As a women’s health practitioner, I meet so many women who’ve spent years wondering if their pain is “just bad periods” or something more. If that sounds familiar, you’re not alone. Endometriosis is one of the most misunderstood and underdiagnosed conditions in reproductive health, even though it affects an estimated one in ten women of reproductive age.
Endometriosis is a chronic inflammatory condition that occurs when tissue similar to the uterine lining grows outside the uterus, often on the ovaries, fallopian tubes, or pelvic cavity. These growths can trigger pain, inflammation, and sometimes challenges with fertility and pregnancy. Because symptoms often mimic other issues like irritable bowel syndrome or pelvic infections, diagnosis can take, on average, nearly a decade. In fact, almost 60% of women see more than three gynecologists before finally receiving a diagnosis, typically after seven years of unanswered symptoms.
The good news? Awareness, better testing, and a more holistic approach to fertility and hormone health are changing the way we understand and manage this condition.
RELATED: Inflammation and fertility: How it impacts pregnancy & IVF
What are the first signs of endometriosis?
For many, the earliest clue is pain that feels disproportionate to a normal period. Cramping that forces you to miss work, pain during intercourse, or discomfort that radiates into the lower back or legs may all signal something more than typical menstrual discomfort. Endometriosis can also cause heavy bleeding, fatigue, digestive issues like bloating or constipation, and pain during bowel movements or urination.
One of the most challenging realities is that the severity of symptoms rarely correlates with the severity of disease. Some women have extensive endometriosis with little to no pain, while others experience debilitating symptoms despite minimal visible lesions. This mismatch is a major reason endometriosis is often missed or minimized for years.
And because menstrual pain is often normalized, these symptoms are frequently dismissed or misinterpreted as “just how it is.” But when pain interferes with your daily life, it’s not normal and it deserves attention.
How do doctors diagnose endometriosis?
Diagnosis is often a long road, partly because there’s no single, noninvasive test that can confirm the condition. Most evaluations begin with a pelvic exam, though it’s important to note that even experienced surgeons rarely feel true “nodularity” on exam, it’s present only in a small minority of cases. Ultrasound is usually the first imaging study ordered and can identify ovarian endometriomas, but it often fails to detect most forms of endometriosis. An ultrasound being “normal” tells us almost nothing. MRI may help identify deep or advanced-stage disease, but it is most useful when endometriosis has progressed significantly.
The true gold standard remains laparoscopic surgery with excision, which allows direct visualization and removal of lesions. This is also the only way to stage disease accurately. When choosing a surgeon, it’s essential to seek out someone trained specifically in endometriosis surgery, ideally an OB-GYN who specializes in minimally invasive gynecologic surgery (MIGS).
Because many women with endometriosis also have adenomyosis and/or fibroids, it’s critical to choose a surgeon capable of addressing all conditions in the same procedure. Operating on each separately dramatically increases recovery time and surgical risk.
Research is ongoing into blood-based biomarkers like CA-125, microRNAs, and inflammatory cytokines, but none are yet reliable enough for routine use. The absence of a quick diagnostic test continues to contribute to the long delay between symptom onset and treatment.
When should you ask your doctor about testing?
If you’ve ever been told your pain is “just part of being a woman,” it might be time to advocate for further evaluation. Period pain that disrupts your routine, pain during or after sex, bowel or bladder pain that coincides with menstruation, or persistent fatigue and digestive symptoms all warrant a closer look.
Keeping a detailed record of your symptoms like when they happen, how severe they are, and what helps, can provide valuable context for your provider. If you feel unheard, don’t hesitate to ask for a referral to an OB-GYN with expertise in endometriosis or a reproductive endocrinologist who understands the intersection between endometriosis and fertility.
Above all, the most important diagnostic tool is listening to the patient. Endometriosis is one condition where your lived experience is often more telling than any imaging.
How does endometriosis impact fertility and pregnancy?
Endometriosis is one of the leading causes of infertility, though its impact varies widely. Some women conceive naturally, while others struggle due to inflammation, scarring, or blocked fallopian tubes. Endometrial tissue outside the uterus can alter pelvic anatomy and create an inflammatory environment that affects egg quality, sperm motility, and implantation. In more severe stages, adhesions can distort the ovaries and tubes, making fertilization difficult.
The good news is that fertility treatments have advanced significantly. Surgical removal of endometriosis lesions can improve spontaneous pregnancy rates, especially in mild or moderate disease. In more complex cases, in vitro fertilization (IVF) often bypasses the mechanical barriers created by scarring, with success rates comparable to women without endometriosis when managed carefully.
For those not ready to conceive but concerned about future fertility, egg freezing offers an additional layer of protection. Studies also show that women with endometriosis who do become pregnant often have healthy pregnancies, though close monitoring for preterm labor or placenta previa is sometimes recommended.
RELATED: How to prepare for IVF & egg freezing: 5 clinically backed strategies to improve egg quality
Can endometriosis come back after surgery?
Unfortunately, endometriosis behaves like a chronic condition, and recurrence is common. Research suggests that up to half of women experience some return of symptoms within five years of surgery. The risk depends on age, the extent of disease, and whether hormonal suppression is used afterward.
Even with excellent excision surgery, recurrence is possible because surgeons can only remove lesions visible to the naked eye. Endometriosis also exists microscopically, which is why postoperative hormonal suppression is critical for anyone not actively trying to conceive. These therapies help keep microscopic lesions dormant and reduce inflammation over time.
Lifestyle factors also play a role; maintaining a nutrient-dense, anti-inflammatory diet and managing stress may help reduce inflammation and improve long-term outcomes.
RELATED: The fertility-boosting diet: Mediterranean Diet for fertility
What treatments are available for endometriosis?
Treatment should always be tailored to your goals whether that’s pain relief, fertility, or both. For symptom control, nonsteroidal anti-inflammatory drugs (NSAIDs) and hormonal therapies remain first-line options. Hormonal treatments such as birth control pills, progestins like dienogest, or the levonorgestrel IUD work by suppressing the hormonal fluctuations that feed endometriotic tissue. In more severe cases, GnRH agonists or antagonists can induce a temporary “medical menopause” to reduce symptoms, often paired with low-dose “add-back” therapy to minimize side effects.
For those seeking fertility or when pain persists despite medication, laparoscopic excision surgery can remove visible lesions and restore pelvic anatomy. Many patients benefit most from a comprehensive approach which combines surgery, hormonal regulation, physical therapy for pelvic pain, and lifestyle interventions such as an anti-inflammatory diet, exercise, and stress management. In rare, refractory cases, hysterectomy may be considered, but only after careful discussion, especially for women who still wish to conceive.
What happens if endometriosis is left untreated?
Untreated endometriosis can lead to chronic pain, worsening inflammation, and a decline in fertility potential over time. As adhesions form and the disease progresses, pelvic organs may become scarred which can complicate both natural conception and surgical outcomes.
Beyond physical symptoms, the emotional toll is significant as depression, anxiety, and reduced quality of life are all common in women living with unmanaged endometriosis. Early recognition and proactive management can help preserve fertility, minimize long-term damage, and improve day-to-day well-being.
How to advocate for yourself
Endometriosis care has improved, but patient advocacy remains crucial. If you suspect something is wrong, trust your intuition. Document your symptoms, ask pointed questions, and seek specialists who take your pain seriously. Endometriosis is real, it’s common, and it’s treatable, but it often requires persistence and partnership with the right healthcare team.
A note from WeNatal on understanding Endometriosis
If any part of this article feels familiar, please know you’re not alone. Endometriosis is far more than a painful period, it’s a chronic inflammatory condition that can affect your daily life, hormones, and fertility. And while getting answers can take time, there are effective ways to manage symptoms, support your fertility, and feel more in control of your health.
At WeNatal, we believe that informed, empowered women make the best decisions for their bodies. Alongside proper medical care, nourishing your system with the right nutrients can help calm inflammation and support reproductive health. That’s why so many in our community rely on essentials like WeNatal Omega DHA+, a clean, science-backed source of anti-inflammatory omega-3s that supports hormone health, egg quality, and overall well-being.
Wherever you are on your endometriosis or fertility journey, we’re here with evidence-based guidance from clinical experts, thoughtful nutrition support from our team of dietitians, and a reminder that you deserve to feel heard, and supported, every step of the way.
References
Cooper KG, Bhattacharya S, Daniels JP, et al. Preventing recurrence of endometriosis-related pain by means of long-acting progestogen therapy: the PRE-EMPT RCT. Health Technol Assess. 2024;28(55):1-77. doi:10.3310/SQWY6998
Greene R, Stratton P, Cleary SD, Ballweg ML, Sinaii N. Diagnostic experience among 4,334 women reporting surgically diagnosed endometriosis. Fertil Steril. 2009;91(1):32-39. doi:10.1016/j.fertnstert.2007.11.020
Zondervan KT, Becker CM, Missmer SA. Endometriosis. N Engl J Med. 2020;382(13):1244-1256. doi:10.1056/NEJMra1810764
