For millions of women worldwide, monthly period pain is a debilitating reality that goes far beyond normal menstrual cramps. It is a pain that can cause them to miss school, work, and social events, a pain that is too often dismissed by society and even by healthcare providers as being “just part of being a woman.” In many of these cases, the underlying cause of this suffering is endometriosis, a common, chronic, and often painful inflammatory disease. It is crucial for women to understand that the pain of endometriosis is real, physical, and deserves to be taken seriously. While there is currently no cure, a correct diagnosis is the first and most important step toward accessing effective treatments that can manage the pain, address fertility challenges, and significantly improve quality of life.

Endometriosis is a condition in which tissue that is similar to the lining of the uterus, known as the endometrium, grows outside of the uterus. These out-of-place growths are called endometrial implants or lesions. They are most commonly found within the pelvic cavity, affecting organs such as the:

• Ovaries
• Fallopian tubes
• The outer surface of the uterus
• The ligaments that support the uterus
• The lining of the pelvic cavity (the peritoneum)

In rarer cases, these lesions can be found on the bowel, bladder, and even in distant locations like the diaphragm or lungs.

The core problem in endometriosis is that these misplaced patches of tissue behave just like the true endometrium inside the uterus. They respond to the monthly hormonal cycle. Each month, they thicken, break down, and bleed. However, unlike the menstrual blood from the uterus that has a path to exit the body, this internal bleeding has nowhere to go. This trapped blood is a powerful irritant to the surrounding tissues, triggering a significant inflammatory response.

A helpful analogy is to think of the lining of your uterus as a patch of “specialized garden soil” inside a pot.

• Every month, this soil prepares for a seed to plant. If no seed arrives, the soil sheds and exits the pot (your period).
• In endometriosis, it is as if seeds of this special soil have been scattered outside the pot, landing on the surrounding patio and furniture (the ovaries, pelvic walls, and other organs).
• Every month, these misplaced patches of soil still follow your body’s hormonal instructions. They thicken and then try to shed, but they are trapped.
• This internal bleeding creates a recurring, localized inflammatory reaction, like a small chemical burn. This chronic inflammation is what causes the deep, persistent pain of endometriosis. Over time, it can also lead to the formation of scar tissue, known as adhesions, which can bind organs together, and the development of blood-filled cysts on the ovaries, called endometriomas.

In my experience, many women endure years of painful periods before finally being diagnosed with endometriosis, often dismissed as “normal cramps” until fertility becomes a concern.

The exact cause of endometriosis is still unknown. It is a complex disease, and researchers believe it likely results from a combination of several different factors. The leading theories include:

• Retrograde Menstruation: This is the most well-known theory. It suggests that during menstruation, some of the menstrual blood containing endometrial cells flows backward through the fallopian tubes and into the pelvic cavity, instead of out of the body. These displaced cells then implant on the pelvic organs and begin to grow. While most women experience some degree of retrograde menstruation, it is thought that in women who develop endometriosis, a faulty immune system fails to clear away these cells.
• Immune System Dysfunction: It is clear that the immune system plays a key role. In women with endometriosis, the immune system may not only fail to recognize and destroy the out-of-place tissue but may also contribute to the inflammatory process that drives the disease.
• Coelomic Metaplasia: This theory proposes that the cells lining the pelvic organs have the ability to transform into endometrial-like cells under certain conditions.
• Genetics: Endometriosis has a strong genetic component and clearly runs in families. A woman with a first-degree relative (mother or sister) with the condition has a significantly higher risk of developing it herself.

Clinically, I’ve seen theories range from retrograde menstruation and coelomic metaplasia to immune dysfunction, though the exact cause remains multifactorial and poorly understood.

A woman develops endometriosis due to a combination of genetic predisposition and other, not yet fully understood, factors. It is not contagious and cannot be acquired from another person.

While the exact cause is not known, several factors are associated with an increased risk of developing the condition:

• Family History: Having a mother, sister, or daughter with endometriosis is the strongest risk factor.
• Menstrual History: Starting your period at an early age (before age 11), having short menstrual cycles (less than 27 days), or having heavy periods that last longer than seven days.
• Never Having Given Birth: Pregnancy appears to have a protective effect.
• Uterine Abnormalities: Any medical condition that obstructs the normal flow of menstrual blood out of the body can increase the risk.

In my experience, most patients don’t do anything to “get” endometriosis, it often develops silently over years, with symptoms becoming apparent in late adolescence or early adulthood.

The symptoms of endometriosis can vary widely from one person to another. It is crucial to understand that the severity of a woman’s pain does not correlate with the extent or stage of her disease. A woman with a few small implants may experience debilitating pain, while another with severe, widespread disease may have few symptoms.

The hallmark symptom of endometriosis is pelvic pain, particularly associated with the menstrual cycle.

• Severe Dysmenorrhea: This is more than just normal period cramps. It is a severe, debilitating pain that can begin before the period starts and last for several days.
• Chronic Pelvic Pain: A persistent, dull, aching, or cramping pain in the lower abdomen or back that is present even when not menstruating.
• Dyspareunia: Deep pain during or after sexual intercourse.
• Pain with Bowel Movements or Urination: This is especially common during menstrual periods, as the endometrial implants on the bowel or bladder become inflamed.
• Heavy Menstrual Bleeding (Menorrhagia) or bleeding between periods.

Other common symptoms include:

• Infertility: Endometriosis is a leading cause of infertility. It is estimated that up to half of all women with infertility have endometriosis.
• Gastrointestinal Issues: Symptoms that mimic irritable bowel syndrome (IBS), such as bloating, diarrhea, and constipation, especially during menstruation.
• Fatigue: A profound and persistent sense of exhaustion.

Clinically, I always consider endometriosis in women with cyclical pelvic pain unresponsive to standard treatments, especially if symptoms worsen over time.

The journey to an endometriosis diagnosis is notoriously long and frustrating for many women, with an average delay of seven to ten years from the onset of symptoms. This is because the symptoms are often normalized or misdiagnosed as other conditions. A diagnosis requires a high index of suspicion from a healthcare provider, usually a gynecologist.

1. Medical History and Pelvic Exam: The diagnostic process begins with a detailed discussion of your symptoms, particularly the nature and timing of your pain. During a pelvic exam, a doctor may be able to feel areas of tenderness, nodules, or scarring behind the uterus.
2. Imaging Studies: Imaging can be helpful for identifying larger endometriomas or deep infiltrating disease, but it cannot rule out endometriosis.
   • Pelvic Ultrasound: A transvaginal ultrasound is the best initial imaging test. It is very effective at identifying ovarian cysts, including endometriomas (often called “chocolate cysts” due to their appearance).
   • Magnetic Resonance Imaging (MRI): An MRI can provide more detailed images of the pelvic organs and can be useful for mapping out the extent of deep, invasive endometriosis before surgery.
   • It is essential to know that a normal ultrasound or MRI does not rule out endometriosis. These scans cannot see the small, superficial implants or adhesions that cause most of the pain.
3. Laparoscopic Surgery: The only way to definitively diagnose endometriosis is through a laparoscopy.
   • This is a minimally invasive surgical procedure performed under general anesthesia.
   • A surgeon makes a small incision in the abdomen and inserts a thin, lighted tube with a camera (a laparoscope) to look directly inside the pelvic cavity.
   • This allows the surgeon to visualize the endometrial implants, which can appear as red, blue, black, or clear lesions, as well as any scar tissue.
   • During the laparoscopy, the surgeon will take small tissue samples (biopsies) of the suspected lesions, which are then sent to a pathologist to be examined under a microscope to confirm the diagnosis.

In my experience, diagnosis is often delayed, averaging 7–10 years from symptom onset due to normalization of menstrual pain and overlap with other pelvic disorders.

There is currently no cure for endometriosis. Treatment is focused on managing the symptoms primarily pain and infertility and improving quality of life. The treatment plan is highly individualized and depends on the severity of the symptoms, the extent of the disease, and the patient’s family-planning goals.

1. Pain Management

For mild pain, over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, can be helpful.

2. Hormonal Therapies

This is the mainstay of medical management for endometriosis-related pain. The goal is to suppress the menstrual cycle, which prevents the endometrial implants from bleeding and growing, thereby reducing inflammation and pain.

• Combined Oral Contraceptives (Birth Control Pills): Often used continuously to skip periods altogether.
• Progestin-Only Therapies: These can be taken as pills, an injection, or through a progestin-releasing intrauterine device (IUD).
• GnRH Agonists and Antagonists: These are powerful drugs that work by inducing a temporary, reversible menopause. They are very effective at reducing pain but are typically used for short periods due to side effects.

3. Surgical Treatment

For women with severe pain or infertility, or those who do not respond to hormonal therapies, surgery is often the next step.

• Laparoscopic Excision Surgery: This is considered the gold standard for the surgical treatment of endometriosis. An expert surgeon uses the laparoscope to meticulously cut out (excise) and remove as much of the endometrial implants, cysts, and scar tissue as possible. Excision surgery has been shown to be more effective for long-term pain relief than older methods that just burned the surface of the lesions (ablation).

4. Hysterectomy

Surgical removal of the uterus (hysterectomy), often with the removal of the ovaries (oophorectomy), is considered a last resort. It is reserved for women with severe, debilitating disease who have completed their childbearing and have not found relief with other treatments. It is not a guaranteed cure, as any endometrial implants left behind can still cause pain.

Clinically, I’ve found that combining medical and surgical management often yields the best long-term outcomes, especially in cases involving deep infiltrating endometriosis.

Endometriosis is a common, chronic, and often painful inflammatory disease that affects millions of women during their most productive years. It is crucial to reject the outdated notion that debilitating period pain is normal. The pain of endometriosis is real, and it deserves a serious and compassionate medical evaluation. While the diagnostic journey can be long, a definitive diagnosis through laparoscopy is the key to understanding the cause of the symptoms. Although there is no cure, endometriosis is a manageable condition. Clinically, early recognition and personalized care plans make a meaningful difference especially for young women navigating chronic pain, fertility concerns, and emotional distress.

1. The American College of Obstetricians and Gynecologists (ACOG). (2021). Endometriosis. Retrieved from https://www.acog.org/womens-health/faqs/endometriosis
2. Endometriosis Foundation of America. (n.d.). What is Endometriosis? Retrieved from https://www.endofound.org/endometriosis
3. The Mayo Clinic. (2023). Endometriosis. Retrieved from https://www.mayoclinic.org/diseases-conditions/endometriosis/symptoms-causes/syc-20354656