The uterus, or womb, is where a fetus grows in a person's body when they are pregnant. The uterus is lined with tissue known as the endometrium, which is key for implantation and growth of a fetus and the placenta. The endometrium is critical to a healthy pregnancy.

When someone of reproductive age is not pregnant, that tissue, along with some blood and mucus, sheds each month. This process is known as menstruation, or a period.

For people with a condition called endometriosis, tissue that is similar to the lining of the uterus grows in other places in their body, including:

• On the ovaries
• On the fallopian tubes, which carry eggs from the ovaries to the uterus
• Behind the uterus
• On the tissues that hold the uterus in place
• On the bowels or bladder

When this tissue grows in other places in the body, it can cause inflammation, bleeding, pain or irritation, and other complications.

Who is affected?

Endometriosis can affect anyone who has a period. Endometriosis is common. It occurs in about 10% of women of reproductive age.

What are some risk factors?

• Periods that started at an early age (before age 11)
• Short monthly cycles (fewer than 27 days)
• Heavy periods that last more than 7 days
• Having other family members with endometriosis

What are the symptoms?

The main symptoms of endometriosis are pelvic pain and infertility or problems getting pregnant. This pain can happen anytime and is usually worse during menstruation. Other common symptoms include:

• Extreme lower abdominal pain or bloating
• Low back pain
• Pain with bowel movements or urination
• Nausea, vomiting, or feeling lightheaded
• Heavy periods or spotting in between periods
• Pain during sex
• Fatigue

Those with endometriosis may have some or many of these symptoms. Because endometriosis can be difficult to diagnose, be sure to discuss all of your symptoms with your health care provider to make sure you are diagnosed correctly.

How is endometriosis diagnosed?

First, a health care provider will take a full medical history and give a complete physical and medical exam. They will do this before performing a surgery, which is the only way to diagnose endometriosis.

The most common type of surgery to diagnose endometriosis is called a laparoscopy. In this surgery, a surgeon uses a tiny camera attached to a thin tube (called a laparoscope) to see inside the uterus, fallopian tubes, ovaries, and bladder and around the intestines. Sometimes a small sample of tissue, called a biopsy, is taken during surgery to confirm the diagnosis.

Doctors can also use imaging techniques such as an ultrasound or magnetic resonance imaging (MRI) to help diagnose the condition.

How is endometriosis treated?

Although endometriosis can’t be cured or prevented, it can be treated.

Certain medications that contain hormones, including pills, injections, or nasal spray, can help lessen pain and bleeding. However, symptoms can come back if the medicine is stopped. Over-the-counter pain medication may also be helpful.

Surgical treatments, including laparoscopies and laparotomies, to remove small sections of scar tissue are also available. A laparotomy is a more invasive surgery, where a cut is made in the abdomen to explore or remove scar tissue. Surgeons may also cut nerves in the pelvis to help with endometriosis pain.

If you suspect you may have endometriosis, talk to your doctor or gynecologist. They can review your medical history, discuss your symptoms with you, and help with diagnosis and potential treatment.

A mother's perspective

"How do you measure pain when no one talks about it?"

"If you have pain and other symptoms of endometriosis, don't downplay your symptoms."- Suzanne Chutchian

That's what Suzanne Chutchian, a licensed clinical social worker and therapist, remembers about her endometriosis before she got treatment.

Endometriosis happens when tissue similar to the lining in a woman's uterus grows in other parts of the body. It can cause heavy bleeding and severe back and abdominal pain during a woman's menstrual cycle, or period. It can also cause intestinal problems and infertility.

Suzanne recalls trying to walk up the stairs at Boston University when she was 27 years old.

"I couldn't do it—the pain was horrible," she says. "My friend told me that menstrual cramps shouldn't prevent me from climbing stairs."

That's when Suzanne decided to discuss her symptoms with a gynecologist, a doctor who specializes in women's health.

A hereditary condition

Before getting help, Suzanne tried to manage her pain with over-the-counter pain relievers like aspirin and ibuprofen. She also used hot-water bottles to help ease her stomach cramps.

Her condition had a big impact on her daily life. In addition to painful menstrual cramps, she also had bad digestive pain and unpredictable bowel movements during her period.

Suzanne's mother also had endometriosis. But it wasn't something that was discussed much back then, so Suzanne, like many women, didn't know what to do about it.

"My mother thought it was somewhat normal to have pain, but she still encouraged me to seek treatment for it," she says.

Two options

When Suzanne finally discussed her pain and other challenges with her gynecologist, he gave her two options: laparoscopic surgery or pain killers.

She chose laparoscopic surgery, which confirmed that she indeed had endometriosis and treated it.

"After the surgery, I had no pain at all, and no stomach or bowel pain," she says. "I had freedom! I could do anything I wanted to do."

Pregnancy issues

Because endometriosis can produce scar tissue in the pelvis, it can be difficult for women to become pregnant. So Suzanne's doctor prescribed medication to help Suzanne increase her chances of getting pregnant.

After several years of trying to get pregnant with no success, Suzanne looked into adoption.

A year later, soon after she adopted a baby boy, her son Eric, she learned she was pregnant.

Her pregnancy was not difficult, but she had frequent bleeding. Twelve weeks into her pregnancy, Suzanne learned that she had been carrying twins, but only one baby survived.

That baby, her daughter, Rachel, is now 25 years old. Rachel also has endometriosis.

Paying it forward

Suzanne is glad that today there are more treatment options for Rachel and other women with endometriosis. Suzanne has had a number of laparoscopic surgeries since her first one. Doctors also removed the parts of her ovaries that were covered with excess tissue from endometriosis.

As a therapist and mom, Suzanne regularly gives advice to young women with the condition, urging them not to try to "tough it out" alone, but rather get treatment.

"If you have pain and other symptoms of endometriosis, don't downplay your symptoms or think you're not strong enough. Talk with a woman's health specialist," she says.

A daughter's journey

When she was just 10 years old, Rachel Chutchian-O'Sullivan got her first period.

"Take us seriously when we complain about horrible pain like this."- Rachel Chutchian-O'Sullivan

Each month, it lasted for 10 to 14 days, which is considered a long cycle. She also had severe menstrual cramps, pain in her lower spine, and stomach problems.

Rachel's pain was often so bad that she was late for school or missed it altogether.

"I remember walking to the restroom at school and stopping in my tracks," Rachel says. "I couldn't move at all."

Some days she couldn't focus because the pain was so severe. She was also embarrassed.

"It's not something you want to talk about when you're that young—or ever," Rachel says. Even with a doctor's note, Rachel remembers that her school administrators weren't very understanding about her tardiness or absences due to endometriosis.

Diagnosing the pain

In her early teens, Rachel had numerous doctors visits. Though she suspected it was endometriosis, a condition both her mother and grandmother had, providers wanted to rule out other issues.

They performed several tests, including computed tomography (CT) scans, ultrasounds, a colonoscopy, and an endoscopy.

Getting treatment

Initially, Rachel's pediatrician prescribed birth control pills to help control her menstrual cycle and relieve some of the pain.

"It was still painful, but not as bad as it was before," she says.

Later, Rachel's doctor prescribed a birth control injection, medroxyprogesterone, which also helped ease the pain.

Side effects

The injection did have side effects, including weight gain. Rachel got the injections for several years, but eventually stopped because of a more serious side effect: decreased bone density. So, she went back to taking birth control pills.

"Ever since I was diagnosed, I've been afraid that I won't be able to get pregnant some day," she says. "Knowing that it's hereditary, I fear that if I do have children, I'll pass it on to them, too."

Advice for others

Today, Rachel still experiences cramps, but they're much less severe than when she was younger. At age 25, she's pursuing a master's degree in social work, as her mother did around that age.

She offers the same advice to all people, both women with the condition and the men and women supporting them: "Take us seriously when we complain about horrible pain like this."

She also advises women of all ages who have severe cramps or lower abdominal pain to talk with a women's health specialist as soon as symptoms appear.

"Make it known if you are having issues," Rachel says. "I didn't talk about it when I was younger, but now I do. There's more awareness now."

Surgery is currently the only way to confirm a diagnosis of endometriosis.

The most common surgery is called laparoscopy.

In this procedure:

• The surgeon uses an instrument to inflate the abdomen slightly with a harmless gas.
• After making a small cut in the abdomen, the surgeon uses a small viewing instrument with a light, called a laparoscope, to look at the reproductive organs, intestines, and other surfaces to see if there is any endometriosis.
• If patches of tissue are present, the surgeon examines them to determine whether they are endometriosis and, if so, at what stage they might be.
• In some cases, the surgeon will also do a biopsy, which involves taking a small tissue sample and studying it under a microscope, to confirm the diagnosis.
• The most common surgery is a laparoscopy, but sometimes a laparotomy—a surgical procedure involving a larger incision—is used to make a diagnosis.

Healthcare providers may also use imaging methods to produce a “picture” of the inside of the body. Imaging allows them to locate larger endometriosis areas, such as nodules or cysts. The two most common imaging tests are ultrasound, which uses sound waves to make the picture, and magnetic resonance imaging (MRI), which uses magnets and radio waves to make the picture. These types of imaging do not help diagnose small lesions or adhesions.

Your healthcare provider will perform a laparoscopy only after learning your full medical history and giving you a complete physical and pelvic exam. This information and exam, in addition to the results of an ultrasound or MRI, will help you and your healthcare provider make more informed decisions about treatment.

Researchers are also seeking less invasive ways to diagnose endometriosis and determine how severe it is. NICHD-funded researchers in the National Centers for Translational Research in Reproduction and Infertility created a “diagnostic classifier” for endometriosis based on the presence of particular genes. The classifier was 90% to 100% accurate. Once the classifier is validated, a simple biopsy in the doctor’s office may be a nonsurgical way to diagnose endometriosis in most women.

Yes. Many women with endometriosis get pregnant. But, you may find it harder to get pregnant. Researchers think endometriosis may affect as many as one in every two women with infertility.

No one knows exactly how endometriosis might cause infertility. Some possible reasons include:

• Patches of endometriosis block off or change the shape of the pelvis and reproductive organs. This can make it harder for the sperm to find the egg.
• The immune system, which normally helps defend the body against disease, attacks the embryo.
• The endometrium (the layer of the uterine lining where implantation happens) does not develop as it should.

If you have endometriosis and are having trouble getting pregnant, talk to your doctor. He or she can recommend treatments, such as surgery to remove the endometrial growths.

In most cases, healthcare providers will recommend laparoscopy to remove or vaporize the growths to also improve fertility in women who have mild or minimal endometriosis. Although studies show improved pregnancy rates following this type of surgery, the success rate is not clear.

If pregnancy does not occur after laparoscopic treatment, in vitro fertilization (IVF) may be the best option to improve fertility. Taking any other hormonal therapy usually used for endometriosis-associated pain will suppress ovulation and delay pregnancy. Performing another laparoscopy is not the preferred approach to improving fertility unless pain symptoms prevent undergoing IVF. Multiple surgeries, especially those that remove cysts from the ovaries, may reduce ovarian function and hamper the success of IVF.

IVF makes it possible to combine sperm and eggs in a laboratory to make an embryo. The resulting embryos are placed into the woman’s uterus. IVF is one type of assisted reproductive technology that may be an option for women and families affected by infertility related to endometriosis.

In general, the process of IVF involves the following steps. First, a woman takes hormones to cause “superovulation,” which triggers her body to produce many eggs at one time. Once the eggs are mature, a healthcare provider collects them using a probe inserted into the vagina and guided by ultrasound. The collected eggs are placed in a dish for fertilization with a man’s sperm. The fertilized cells are then placed in an incubator, a machine that keeps them warm and allows them to develop into embryos. After 3 to 5 days, the embryos are transferred to the woman’s uterus. It takes about 2 weeks to know whether the process is successful.

Even though the use of hormones in IVF is successful in treating infertility related to endometriosis, other forms of hormone therapy are not as successful. For instance, ACOG does not recommend using oral contraceptive pills or GnRH agonists to treat endometriosis-related infertility. Using these hormonal agents prevents ovulation and delays pregnancy.

In addition, the hormones used during IVF do not cure the endometriosis lesions, which means that pain may recur after pregnancy and that not all women with endometriosis are able to become pregnant with IVF. Researchers are still looking for hormone treatments for infertility due to endometriosis.

Endometriosis is the presence of endometrial tissue outside of the uterus. The diagnosis of endometriosis is often made clinically based on history, with women reporting dysmenorrhea, pelvic pain, dyspareunia, and fertility issues. Endometriosis can sometimes be detected on transvaginal ultrasound. However, definitive diagnosis requires laparoscopy with biopsy.

Approximately 10% of women are affected by this condition. Risk factors include an affected first-degree relative, no previous use of oral contraceptive pills, history of Graves disease, and history of inflammatory gynecologic disease.

There are many theories regarding the pathogenesis of endometriosis. The most commonly accepted theory is that endometriosis is caused by retrograde reflux of menstrual tissue through the fallopian tubes into the pelvis. Endometriosis involves overproduction of local estrogen from increased aromatase activity, and pain results from the production of inflammatory prostaglandins and development of lesions near nerve fibers.

Conventional treatment approaches depend on whether future fertility is desired. Options include anti-inflammatory approaches such as NSAIDs and medical suppressive therapies including hormonal contraceptives and gonadotropin-releasing hormone (GnRH) agonists. If painful symptoms persist, surgical intervention includes ablation or excision of the endometriomas or hysterectomy. The American College of Obstetricians and Gynecologists reviews these interventions in their guidelines for the management of endometriosis.

Despite a lack of research on integrative approaches to treating endometriosis, they offer potential benefits with limited risks and should be considered.

1. Prevention

There is not much evidence for interventions to prevent the development of endometriosis. For women at increased risk due to an affected first-degree relative, consider increasing dairy intake and encouraging breastfeeding, if applicable. Women in the Nurses Health Study who ate three or more servings of dairy per day were 18% less likely to be diagnosed with endometriosis.. Evidence suggests that breastfeeding may be protective.

2. Inflammation

Reduce inflammation with an anti-inflammatory diet. Consider anti-inflammatory botanicals such as ginger (Zingiber officinale) and turmeric (Curcuma longa), in addition to omega-3 fatty acid supplementation of 1,000-2,000 mg of EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid) daily if dietary intake is inadequate.

3. Estrogen Dominance

Consider lifestyle changes to decrease estrogen dominance in the body, because estrogen has been shown to support the growth of endometrial tissue. Approaches include a diet high in cruciferous vegetables, omega-3 supplementation, avoidance of xenoestrogens, and promotion of a healthy intestinal microbiome.

4. Botanicals

Botanicals may help improve the symptoms of endometriosis, because they are often used in dysmenorrhea. Although only small studies support their use for endometriosis, many women may prefer a trial due to their low risk and rare side effects.

• Chaste tree berry (Vitex agnus-castus) is used to treat menstrual irregularities, including menometrorrhagia. The exact mechanism of action is unknown, but it has effects on multiple neurotransmitters and hormones, including a progesterogenic effect on the endometrial lining. The typical dose is 20-240 mg per day of crude herb. It is generally well tolerated; side effects include headache, gastrointestinal disturbance, acne, and rash.
• Ginger (Zingiber officinale) and turmeric (Curcuma longa) may be beneficial due to their anti-inflammatory activity. Ginger is often used to decrease heavy menstrual flow. Ginger dose is typically 1-4 gm per day of dried powder or 100 mg per day of ginger root extract. Turmeric dose is typically 500 mg twice daily.

5. Muscle Tension and Chronic Pain

Chronic muscle tension may contribute to pain. Consider recommending regular movement, stretching, massage, osteopathic manipulation, and even targeted pelvic floor physical therapy. Use of heat, such as placing a castor oil pack over the pelvis for 20-30 minutes, may increase blood flow and improve pain.

6. Acupuncture and Acupressure

Using acupuncture and acupressure may help with the symptoms of dysmenorrhea experienced in endometriosis. Data is inconclusive because of the limitations of many research studies. Meta-analysis of higher-quality studies suggests that acupuncture and acupressure is effective for treatment of dysmenorrhea and improves pain compared to placebo in endometriosis.