Q: I am a 39 years old woman who has severe pain during periods i.e. for 4 days. I got Mirena inserted 8 months back but of no use. I have enlarged retroverted uterus, ovarian cyst of 3 cm, endometriosis, bleeding for 7 days and spotting throughout the month. I have a scanning and pap smear test done every 6 months. The doctor has suggested surgery, but I am afraid of the side effects or complications in the surgery for endometriosis. I had acupressure treatment too. Please suggest.

A:Your history is not very clear. I wonder why you are having smears so often (every six months!). Pap smear is a screening method for identifying precancerous cells in the cervix. If the smear is normal, it need not be repeated so often. It may be repeated after 3 years. If it is not normal, further approach would depend on the type of abnormality identified. Abnormal smear does not give you heavy periods or pain during periods. Pain during your periods could be because of endometriosis - which you seem to have. The gold standard method of diagnosing it is by laparoscopy. If you have an experienced laparoscopic surgeon, he can treat it at the same time. Endometriosis in the ovary can present as a cyst (endometrioma). This can also be treated effectively by laparoscopic approach. Other condition in which pain is associated with heavy bleeding is adenomyosis - a condition where your lining of uterus (womb) encroaches in the body of the womb. If Mirena has not helped, then one may need hysterectomy (removal of uterus). This is obviously quite a radical approach but one must be sure that the symptoms are severe enough to warrant this type of surgery (and of course if you have completed your family). If this is not a suitable option for you, it may mean you can be managed with more conservative approach, which will mean taking painkillers during your periods. The other approach to get rid of the pains is by taking combined oral contraceptive pills. You can take the pills back to back (without taking the 7 day break which manufacturer recommend). Take it for 3 months and then take a break i.e. pill free period when you should get periods. If these periods are painful and heavy, you may take mefenamic acid 500 mg. and tranexamic acid 1 gram, both three times a day.