Understanding Endometriosis: Symptoms, Diagnosis & Treatment

Endometriosis is a condition in which tissue similar to the lining of the uterus grows outside the uterus — on the ovaries, fallopian tubes, pelvic lining, and occasionally elsewhere. It affects approximately 1 in 10 women of reproductive age, yet the average time from first symptoms to diagnosis is still 7–10 years. Understanding endometriosis starts with recognising that it is not just "bad periods."

Symptoms to Watch For

The hallmark symptom of endometriosis is pelvic pain — but not all pain is endometriosis, and not all endometriosis causes pain. Common presentations include:

• Painful periods (dysmenorrhoea) that worsen over time and are not adequately controlled by standard painkillers
• Deep pain during or after intercourse (dyspareunia)
• Pelvic pain outside of menstruation
• Pain on opening the bowels or urinating during a period
• Heavy or irregular periods
• Difficulty conceiving
• Fatigue, bloating, and nausea around the time of a period

Some women have severe disease with minimal symptoms; others have mild disease with debilitating pain. The stage of endometriosis does not reliably predict the level of pain or the degree of fertility impact.

How Is Endometriosis Diagnosed?

Endometriosis cannot be definitively diagnosed from symptoms or even from ultrasound alone, though a skilled sonographer can identify endometriomas (ovarian cysts filled with old blood) and deeply infiltrating lesions. The gold standard is laparoscopy — a minimally invasive surgical procedure that allows direct visualisation of the pelvis and, if abnormal tissue is seen, biopsy for histological confirmation.

Given the surgical nature of diagnosis, the current clinical approach is to treat suspected endometriosis empirically (with hormonal therapy or at the time of surgery) without delaying on the basis of awaiting laparoscopic proof in straightforward cases. However, in women who are trying to conceive, or in whom lesions affecting the ovaries or tubes are suspected, laparoscopy and surgical treatment often go together.

Endometriosis and Fertility

Endometriosis impairs fertility through several mechanisms: distortion of pelvic anatomy from adhesions, damage to ovarian tissue (particularly from endometriomas), impaired egg quality, and an inflammatory environment hostile to implantation. The degree of fertility impact depends on disease extent, location, and the woman's age and ovarian reserve.

Surgical removal of endometriomas and adhesions can improve natural conception rates and IVF outcomes in selected patients, but must be balanced against the risk of damaging healthy ovarian tissue. This is a nuanced decision best made after a thorough specialist assessment.

Treatment Options

Medical management with hormonal therapy (combined pill, progestins, GnRH analogues) suppresses the growth of endometriotic implants and provides effective pain relief, but is not suitable when trying to conceive.

Laparoscopic surgery to excise or ablate endometriotic lesions, drain and remove endometriomas, and release adhesions can significantly reduce pain and improve fertility. Excision (cutting out the lesion) is generally preferred over ablation (burning) as it allows histological confirmation and has lower recurrence rates.

Assisted reproduction — IUI for mild disease with patent tubes, IVF for moderate-severe disease or when other factors are present — offers effective pathways to pregnancy for women whose natural fertility is compromised.

If you have been experiencing symptoms that sound like endometriosis — or have already been diagnosed and are now thinking about fertility — a specialist consultation is the right next step.