Endometriosis: Symptoms | Diagnosis | Treatment

Endometriosis is a chronic medical condition that is characterized by growth of endometrium-like tissue outside the uterus. Endometrium is the inner lining of the uterus (womb) that usually sheds away every month causing Menstruation in women that are in child bearing age.

Layers of the Uterus showing Perimetrium, Myometrium and Endometrium.
Uterus layers

This tissue causes intense pain around the menstrual period because it responds to hormonal changes the way Endometrium in the uterus responds. There is a direct link between Endometriosis and infertility as people with endometriosis also suffer Infertility.

The exact cause of endometriosis is not fully understood, but several factors such as hormonal imbalances and genetic predisposition are thought to play a role. It is estimated that about 2% to 10% of women are affected by endometriosis, that is a huge number on a global scale.

How Endometriosis Occurs?

The inner lining of the uterus, called the endometrium is responsible for menstrual blood that women see every 21 to 28 days of the menstrual cycle. This happens after there was ovulation and no fertilization took place.

In endometriosis, the endometrium is implanted outside the uterus. It can be in the fallopian tubes, bladder, intestines or cervix.

Location of Endometrial Tissue in endometriosis is outside the uterus
Location of Endometriosis

Even though it is outside the uterus, it still responds to the changes in the hormones that happen during menstrual cycle.

Signs and Symptoms of Endometriosis

The Three classic symptoms of Endometriosis are Dysmenorrhea (not to be confused with Amenorrhea), Dyspareunia and Infertility.

For Dysmenorrhea, the pain is midline lower abdominal or pelvic pain that precedes or occur during menses monthly. It is severe and forces the person to take something for pain and stop their normal activities. They usually miss work or school due to Period pains. The pain may progress to chronic pelvic pain if it lasts>6 months.

Dyspareunia is pain during sexual intercourse, which leads to woman avoiding intimacy in her relationships.

There may also be waist ache, increased urination frequency and urgency. Some people have Urinary urge incontinence. Pain during exercise and vomiting is also common.

Most women (as much as 50% of infertile women) with endometriosis cannot get pregnant because the Endometrium tissue where the implantation of the fertilized egg is outside the uterus.

Causes And Risk factors

There is no known direct cause of Endometriosis. There are multiple factors that increase the risk and contribute to the development of endometriosis. These factors include:

  • Delayed childbearing: Getting pregnant at later age is a risk factor according to some studies
  • Early Menarche: Staring menstruation at an early age of less than 13 years is also a risk factor.
  • Nulliparity: Not having a child
  • Long duration of Menstrual flow: Menstrual flow that lasts more than 7 days every month increases risk of retrograde flow of menstrual tissue especially if they are heavy.
  • Family History: Having a first degree relative with Endometriosis is a risk factor as there is a genetic link associated with the condition.


Endometriosis diagnosis is made through careful history and physical examination. Laparoscopy is minimally invasive and done to visually identify where the endometrial tissue is located.

Sometimes there is misdiagnosis and eventually delayed treatment of endometriosis since the symptoms are vague and non-specific. Most clinicians confuse it with Pelvic Inflammatory Disease (PID) or bladder infection due to the shared symptoms with the two medical conditions.

Additional tests such as Ultrasound of the pelvis and reproductive system is done to exclude other causes of pelvic pain. If a tissue is visible, a biopsy may be done to confirm endometriosis. It is not a Requirement.

Treatment and Management

The treatment approach of endometriosis involves pelvic pain management and suppression of Ovarian function with drugs. If such treatment is not working, Surgery is done to remove the uterus (Hysterectomy) and even the ovaries plus the Fallopian Tubes.

For pain, Nonsteroidal Anti-Inflammatory Drugs (NSAIDS) such as Ibuprofen 400mg oral every 8 hours, or Naproxen 250mg oral 8 hourly. NSAIDs should be taken with food as they cause Stomach Ulcers.

NSAIDs are used in combination with Combined Oral Contraceptives (COCs) such as OVRAL® for 6 months to supress ovarian function. Sometimes Medroxyprogesterone 30mg oral daily for at least 3 months is used.

Gynaecologist involvement is important to address other causes of Infertility.

Hysterectomy is reserved for patients who have severe form of the disease and have completed childbearing.

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