopic surgery (RALS) and conventional laparoscopy (LPS) emphasizes that many endometriosis surgeries—particularly deep infiltrating endometriosis cases—are complex. In that context, what matters most is often not the tool (robot vs standard laparoscopy), but the surgeon’s training, skill and ability to completely and safely excise disease in difficult locations. The review suggests overall complication outcomes are broadly similar between approaches, while robotic surgery often takes longer in the operating room and is limited by cost and access. For patients, the practical takeaway is this: if pain persists, it’s reasonable to ask whether there were areas where complete excision wasn’t possible—or where a conservative approach was chosen to protect organs. Or, sadly, the surgeon overestimated their abilities and that resulted in suboptimal surgery for you.

It’s also important to know that symptom severity doesn’t always correlate with “stage.” Inflammation-driven nerve changes can make pain feel severe even when lesion burden is small—so persistent pain does not automatically prove “the disease is persistent or back everywhere,” but it does justify careful reassessment.

Reason #2: Adhesions and scar tissue can create new pain generators

Even when endometriosis is thoroughly removed, the healing process itself can lead to adhesions (bands of scar tissue that can tether organs). Adhesions can contribute to pain by limiting organ mobility, creating traction with movement, or irritating nearby nerves—especially in a pelvis that has already been inflamed. Extensive fibrosis can produce molecular signals that stimulate more nerve growth in the area (neuroangiogenesis).

Research syntheses on surgical approach (including the 2024 robotic vs laparoscopic review) generally frame robotic surgery as “not inferior” to standard laparoscopy for major perioperative outcomes, but they also underscore a bigger point: endometriosis surgery is still surgery. Gentle tissue handling, dissection planes, bleeding control, and the extent of disease all influence the inflammatory environment that can set the stage for adhesions and fibrosis. Basically sloppy, swashbuckling, bloody, rip and tear blunt dissection leads to more damage and that leads to more adhesions and fibrosis. Along those lines, laparoscopy is not as finesse-based as robotics, plain an simple. Also, even experts can get sloppy because they may have multiple surgeries scheduled on any given day. Rushing does not help when the schedule falls behind. Parenthetically, this is the Achilles heel of "high volume surgeon". Doing a lot of simple cases does not an expert make.

If your pain feels more “pulling,” positional, sharp with stretching/twisting, or tied to certain movements, adhesions may be one part of the puzzle. Unfortunately, adhesions often don’t show up well on routine imaging, so clinicians may use symptom patterns, exam findings, and history to guide next steps rather than relying on a single scan.

Reason #3: Your nervous system may still be on high alert (sensitization)

Sometimes the “why” is less about what’s left behind and more about what your body learned during years of pain.

The 2025 mechanistic review describes how chronic inflammation can promote nociceptive sensitization—essentially turning up pain sensitivity through neuro-immune signaling, inflammatory mediators, and changes in how nerves and the spinal cord process signals. One crucial implication: pain can persist even after lesion removal, because the nervous system pathways that were repeatedly activated don’t necessarily reset immediately (or automatically).

This doesn’t mean “it’s all in your head.” Sensitization is a biological process. It also helps explain why some people have widespread symptoms (fatigue, body pain, headaches) alongside pelvic pain, and why pain relief may require treating more than the pelvis.

(We’ll go deeper on this in the next post in the series: “When Your Nervous System Won’t Stand Down.”)

Reason #4: Overlapping pain conditions can keep pain high—even if pelvic disease improved

One of the most validating findings in recent patient-reported research is that many people with endometriosis don’t just have pelvic pain—they also have other chronic pain conditions that stack together.

In a 2024 cross-sectional survey of women with chronic pelvic–abdominal pain, those who reported endometriosis also reported higher pelvic pain severity and greater day-to-day interference than those without endometriosis. Importantly, participants with endometriosis were more likely to report a higher number of chronic overlapping pain conditions (COPCs), and about 1 in 4 reported three or more overlapping pain conditions. Conditions reported more often alongside endometriosis included fibromyalgia, chronic fatigue syndrome, and temporomandibular disorder (which can affect more than just your jaw and face).

Even more telling: across the whole sample (with or without endometriosis), the more overlapping pain conditions someone had, the worse their pain severity and life impact. That means persistent pain after surgery may reflect a broader pain landscape—not a failed operation.

If you recognize yourself in this, it can be a turning point. Instead of repeating surgeries in search of a single pelvic cause, it may be more effective to screen for and treat overlapping pain drivers alongside pelvic care.

What should you expect for timeline and recovery?

There isn’t one “normal,” but a few patterns can help set expectations:

• Early weeks: it’s common to have postoperative soreness, cramping, and tissue-healing discomfort that gradually improves.
• Months later: if pain is unchanged from pre-op levels, if it initially improved then returned, or if it has changed character (new pulling, burning, nerve-like pain), that’s a signal to reassess rather than “wait it out.”
• Longer term: if sensitization and overlapping pain conditions are involved, pain improvement may require a multi-part plan and can be slower—because you’re retraining a pain system, not just healing an incision.

Practical takeaways: how to talk to your doctor without getting dismissed

Bring your symptoms, timeline, and goals into the conversation. You don’t need to prove your pain—just describe it clearly and ask targeted questions.

Here are focused questions you can use (and reuse):

• “Based on my surgical report, were there areas you couldn’t safely excise or suspected deep disease near bowel/bladder/ureters?”
• “Does my current pain pattern fit adhesions/scar tissue, pelvic floor spasm, nerve pain, or recurrence—and how would we tell the difference?”
• “Can we screen for overlapping pain conditions (like migraine, IBS, painful bladder syndrome, fibromyalgia, TMJ/TMD) that could be amplifying my symptoms?”
• “If imaging is normal, what are the next-step treatments you recommend for persistent pain—pelvic PT, neuropathic pain options, anti-inflammatory strategies, multidisciplinary pain care?”
• “What outcomes should we track—pain days, function, bleeding, bowel/bladder symptoms—so we can tell if the plan is working?”

What to watch for (and document) before your next appointment

Keep it simple: a few notes can dramatically improve the quality of your visit.

Track:

• Whether pain is cyclical (tied to your period/ovulation) or daily
• Whether it’s positional/movement-related (stretching, twisting, bowel movements, intercourse)
• Pain quality (pulling, stabbing, aching, burning, electric)
• Co-symptoms (bowel/bladder flares, headaches, jaw pain, widespread body pain, fatigue)

These clues help your clinician decide whether recurrence, adhesions, sensitization, or overlapping conditions are most likely.

What we still don’t know (and why your experience may differ from someone else’s)

Despite a growing body of research and knowledge base, there are real limitations:

We don’t yet have perfect tools to predict who will have persistent pain after surgery, because pain is influenced by disease location, inflammation, nervous system sensitivity, and coexisting pain conditions—not just what can be seen and removed.

We also need stronger long-term, patient-centered comparisons of surgical techniques. The 2024 review on robotic vs standard laparoscopy highlights that much of the comparative evidence is retrospective and that long-term outcomes (including durable pain relief) are still not well established. So if you’re wondering whether a different surgical platform (robotics or laparoscopy) would have prevented your pain, the current evidence doesn’t support a simple yes/no. However, looking for the the most knowledgeable, experienced surgeon that is not "too busy" to talk to you in depth, is prudent. Again, robotics is technologically vastly superior to laparoscopy on many levels but the surgeon has to be an expert on that platform for best results.

The bottom line

If you’re still in pain after endometriosis surgery, it can be due to recurrence or persistent disease, adhesions/scar tissue, sensitization, and/or overlapping pain conditions—often in combination. The most helpful next step, after ruling out a clearly inadequate or botched surgery, is usually not to argue about whether surgery “worked,” but to broaden the question to: What is driving my pain now, and what’s our plan to treat each driver?

In the next post in this series, we’ll focus on the nervous system piece: why pain can linger even when the pelvis looks “surgically fixed,” and what treatments are commonly used when sensitization is part of the picture.