Endometriosis

Endometriosis can cause a wide range of symptoms, and the experience varies significantly from person to person. Some individuals have severe pain, while others have mild symptoms or no symptoms at all.

Common Symptoms

• Painful periods (dysmenorrhea): Severe menstrual cramps that may begin before bleeding starts and continue throughout the period.

• Chronic pelvic pain: Persistent or recurring pain in the lower abdomen, pelvis, or lower back, even between menstrual periods.

• Pain with intercourse (dyspareunia): Particularly deep pelvic pain during or after intercourse.

• Painful bowel movements: Especially during menstruation, sometimes accompanied by bloating, constipation, or diarrhea.

• Bladder symptoms: Pain with urination, urinary urgency, or bladder discomfort, particularly around menstruation.

• Difficulty becoming pregnant: Endometriosis may contribute to infertility, even in patients without significant pain.

• Other symptoms: Fatigue, abdominal bloating, and occasionally nausea.
  
  

Important Things to Know

• The severity of pain does not necessarily reflect the amount or stage of endometriosis. Even minimal disease can cause significant symptoms.

• Symptoms may initially occur only during menstruation but can become more persistent over time.

• Endometriosis can overlap with other conditions, including adenomyosis, irritable bowel syndrome (IBS), and pelvic floor muscle dysfunction.

• Not everyone with endometriosis experiences symptoms. Some cases are discovered during evaluation for infertility or surgery for another condition.

If painful periods or pelvic pain are interfering with your daily life, further evaluation may be appropriate.

• • Symptoms of Endometriosis (Lora Shahine, MD, video)

  • Endometriosis Warning Signs (Natalie Crawford, MD, video)

Diagnosing endometriosis can be challenging because symptoms overlap with many other conditions, and endometriosis is not always visible on imaging.

How Is Endometriosis Diagnosed?

• Medical history & symptoms: Painful periods, chronic pelvic pain, painful intercourse, and cyclical bowel or bladder symptoms may raise suspicion for endometriosis.

• Pelvic examination: May identify tenderness, nodules, or reduced mobility of pelvic organs, although the examination is often normal.

• Pelvic ultrasound: Can identify ovarian endometriomas (cysts associated with endometriosis) and sometimes deeper endometriosis lesions. Ultrasound also helps evaluate other possible causes of pelvic pain.

• Pelvic MRI: May be recommended when deep endometriosis is suspected, particularly if the bowel, bladder, or other pelvic structures may be involved.

• Laparoscopy: Minimally invasive surgery allows direct visualization of endometriosis lesions and, when appropriate, tissue biopsy for confirmation. Endometriosis can often be treated during the same procedure.
  
  

Do I Need Surgery to Be Diagnosed?

Not necessarily! Endometriosis can often be suspected based on your symptoms, examination, and imaging findings. A clinical diagnosis may be sufficient to begin treatment without undergoing surgery. Laparoscopy with tissue confirmation can establish a definitive diagnosis, but surgery is not required for every patient.

Important Things to Know

• A normal ultrasound or MRI does not rule out endometriosis. Superficial endometriosis lesions are often too small to be detected on imaging.

• The severity of symptoms does not necessarily correlate with the amount of endometriosis present.

• There is currently no reliable blood test that can diagnose or exclude endometriosis.

• Additional testing may be recommended to evaluate other conditions that can cause similar symptoms.

The goal of evaluation is not only to identify possible endometriosis, but also to understand your symptoms and develop an appropriate treatment plan.

• Diagnosing Endometriosis (Informed Health)

Endometriosis is a chronic, estrogen-responsive inflammatory condition. Although there is no definitive cure, treatment can help control symptoms and improve long-term quality of life.

Benefits of Treatment

• Reduce pain and inflammation: Hormonal treatments can decrease menstrual-related inflammation and improve painful periods, chronic pelvic pain, and other symptoms.

• Reduce or eliminate menstrual periods: Continuous hormonal suppression can minimize cyclical pain by reducing or stopping menstrual bleeding.

• Improve quality of life: Effective treatment may improve sleep, daily activities, sexual comfort, and overall well-being.

• Reduce symptom recurrence after surgery: Ongoing hormonal suppression may help decrease the likelihood of pain returning or endometriomas recurring after surgical treatment.

• Limit ongoing disease activity: Hormonal suppression reduces the hormonal stimulation of endometriosis and may help limit inflammation and disease activity over time. Although it cannot guarantee that endometriosis will not progress, controlling symptoms and disease activity may help some patients avoid or delay surgery.

• Consider future reproductive health: Endometriosis can contribute to inflammation, scar tissue (adhesions), and changes in pelvic anatomy that may affect fertility. Treatment decisions should consider future pregnancy goals, although hormonal suppression has not been proven to prevent infertility.
  
  

Why Is Ongoing Suppression Often Recommended?

Because endometriosis is influenced by reproductive hormones, symptoms may return when hormonal treatment is discontinued. For patients who are not actively trying to conceive, long-term menstrual suppression is often an effective strategy for managing symptoms and reducing recurrence. However, treatment does not guarantee that endometriosis will stop progressing, and not everyone requires continuous medication.

What If I'm Trying to Get Pregnant?

Hormonal suppression generally prevents ovulation or otherwise interferes with conception and is not used to improve fertility while actively trying to conceive. If pregnancy is a goal, treatment recommendations may differ depending on your symptoms, age, fertility history, and extent of suspected disease.

Treatment should always be individualized. The goal is to manage symptoms, protect quality of life, and support your reproductive goals while minimizing unnecessary side effects or procedures.

Endometriosis is a chronic condition, and treatment often focuses on reducing pain, suppressing hormonal stimulation of endometriosis, and improving quality of life. Hormonal suppression is a cornerstone of treatment for patients who are not actively trying to conceive. Some medications reduce or eliminate menstrual periods, while others more directly suppress ovarian hormone production. The best treatment depends on your symptoms, medical history, reproductive goals, and preferences. Finding the right approach may require trying more than one option.

Anti-Inflammatory & Pain Medications

These medications can help manage discomfort but do not suppress endometriosis itself.

• NSAIDs (ibuprofen, naproxen): May help relieve menstrual cramps and pelvic pain by reducing prostaglandin production. They are often most effective when started just before or at the beginning of menstruation.

• Acetaminophen (Tylenol): May provide additional pain relief, although it does not directly reduce inflammation.
  
  

Hormonal Birth Control

Hormonal contraception is often a first-line treatment for endometriosis-related pain, particularly for patients who also desire pregnancy prevention. Continuous hormonal suppression is often more effective for menstrual-related pain than allowing regular withdrawal bleeding.

• Combined hormonal contraception: Birth control pills, patches, or vaginal rings can reduce menstrual pain and bleeding. Continuous use, without scheduled hormone-free intervals, may provide additional benefit by reducing or eliminating periods.

• Progestin-only birth control: Options such as progestin-only pills, the contraceptive injection (Depo-Provera), or the hormonal implant (Nexplanon) may help suppress menstrual cycles and improve pain.

• Hormonal IUDs (Mirena, Liletta): Release levonorgestrel directly into the uterus and can significantly reduce menstrual bleeding and cramping. Although they do not consistently suppress ovulation, they may improve endometriosis-associated pain.
  
  

Oral Progestin Therapy

Oral progestins are commonly used to treat endometriosis, particularly when estrogen-containing medications are not appropriate or when additional menstrual suppression is desired. Potential side effects include irregular bleeding, breast tenderness, bloating, mood changes, or acne. These medications may be used long-term when effective and well tolerated.

• Norethindrone acetate (Aygestin): Frequently prescribed daily to suppress menstruation and reduce endometriosis-related pain. Dosing can be adjusted based on symptoms and breakthrough bleeding.

• Medroxyprogesterone acetate (Provera): Another oral progestin that may be used for menstrual suppression, although its effectiveness can vary depending on the dose and regimen.
  
  

GnRH Agonists & Antagonists

For patients with persistent or more severe symptoms, medications that reduce ovarian hormone production may provide additional relief. These treatments create a low-estrogen environment that decreases stimulation of endometriosis. These medications can be effective but may cause hot flashes, vaginal dryness, mood changes, and decreased bone density. Treatment duration is limited for some medications because of bone health and other safety considerations. Your physician will discuss the benefits, risks, and appropriate duration of therapy.

• Elagolix (Orilissa): An oral GnRH antagonist used to treat moderate to severe endometriosis-associated pain. Different doses provide different levels of hormone suppression.

• Relugolix combination therapy (Myfembree): A daily oral medication containing relugolix, estradiol, and norethindrone acetate. It suppresses ovarian hormone production while including low-dose hormones to help reduce certain side effects.

• Leuprolide (Lupron): An injectable GnRH agonist that temporarily suppresses ovarian hormone production. It may be used with add-back therapy to reduce menopausal symptoms and bone loss.
  
  

Pelvic Floor Physical Therapy

Endometriosis-related pain can contribute to chronic tightening and dysfunction of the pelvic floor muscles, even when the underlying endometriosis is being treated. Treatment may include muscle relaxation, stretching, manual therapy, breathing exercises, and strategies to improve pelvic floor coordination. Pelvic floor physical therapy can be an important part of treatment even when endometriosis is the primary diagnosis.

Pelvic floor physical therapy may help with:

• Persistent pelvic pain or muscle tension

• Painful intercourse

• Pain with bowel movements

• Pelvic floor spasms or difficulty relaxing the pelvic muscles
  
  

Other Supportive Treatments

Because chronic pelvic pain often involves multiple contributing factors, additional approaches may be helpful:

• Heat therapy: Heating pads or warm baths may provide temporary pain relief.

• Physical activity: Gentle exercise, stretching, and movement may help improve comfort and overall well-being.

• Pain management strategies: Cognitive behavioral therapy (CBT), mindfulness, and other pain-coping techniques can help reduce the impact of chronic pain on daily life.

• Treatment of overlapping conditions: Irritable bowel syndrome, painful bladder syndrome, pelvic floor dysfunction, and other conditions may require additional evaluation and treatment.

• Specialized pain medications: For selected patients with persistent pain or features of nerve-related pain, additional medications or referral to a pelvic pain specialist may be appropriate.
  
  

What If Medical Treatment Isn't Enough?

If symptoms remain significant despite medical management, additional evaluation or surgical treatment may be appropriate. However, surgery is not always necessary, and many patients successfully manage endometriosis with long-term hormonal suppression and supportive care. Treatment should be individualized, with the goal of achieving meaningful symptom relief while minimizing medication side effects and unnecessary procedures.

• Treating Endometriosis with Medication (Informed Health)

• Decision Aid: Endometriosis Treatment Options (Informed Health)

Surgery may be considered when endometriosis causes significant pain despite medical treatment, when medications are not tolerated or desired, when imaging suggests more extensive disease, or when fertility concerns influence treatment decisions. The goal of surgery is to identify and treat endometriosis while preserving healthy tissue and minimizing risks. However, surgery does not guarantee complete resolution of pain, and endometriosis may recur over time.

Laparoscopic Surgery for Endometriosis

Most endometriosis surgery is performed laparoscopically, using small abdominal incisions and a camera to examine the pelvis. During surgery, endometriosis may appear as superficial implants, deeper nodules, ovarian cysts (endometriomas), or adhesions (scar tissue) involving the pelvic organs.

Common surgical treatments include:

• Excision: Surgically removing endometriosis lesions, including deeper disease when safely possible.

• Ablation: Destroying superficial endometriosis lesions using heat or other energy sources.

• Adhesiolysis: Carefully releasing scar tissue that may restrict the normal movement of pelvic organs.

• Endometrioma surgery: Removing or treating ovarian cysts caused by endometriosis, when appropriate.

The surgical approach depends on the location and extent of disease, symptoms, reproductive goals, and potential risks. Excision is often preferred for deep endometriosis, while either excision or ablation may be appropriate for selected superficial lesions. Surgery involving the ovaries requires particular consideration, since removal of endometriomas can also damage healthy ovarian tissue and potentially reduce ovarian reserve.

When Might a MIGS Specialist Be Recommended?

A minimally invasive gynecologic surgery (MIGS) specialist is a gynecologist with advanced training in complex laparoscopic and robotic surgery. MIGS specialists may work with colorectal surgeons, urologists, or fertility specialists when endometriosis involves multiple organs. Not every patient with endometriosis needs a MIGS specialist. However, consultation can be valuable when more extensive disease is suspected or complex surgical treatment is being considered.

Referral may be especially helpful for patients with:

• Suspected deep infiltrating endometriosis

• Possible bowel, bladder, or ureter involvement

• Large or recurrent ovarian endometriomas

• Extensive adhesions or distorted pelvic anatomy

• Persistent or recurrent symptoms after previous surgery

• Complex surgical needs requiring a multidisciplinary team
  
  

Will Endometriosis Return After Surgery?

Endometriosis is a chronic condition, and symptoms or lesions may return even after successful surgery. For patients who are not immediately trying to conceive, ongoing hormonal suppression is often recommended after surgery to reduce the risk of recurrent pain and endometriomas. Options may include continuous hormonal contraception, oral progestins, hormonal IUDs, or other endometriosis medications. Some patients experience substantial long-term improvement after surgery, while others continue to have pain related to pelvic floor dysfunction, nerve sensitization, or other overlapping conditions.

Is Hysterectomy an Option?

Hysterectomy (removal of the uterus) may be considered for selected patients with severe symptoms who have completed childbearing, particularly when adenomyosis or other uterine conditions contribute to pain. However, hysterectomy alone does not necessarily cure endometriosis, because endometriosis lesions can remain outside the uterus. When appropriate, visible endometriosis should also be addressed during surgery.

An important decision is whether to preserve or remove the ovaries:

• Ovarian preservation: Avoids immediate surgical menopause and its associated health consequences, but endometriosis may remain hormonally active or recur.

• Removal of both ovaries (bilateral oophorectomy): Significantly reduces ovarian estrogen production and may lower the risk of recurrent symptoms, but causes immediate surgical menopause in patients who have not yet reached menopause.

Removing the ovaries before natural menopause can increase the risks of bone loss, cardiovascular disease, and other long-term health concerns. Menopausal hormone therapy (HRT) may be recommended afterward, although treatment requires individualized consideration in patients with a history of endometriosis.

Removing the ovaries is not automatically recommended when performing a hysterectomy for endometriosis. The decision should involve careful discussion of age, disease severity, prior treatments, reproductive goals, and the benefits and risks of surgical menopause.

Choosing the Right Surgical Approach

Surgery should be individualized based on your symptoms, examination and imaging findings, prior treatments, fertility goals, and personal preferences. For patients with complex or recurrent endometriosis, consultation with a MIGS specialist may help clarify surgical options and establish realistic expectations. The goal is meaningful, lasting improvement in symptoms and quality of life while minimizing unnecessary surgical risks.

• • When To Consider Surgery For Endometriosis  (Medical City Dallas, video)

  • Laparoscopic Surgery 

Many people with endometriosis are able to conceive naturally and have healthy pregnancies. However, endometriosis can sometimes make becoming pregnant more difficult, even in patients who have relatively mild symptoms.

How Can Endometriosis Affect Fertility?

Endometriosis may interfere with fertility in several ways:

• Inflammation: Chronic inflammation within the pelvis may affect egg quality, fertilization, or the reproductive environment.

• Scar tissue (adhesions): Endometriosis can cause adhesions that distort pelvic anatomy or interfere with normal movement of the fallopian tubes and ovaries.

• Ovarian endometriomas: Endometriosis-related ovarian cysts may affect healthy ovarian tissue and ovarian reserve.

• Altered pelvic anatomy: More extensive disease can interfere with the ability of the fallopian tubes to capture an egg after ovulation.

The severity of endometriosis does not always predict fertility. Some patients with extensive disease conceive naturally, while others with minimal disease experience difficulty becoming pregnant.

Does Hormonal Suppression Improve Fertility?

Hormonal treatments such as birth control pills, oral progestins, and GnRH medications are effective for managing endometriosis-related pain, but they do not improve fertility while being used to suppress menstrual cycles. These treatments are generally discontinued when actively trying to conceive. There is also no clear evidence that using hormonal suppression beforehand improves future natural pregnancy rates.

Can Surgery Improve Fertility?

Surgical treatment may improve the chances of natural conception in selected patients, particularly when endometriosis affects pelvic anatomy or contributes to infertility. However, surgery is not always necessary or beneficial.

• Removing superficial endometriosis may modestly improve natural pregnancy rates in some patients.

• Surgery for more extensive disease may help restore pelvic anatomy, although fertility benefits are less predictable.

• Surgery involving ovarian endometriomas requires special consideration, because removing these cysts can also damage healthy ovarian tissue and reduce ovarian reserve.

For patients considering in vitro fertilization (IVF), routine removal of endometriomas before treatment is generally not recommended solely to improve pregnancy outcomes. Surgery may still be appropriate for significant pain, concerning imaging findings, or difficulty accessing ovarian follicles during egg retrieval.

When Should I Consider a Fertility Specialist?

If you have endometriosis and are planning pregnancy, it may be helpful to discuss your reproductive goals before deciding on medical or surgical treatment.

Referral to a reproductive endocrinology and infertility (REI) specialist may be appropriate if:

• You have been trying to conceive without success.

• You have known or suspected moderate to severe endometriosis.

• You have ovarian endometriomas or concerns about diminished ovarian reserve.

• You are considering surgery that may affect your ovaries.

• You are interested in fertility preservation or assisted reproductive treatments.

Earlier fertility evaluation may be appropriate for patients with known endometriosis, particularly those age 35 or older or with additional fertility risk factors.

The Bottom Line

Having endometriosis does not mean you cannot become pregnant. Many patients conceive without assistance, while others benefit from fertility treatment or carefully selected surgery. The best approach depends on your age, symptoms, ovarian reserve, extent of disease, and pregnancy goals. Coordinating care between your gynecologist, a MIGS specialist, and a fertility specialist can be particularly helpful when complex endometriosis is present.

• Endometriosis and Infertility (ASRM)

• Endometriosis and Fertility (Brigham and Women's Hospital)

• Fertility & Endometriosis (Natalie Crawford, MD, video)

• How Endometriosis Impacts Fertility (Lora Shahine, MD, video)

Endometriosis is influenced by estrogen, so symptoms often improve after menopause as hormone levels decline. However, endometriosis does not always disappear after menopause, and some patients continue to experience pelvic pain or other symptoms.

During perimenopause, fluctuating hormone levels may contribute to ongoing symptoms. Menopausal hormone therapy (HRT) can sometimes reactivate or worsen endometriosis, although a history of endometriosis does not automatically mean HRT cannot be used.

Treatment should be individualized, particularly for patients with persistent symptoms, a history of extensive endometriosis, or those considering HRT after natural or surgical menopause.

Living with endometriosis can be physically and emotionally challenging, particularly when symptoms affect daily activities, relationships, or fertility.  You don't have to navigate endometriosis alone. Connecting with others who understand the condition, learning about treatment options, and advocating for your needs can be valuable parts of long-term care.

• Endometriosis Foundation of America

• My Endometriosis Team

• Advocating for Your Endometriosis Care (Karen Tang, MD, video)