A Simple Guide to Endometriosis

by | May 12, 2025

What Is Endometriosis?

Endometriosis is the presence of endometrial-like tissue (the lining of the uterus) found outside of the uterus. These implants most commonly occur on the ovaries, but can also be found on the pelvic ligaments, the cul-de-sacs behind the uterus, and even on the bladder or bowel. These implants often trigger inflammation, pain, and scar tissue.

Who Is Affected? 

  • About 10% of women of reproductive age have endometriosis.
  • It affects 40% of women with infertility.
  • Up to 80% of women with chronic pelvic pain may have the condition.

Risk Factors:

  • Family history (especially in first-degree relatives)
  • Early menarche (before age 11)
  • Short menstrual cycles (<27 days)
  • Heavy or prolonged periods
  • Low parity (not having children)
  • High consumption of trans fats

Protective Factors:

  • Later onset of menstruation
  • Regular exercise (more than 4 hours/week)
  • Higher number of pregnancies
  • Prolonged breastfeeding
  • Omega-3-rich diet

Why Does It Hurt?

Endometriosis isn’t just about where the tissue ends up—it’s how the body reacts. The implants release inflammatory cytokines (like IL-1 and TNF) which activate prostaglandins and stimulate nerve endings, leading to pain and uterine contractions.

How Does Endometriosis Present?

Symptoms vary from person to person. Some experience debilitating pain, while others have no symptoms at all.

Common symptoms include:

  • Chronic pelvic pain (especially during menstruation)
  • Pain with sex (especially deep penetration)
  • Heavy periods
  • Pain with bowel movements or urination (less common)
  • Infertility

Average age of diagnosis is 28, though symptoms often start in the teen years. On average, there is a 7 to 8-year delay between symptom onset and diagnosis.

Diagnosis

  • Pelvic exam: May reveal tenderness or a retroverted uterus.
  • Ultrasound: Best for detecting ovarian endometriomas, which appear as cysts filled with old blood (“ground glass” appearance).
  • Laparoscopy: The gold standard for diagnosis. It allows direct visualization and potential removal of endometriotic lesions.

Stages of Endometriosis (ASRM Classification)

    • Stage I – Minimal: Few, superficial implants
    • Stage II – Mild: More implants, still superficial
    • Stage III – Moderate: Deeper implants and some adhesions
    • Stage IV – Severe: Multiple deep implants, large cysts, dense adhesions
    Important note: Staging doesn’t always correlate with symptoms. Someone with Stage I may have severe pain, while someone with Stage IV may have none.

Treatment Options

Medical Therapy:

Goal: Manage pain—not necessarily improve fertility.

  • NSAIDs (e.g., ibuprofen, naproxen) for pain relief
  • Hormonal Therapy:
    • Combined oral contraceptives (cyclic or continuous)
    • Progestins (e.g., norethindrone, DMPA, LNG-IUD)
    • GnRH agonists (e.g., leuprolide) with add-back therapy
    • GnRH antagonists (e.g., elagolix)
    • Aromatase inhibitors (in combination with ovarian suppression)

Side Note for Patients: Some medications can cause menopausal-like symptoms such as hot flashes or mood changes. We always try to balance relief with tolerability. Surgical Management:

  • Laparoscopic excision of endometriosis can relieve pain and improve fertility.
  • Endometriomas (ovarian cysts from endometriosis) are best treated with cyst removal rather than drainage.
  • In severe, refractory cases—particularly if childbearing is complete—a hysterectomy with removal of the ovaries may be considered.

Special Procedure: Presacral Neurectomy

  • A surgical option for patients with central pelvic pain who haven’t responded to other treatments. It targets pain transmission from pelvic organs.

Endometriosis and Fertility

Endometriosis can interfere with fertility by causing inflammation, scarring, and distortion of pelvic anatomy. However, not all women with endometriosis are infertile. Many conceive naturally, especially with mild disease. Fertility Treatments:

  • Mild cases: Ovulation induction, intrauterine insemination (IUI)
  • Advanced cases or failed prior treatments: In vitro fertilization (IVF)

Living With Endometriosis

Endometriosis isn’t just a physical condition—it affects emotional well-being, relationships, work, and quality of life. Supportive Tips for Patients:

  • Track your symptoms to identify patterns
  • Use a heating pad for pain relief
  • Prioritize rest and stress management
  • Seek mental health support if needed
  • Connect with others through support groups or online communities