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What is Endometriosis?




What are the symptoms of endometriosis?


General symptoms of endometriosis can include but are not limited to:

  • Chronic pelvic pain includes lower back pain and pelvic pain.

  • Pain during or after sex.

  • Intestinal pain.

  • Painful bowel movements or painful urination during menstrual periods.

  • Heavy menstrual periods.

  • Premenstrual spotting or bleeding between periods.

  • Infertility not being able to get pregnant.


How would I know if I have endometriosis?

If you think you might have this disease, talk with your health care professional. There are a number of tests a doctor can perform to try to find out if you have endometriosis. Sometimes, imaging tests are used to make a "picture" of the inside of the body, which allows a doctor to locate larger endometriosis areas. The two most common imaging tests are ultrasound, a machine that uses sound waves to make the picture, and magnetic resonance imaging (MRI), a machine that uses magnets and radio waves to make the picture.


What causes endometriosis?





How common is endometriosis?


Is there any age group which is more prone to endometriosis?


Ovarian function is necessary for the development and maintenance of these endometrial implants. Endometriosis is normally not seen before age 15 or after menopause. In recent years, we have seen more patients with endometriosis below the age of 20. This is due to the use of laparoscopy in evaluating women with symptoms suggestive of endometriosis.


Is endometriosis based on a genetic or familial factor?





Why does endometriosis seem to be discussed more in recent years?


The introduction of the laparoscope for more accurate diagnosis of endometriosis has also helped us to diagnose more cases in earlier stages in younger women. The result of this increased attention is that more and more women are now forewarned about the symptoms of the disease.

Is it true that endometriosis is more common in some races?







Are more cases being diagnosed with endometriosis in younger women today?

Yes more cases of endometriosis are being diagnosed right now in a younger age group of women. Twenty-five years ago, the diagnosis was mainly based on severe symptoms and palpable masses in the pelvic area, and was confirmed by laparotomy. Patients were typically in their mid or late 30s. However, with the use of laparoscopy, the typical age at which the diagnosis is being made has dropped significantly. Currently, it is somewhere in the mid to late 20s.

Do you see endometriosis after menopause?


Is endometriosis a disease of modern times?






Although some degree of menstrual backflow occurs almost universally, only those women who are predisposed to having endometriosis will allow the cells to implant in the pelvic area. Patients who have some deficiency in their immunological system, women who have more frequent periods (shorter than 27 days), or women who have longer days of bleeding with their period (more than 7 days) are more prone to develop endometriosis.

Why does the presence of endometriosis cause pelvic pain?

In the early stages of endometriosis, small areas of surface endometriosis tend to rupture, which could produce pelvic irritation and pelvic pain. Another reason for the pain can be the presence of adhesions in the pelvic area which make the pelvic organs rather fixed. Any motion of these organs (e.g., during intercourse), could produce pelvic pain. One other theory for pelvic pain during the menstrual cycle in patients with endometriosis has been the chemical changes that occur in the peritoneal fluid. The sudden onset of severe generalized abdominal pain is highly suggestive of leakage or rupture from an endometrioma into the abdominal cavity.

Can I have endometriosis without having any symptoms?

This does occur in some patients. The symptoms of endometriosis are highly variable. For instance, a patient with very extensive endometriosis may be incapacitated with pain or have very few symptoms. The same variability can be seen in mild endometriosis. Therefore, if the classic symptoms and signs and the physical findings of endometriosis are present in a patient, the diagnosis obviously could be straightforward. However, the absence of symptoms or physical findings does not mean that endometriosis is not present. Infertility is, at times, the only symptom, which is why a work up is necessary in cases of unexplained infertility with diagnostic laparoscopy which will reveal any endometriosis.

What are the characteristics of the pain associated with endometriosis?

Pelvic pain and painful periods in particular are the cardinal symptoms of endometriosis. In the most classic type of endometriosis, the pain usually starts shortly after menarche, which is the first few months right after the start of the period as a teenager. Most patients will attest that they always had pain with their period which eventually got worse as the years went by and increased in intensity and severity. The pain is usually on the sides and often is described by patients to be "a pain deep inside me."

The pain is produced by bleeding and a so-called "miniature period" at the site of endometriosis, which causes swelling of the peritoneum around it, which, in turn, causes pain. Another possible mechanism for the pain could be the chemical changes in the peritoneal fluid (i.e., changes in the prostaglandins which have been postulated to sensitize nerve endings to pain stimuli). However, why some women have painful periods with even a very mild degree of endometriosis cannot be fully understood, especially in view of the fact that other patients with much more extensive disease have much less pain and, in some cases, no pain at all. One other explanation for patients with pain in endometriosis is the involvement of other organs, such as the rectum or colon. Bleeding of the endometriosis around or in the muscle wall of the colon and rectum again causes expansion of this area and associated pain. This causes pressure and some sense of urgency for bowel movements during the menstrual period in some patients, especially if the disease is more extensive and is getting into the lumen of the bowel. It can also cause bloody stools during or prior to menstruation.

Is painful intercourse a symptom of endometriosis?

Painful intercourse (dysparunia) is one of the most common symptoms of endometriosis, especially in the more advanced or severe stages. The pain is described by patients as occurring during deep penetration and also as being deep in the pelvis. Although in its early stages this pain is at the lateral side of the pelvis, soon after it could be anywhere or all over the pelvic area, and can make intercourse unpleasant and miserable for the patient. This may also play a role in subsequent infertility


If the endometriosis has invaded to the rectum or bladder's innermost lining, the mucosa, the patient may have bloody stools or urine during the menstrual cycle when the bleeding occurs in these areas. We must emphasize that these are not very common symptoms of endometriosis. Involvement of these areas is usually seen in extensive or advanced stages of endometriosis, and not many patients progress to these stages today. This is mainly due to our knowledge of endometriosis in recent years and the more liberal use of diagnostic tools, mainly laparoscopy, in the early detection of endometriosis.

I was told that I have uterine fibroids and endometriosis. Does this happen frequently?

Endometriosis can often co-exist with other gynecological problems. These problems could also be a contributing factor in some of the patient's symptomatology (i.e., prolonged and abnormal periods, pelvic pain, pelvic pressure and even infertility). Almost 15 percent of patients with endometriosis have other pelvic pathology, such as uterine fibroids, unrelated to endometriosis.

I have pain all the time and since the pain of endometriosis is usually just prior and during the menstrual cycle, is it possible that I have endometriosis?

Usually, the pain associated with endometriosis is right before or during the menstrual period in the initial stages; however, as the disease progresses, it may occur throughout the cycle. The pain may be acute or chronic. In about half of the patients with severe or extensive endometriosis, the pain is chronic all through the cycle which gets worse right before and during menstruation, and during or shortly after intercourse.

In the past, some clinicians have used pain medications which have been known to be anti-prostaglandin as a test by giving it to the patient and assuming that if they have relief, they have endometriosis. However, this does not appear to be the most valid way of diagnosing endometriosis. In studies, the patient with pelvic pain, painful periods, painful intercourse and infertility has endometriosis unless it is proven otherwise. The best available way at the present time to diagnose endometriosis is a laparoscopy and direct visualization of the lesion.

On pelvic examination, I had a retroplaced uterus and my doctor said I had endometriosis. How common is this?

A uterus tilted backward is not a specific sign of endometriosis; however, when a patient has endometriosis behind the uterus during the years of menstruation, endometrial implants eventually will form and attach adhesions to the uterus and the pelvic wall, which can displace the uterus. A retroverted uterus has been found in 47 percent of patients with documented endometriosis, but in only 17 percent of women without endometriosis. Whether this is a cause or an effect is unknown. However, the experts in the field agree that the presence of a retroplaced, fixed uterus and pelvic pain along with other symptoms of endometriosis definitely deserves further investigation.

I had a hysterectomy and removal of my tubes and ovaries. However, two years later, I had a very painful area in my pelvis and was told that I had endometriosis. Is this possible?

Yes. Sometimes when a total abdominal hysterectomy with removal of both tubes and ovaries is performed, the surgeon cannot remove all of the implants in the pelvic area. When both ovaries are removed, the patient needs replacement of an exogenous hormone, namely estrogen or estrogen and progesterone. These exogenous hormones can stimulate the remaining endometrial implants and cause persistent cyclic bleeding and eventually produce painful nodules of endometriosis in the pelvic area. This is found most commonly in the top of the vaginal area where the uterus has been removed. This can also happen in patients who have a hysterectomy without removal of the ovaries.

Before I had my laparoscopy, I was told I might have endometriosis or a chronic case of pelvic inflammatory disease. How are these different?

A. Chronic pelvic inflammatory disease (PID) has most of the symptoms and physical findings of pelvic endometriosis. Most of the patients with PID have bilateral pelvic adhesions, adhesions around the tubes and ovaries, and they might have a mass in the pelvic area. Since it happens also in younger age groups, these two conditions could be misdiagnosed or could simulate each other very much. These two conditions may also have some similarity in their ultrasound examinations (i.e., a cyst in the ovary as a result of endometriosis could resemble a chronic ovarian abscess). However, if one goes back to the history of these patients with PID, it will usually be found that there is a history of acute pelvic infection, and a history of fever and pain which subsided with antibiotic therapy. Again, for confirming the diagnosis of either of these and differentiating them from each other, diagnostic laparoscopy is necessary and recommended.

What is the best way to diagnose endometriosis?

Direct visualization of the endometrial lesion is currently the best method for definitive diagnosis. This is done by laparoscopy. As we have mentioned again and again, the patient's history will suggest that she might have endometriosis. Pelvic examination will corroborate this diagnosis. However, it is the direct visualization that confirms or verifies the presence of endometriosis. The diagnosis was once done mainly through, or at the time of, laparotomy or major surgery. Today, laparoscopy has replaced other modalities of verifying the diagnosis of endometriosis.

What is laparoscopy?

Laparoscopy is a procedure in which the physician can look directly inside the abdomen and pelvic area and observe the anatomy of the abdominal and pelvic cavity and detect any pathological findings.

In performing a laparoscopy, after induction of anesthesia, a very small incision is made, usually about 1/4 inch, right underneath or inside the folds of the navel. A telescope-like instrument is then inserted which is usually as thin as, and slightly longer than, a pencil. This instrument is attached to a light source which illuminates the pelvic and abdominal cavity. The physician can then look directly inside the cavity and observe the uterus, tubes, ovaries and other pelvic structures. He can then observe any pathological findings, such as pelvic adhesions, ovarian cysts, pelvic endometriosis or any other abnormal conditions.

The diagnosis of endometriosis is not the only use for laparoscopy. It has also been used in the diagnosis of infertile women, especially if the infertility has been longer than two years, or if the infertility screening studies have been normal, or in any patient with so-called unexplained infertility. Another use or indication for laparoscopy has been in other types of pelvic inflammatory disease or patients with pelvic adhesions. Laparoscopy has also been used extensively in the past decade as a tool for the treatment of many pelvic conditions.

What percentage of patients with endometriosis are infertile?

A variety of studies have shown that between 30 and 50 percent of patients who suffer from endometriosis have some degree of reproductive failure. This figure is almost three times higher than the number of women in the general population who have difficulty getting pregnant. In terms of what percent of infertile patients have been found to have endometriosis, again, different studies have shown different figures, but the general consensus is around 15 to 20 percent of infertile patients are suffering to some degree from endometriosis.

In infertile patients with endometriosis, what is causing the infertility?

At the present time, there is not one single factor that can explain the cause of infertility in all patients with endometriosis. Obviously, the cause of infertility in women with severe endometriosis is much easier to understand. In these patients, the extent of the pelvic adhesions, the distortion of the tubes and ovaries, and occasionally because of the destruction of the ovarian tissue, the infertility can be easily explained due to the anatomical distortions that affect the pickup of the egg by the tube and the effect of severe endometriosis of the ovary and ovulation.

However, the cause or relationship of endometriosis in the minimal stage on infertility is not as clear, and what makes matters more fascinating is that we see many women with endometriosis who have normal fertility. However, the fact that 60 to 70 percent of these patients with minimal to mild endometriosis who also have infertility will conceive after treatment, and the fact that the majority of them will conceive within the first year after treatment, is convincing evidence that the presence of endometriosis can interfere with fertility. In a study which was done in a group of patients who received donor semen insemination as a treatment for infertility, it was found that the presence of mild endometriosis decreased their chance of pregnancy. So there is evidence that even minimal endometriosis can interfere with fertility.

The mechanism by which endometriosis could interfere with reproduction has been suggested to be:
  • Interference with normal ovulation by interfering with development of follicular growth and function.

  • Interference with sperm mobility.

  • Interference with the release of eggs, thereby causing inadequate or even no ovulation.

  • Changes in the peritoneal fluid, thereby producing a hostile environment for sperm and ovum.
I was told that I have luteal phase defect. What is this and how common is it?

The luteal phase is the second half of the menstrual cycle. The menstrual cycle traditionally has been divided into two parts. The first two weeks have been called the proliferative phase. This is the time that the ovarian follicle is being developed. The lining inside the uterus is proliferating and getting ready for ovulation and possible implantation.

The second half of the menstrual cycle, or the last two weeks, is characterized by a dramatic increase in the hormone progesterone, which is produced by the part of the ovary which is called the corpus luteum. The presence of progesterone is very critical for proper implantation of the fertilized egg and adequate amounts of this hormone are necessary for implantation.

In patients with endometriosis, several studies have indicated that there is a higher incidence of this luteal phase deficiency or luteal phase defect. Another problem which has recently been described in patients with endometriosis is the so-called luteinized unruptured follicle syndrome. In this case, the patient will ovulate but the egg does not come out of the ovary and it becomes entrapped in the ovary, which can obviously account for infertility in some of the patients with endometriosis.

What are my options for relieving my pain?

Since the pain in women with endometriosis has been attributed to the presence of inflammatory process as a result of the high levels of prostonoids in the endometrial implants, the use of nonsteroidal anti-inflammatory drug (NSAID) that interferes with the production of these chemicals makes quiescence in the patient. Studies have shown that the use of medication such as naproxen sodium (Anaprox-Syntex) can cause substantial pain relief (in over 80 percent of cases) in patients with laparoscopic documented endometriosis. The same results have also been achieved with ibuprofen. I should mention that these medications seem to be more effective when initiated at the first signs of discomfort rather than waiting for severe pain to develop.

The use of codeine-based pain medications, so long as there is close supervision and limited course (a few days each month) has little addiction possibilities and, in many patients, could be extremely helpful in pain relief.

Natural Alternatives for Endometriosis

Bioidentical Progesterone Cream (Progensa 20)


Herbal Formula (ProSoothe)




Evening Primrose Oil

Evening primrose oil (EPO) contains gamma-linolenic acid which is an omega-6 fatty acid. Omega-6 fatty acids decrease inflammation which helps with aberrant endometrial islets which respond monthly to the hormonal changes and become inflammed and shed like normal menstrual tissue.

Recommended Herbs

Endometriosis-Condition Treatments
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