Category Archives: Endometriosis


Can Endometriosis Cause Vomiting?

A Perplexing Condition

Endometriosis, a disorder affecting an estimated 176 million women worldwide, is characterized by the abnormal growth of endometrial-like tissue outside the uterus. While pelvic pain and infertility are well-recognized symptoms, many individuals remain unaware of the connection between endometriosis and gastrointestinal issues, including vomiting.

The Gastrointestinal Manifestations

Contrary to popular belief, gastrointestinal symptoms are nearly as prevalent as gynecological symptoms in women with endometriosis. Interestingly, 90% of patients with this illness initially have gastrointestinal issues such as bloating, diarrhea, constipation, uncomfortable bowel movements, nausea, or vomiting.

Bloating: A Persistent Symptom

Bloating is the most often reported symptom, impacting an astounding 83% of endometriosis-affected women. The ongoing discomfort could significantly affect everyday activities and the general quality of life.

Vomiting and Nausea: The Often Ignored Symptoms

Despite occasionally taking center stage, nausea and vomiting are unpleasant symptoms that can significantly affect people with endometriosis. These symptoms may point to a complex interaction between the disease and gastrointestinal function, regardless of where the endometrial lesions are located in relation to the colon. Additionally, vomiting and nausea can result from severe pain and discomfort.

To make matters worse, endometriosis can mimic symptoms of Irritable Bowel Syndrome (IBS), such as frequent bloating and irregular bowel movements. When seeking assistance from a gastroenterologist, many women receive an IBS diagnosis before identifying the underlying endometriosis.

This is typical: A young woman visits a gastroenterologist due to bloating and constipation. She was diagnosed with IBS following an upper endoscopy and colonoscopy that showed no visible digestive problems. Her IBS symptoms do not go away, though, because endometriosis is the underlying cause of them.

Small Intestinal Bacterial Overgrowth (SIBO)

There is a common link between endometriosis and small intestinal bacterial overgrowth (SIBO), a disorder marked by a notable build-up of bacteria in the small intestine. As a result of this overgrowth, patients with endometriosis may have more severe digestive issues, such as bloating, gas, diarrhea, and abdominal pain.

The lactulose-hydrogen breath test measures the amounts of hydrogen and methane in the breath. It is a straightforward, noninvasive, and reasonably priced method of diagnosing SIBO.

Strategies for Treatment

Although there is currently no recognized treatment for endometriosis, there are several ways to help control symptoms, including nausea and vomiting:

  1. Surgical Intervention: Laparoscopic excision surgery can reduce symptoms by treating the underlying cause by removing endometriosis tissue.
  2. Hormonal Medications and Contraceptives: Hormonal therapy can lessen symptoms.
  3. Pain Management: Physicians may recommend over-the-counter pain relievers to patients to alleviate the discomfort associated with endometriosis and gastrointestinal issues.
  4. SIBO Treatment: Medication alone is not enough to reduce gastrointestinal issues associated with endometriosis; lifestyle modifications are also helpful.

Seeking Professional Guidance

You should consult a physician if you experience nausea, vomiting, or severe abdominal discomfort regularly. A thorough assessment that involves imaging scans, a laparoscopy, and a pelvic examination may be required to get an accurate diagnosis and develop a care plan.

The Value of Prompt Intervention

If endometriosis is not treated, it can have a major negative impact on a person’s quality of life. Recognizing and seeking care for gastrointestinal symptoms such as nausea and vomiting as soon as possible might help people’s chances of receiving treatment and managing their symptoms.


Beyond infertility and pelvic pain, endometriosis is a complex disease. People can increase their chances of receiving treatment and managing their symptoms by recognizing and obtaining care for gastrointestinal symptoms like nausea and vomiting as soon as possible. Women with endometriosis can improve their overall quality of life and take back control of their lives by using a multidisciplinary strategy that includes lifestyle changes, medicinal therapies, and support networks.



Adenomyosis and Endometriosis, Differences and Similarities

Adenomyosis and endometriosis, two different yet similar conditions, have long challenged the medical community with their manifestations and elusive origins. While sharing some similarities, these disorders have characteristics that demand meticulous examination and unique approaches to management. This article discusses adenomyosis and endometriosis, their differences, symptoms, causes, and cutting-edge diagnostic and therapeutic avenues.

Understanding the Fundamental Differences Between Endometriosis and Adenomyosis

A crucial distinction lies at the heart of these conditions: the location of the disease growth. In adenomyosis, the endometrial cells, which typically line the uterine cavity, infiltrate and embed themselves within the muscular walls of the uterus itself. This invasion results in a thickening of the uterine walls, causing potential complications.

Conversely, endometriosis involves the abnormal proliferation of endometrial-like tissue beyond the uterus, often colonizing surrounding organs such as the ovaries, fallopian tubes, and even the bladder or intestines. This misplaced tissue behaves similarly to the endometrium, undergoing cyclic shedding and bleeding, which can lead to the formation of adhesions, cysts, and scarring within the affected areas.

The Spectrum of Symptoms

While adenomyosis and endometriosis share some common symptoms, there are distinct nuances that can help in their differentiation. Both conditions can manifest as pelvic pain, particularly during menstrual cycles, as well as heavy or irregular bleeding patterns. However, adenomyosis may present with an enlarged, tender uterus, while endometriosis can cause pain during bowel movements, urination, or sexual intercourse, depending on the location of the endometrial implants.

The Disease’s Origins and Potential Causes

Despite extensive research, the exact causes of adenomyosis and endometriosis remain unclear. However, certain risk factors have been identified that may increase an individual’s susceptibility to these conditions.

For adenomyosis, factors such as prior uterine surgeries, multiple pregnancies, and increased exposure to estrogen have been implicated as potential contributors. Endometriosis, on the other hand, has been linked to a family history of the condition, early onset of menstruation (before age 11), short menstrual cycles (less than 27 days), and heavy periods lasting more than seven days.

Two widely discussed reasons for the development of endometriosis are cell misplacement during organogenesis and retrograde menstruation. However, the exact mechanisms underlying the development of both conditions remain elusive, highlighting the need for further research.

Diagnosing Endometriosis vs. Adenomyosis

Diagnosing adenomyosis and endometriosis can be a complex and multifaceted process, often requiring a combination of various diagnostic tools and techniques.

For adenomyosis, imaging modalities such as transvaginal ultrasound and magnetic resonance imaging (MRI) can provide valuable insights into the thickness and texture of the uterine walls, potentially revealing the presence of abnormal growths or cysts. However, in some cases, a definitive diagnosis may only be possible by examining uterine tissue samples obtained during a hysterectomy or biopsy.

Endometriosis, on the other hand, frequently requires a surgical procedure known as laparoscopy. During this minimally invasive procedure, a tiny camera is inserted into the abdominal cavity, enabling the surgeon to inspect for the presence of endometriosis implants visually and, if necessary, obtain tissue samples for further analysis.

While imaging techniques like ultrasound and MRI can suggest the presence of endometriosis, they may not always detect smaller lesions or implants, making laparoscopy the gold standard for definitive diagnosis.


The management of adenomyosis and endometriosis is a highly individualized process tailored to each patient’s unique circumstances, symptom severity, and fertility goals. For both conditions, initial treatment often involves over-the-counter pain medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), to alleviate discomfort and manage heavy bleeding. Hormonal contraceptives, including birth control pills, progestin-only intrauterine devices (IUDs), and gonadotropin-releasing hormone (GnRH) agonists, can also be employed to regulate menstrual cycles and suppress the growth of endometrial tissue.

In cases where medical management proves inadequate, surgical interventions may be considered. For adenomyosis, options include robotic-assisted excision of the affected uterine tissue or, in severe cases, a hysterectomy (removal of the uterus). Endometriosis similarly requires laparoscopic surgery to remove endometriosis implants and adhesions or, in some instances, a hysterectomy with bilateral salpingo-oophorectomy (removal of the uterus, fallopian tubes, and ovaries).

It is crucial to note that while surgery can alleviate symptoms, it does not necessarily cure endometriosis, as the condition may recur. Ongoing management and close monitoring are often necessary to ensure optimal outcomes.

Fertility Implications

Both adenomyosis and endometriosis can have profound impacts on an individual’s fertility and reproductive health. Endometriosis, in particular, is a leading cause of infertility and subfertility, as the presence of endometriosis implants and adhesions can impede ovulation, disrupt the fallopian tube function, and create an inhospitable environment for embryo implantation. In cases of adenomyosis, the abnormal thickening of the uterine walls can make it challenging for embryos to implant successfully, increasing the risk of miscarriage or complications during pregnancy.

A multidisciplinary approach involving fertility specialists and gynecologists may be necessary for individuals seeking to conceive. Treatment options may include assisted reproductive technologies (ART) such as in vitro fertilization (IVF), intrauterine insemination (IUI), or the use of fertility medications to induce ovulation. In severe cases of adenomyosis or endometriosis, where fertility preservation is not a priority, a hysterectomy or other surgical interventions may be recommended to alleviate symptoms and improve overall quality of life.

Coping Mechanisms

Living with chronic conditions like adenomyosis and endometriosis can be emotionally and physically taxing, often leading to feelings of anxiety, depression, and a diminished sense of well-being. A holistic approach that addresses these conditions’ physical and psychological aspects can be instrumental in improving overall quality of life.

In addition to medical interventions, complementary therapies such as routine exercise, meditation, massage, and acupuncture can be beneficial for managing pain and reducing stress levels associated with adenomyosis and endometriosis.

Furthermore, seeking support from professional counselors, therapists, or support groups can provide a valuable outlet for individuals to share their experiences, receive emotional support, and learn coping strategies from others navigating similar journeys.

Research and Cutting-Edge Advancements

The field of gynecological research is constantly evolving, with scientists and clinicians tirelessly exploring innovative approaches to understanding, diagnosing, and treating adenomyosis and endometriosis.

One promising avenue is the development of non-invasive diagnostic techniques, such as advanced imaging modalities or biomarker analysis, which could eliminate the need for invasive procedures like laparoscopy in some cases.

Additionally, ongoing research into these conditions’ genetic and molecular underpinnings may yield insights into novel therapeutic targets and personalized treatment strategies tailored to an individual’s unique genetic profile.

Furthermore, advancements in robotic-assisted surgical techniques and minimally invasive procedures continue to enhance precision, reduce recovery times, and minimize the risk of complications associated with traditional surgical interventions.

Raising Awareness

Despite their prevalence, adenomyosis and endometriosis often remain misunderstood and overlooked, leading to delays in diagnosis and inadequate support for patients.

Raising awareness about these conditions is crucial in empowering patients to advocate for their health, seek timely medical attention, and spread understanding within their personal and professional circles.

Everyone should consider promoting open dialogue, sharing personal experiences, and collaborating with healthcare professionals, advocates, and support organizations. By doing so, we can break down barriers, challenge misconceptions, and ensure that individuals affected by adenomyosis and endometriosis receive the compassionate care and support they deserve.

A Multidisciplinary Approach: Collaborating for Comprehensive Care

Endometriosis and adenomyosis are complex. Therefore, they demand a comprehensive and multidisciplinary approach involving various specialties.

Gynecologists, physical therapists, pain management specialists, mental health professionals, and fertility experts are the pieces that can help. These experts must collaborate to develop individualized treatment plans that address each patient’s unique needs and goals.

This multidisciplinary team can provide holistic care through open communication and a collaborative mindset. Holistic care can cover medical management, psychological support, and fertility preservation strategies. The multidisciplinary team and holistic care ensure the best possible outcomes for patients.

A Journey That Needs Hope and Resilience

The challenges posed by adenomyosis and endometriosis can be daunting. Therefore, it is essential to have hope and resilience throughout the journey. These conditions, though chronic, are manageable. Individuals can reclaim control over their lives and pursue their dreams with the proper support, management strategies, and a positive mindset.

In conclusion, the complex nature of adenomyosis and endometriosis demands a multifaceted approach that combines science, compassion, and a deep understanding. By collaboration, raising awareness, and innovative solutions, we can overcome this disease now and in the future.


Endometriosis and Adhesions: Correlations and Treatments

What is Endometriosis?

Endometriosis is a complex disorder characterized by the growth of endometrial-like tissue (the tissue that usually lines the uterus) in locations outside the uterine cavity. This misplaced tissue behaves similarly to the endometrium, thickening, breaking down, and bleeding with each menstrual cycle. However, unlike the endometrium, which is expelled during menstruation, the displaced endometrial tissue cannot exit the body, leading to inflammation, scarring, and the formation of adhesions.

Understanding Adhesions

Adhesions are fibrous bands of scar tissue that form abnormal connections between typically separate organs or tissues. Although they can form anywhere in the body, they are most frequently found in the pelvic area when endometriosis is present, binding organs like the uterus, fallopian tubes, ovaries, and intestines.

Causes of Adhesions in Endometriosis

One major contributing factor to the formation of adhesions in the pelvic cavity is endometriosis. Adhesions may occur as a result of the inflammatory process that endometriotic lesions cause via the following mechanisms:

  1. Bleeding and Inflammation: Endometriotic lesions have the potential to bleed during menstruation, which can trigger an inflammatory reaction in the tissues around them. Scar tissue that forms due to this inflammation may stick to adjacent organs or tissues.
  2. Surgical Interventions: Endometriosis patients frequently require surgery to manage related problems or remove endometriotic lesions. Certain surgical treatments can unintentionally cause adhesions to form while the body repairs itself.
  3. Endometriotic Implants: There is a chance that endometriotic implants will encourage the formation of adhesions. As the implants grow and mature, they may adhere to the surrounding tissues, creating fibrous bands that keep organs together.

Differentiating Between Adhesion Pain and Endometriosis Pain

Adhesions and endometriosis are comparable conditions that frequently coexist. However, there may be some distinctions. The inflammatory process that takes place inside the endometriotic lesions itself is directly related to endometriosis discomfort. Adhesion discomfort, on the other hand, results from the binding and restricted movement of organs because of the scar tissue’s fibrous bands.

Effect on Life Quality

Endometriosis and adhesions both severely impair a woman’s quality of life and are frequently linked to infertility, chronic pelvic discomfort, and other issues. Adhesions can cause organ displacement, intestinal blockages, and disturbances to normal physiological functioning, all of which can worsen the symptoms of endometriosis. They may also make endometriosis surgeries more difficult since they may mask endometriotic lesions and complicate surgical procedures.

Diagnosis and Treatment

Diagnosing Endometriosis Adhesions

It can be difficult to diagnose adhesions linked to endometriosis. Although laparoscopic or open surgery is frequently necessary for a conclusive diagnosis, adhesions may be better understood by using imaging methods like magnetic resonance imaging (MRI) and ultrasound.

The surgeon can visually evaluate the pelvic cavity during a laparoscopic operation to check for adhesions. Adhesions can manifest as thin, filmy, transparent bands or as thick, dense, opaque structures, depending on the severity of the condition.

Treatment Approaches

Adhesions in endometriosis are usually treated with a mix of surgical and pharmaceutical procedures:

  1. If adhesions are severe and substantially reduce a patient’s quality of life, surgery may be necessary to remove them. This can be accomplished via laparoscopic surgery, depending on the degree and location of the adhesions. Carefully separating the adhesions from the afflicted organs during the surgical operation minimizes stress and stops new adhesion formation. Because they lower the chance of new adhesion creation than open treatments, minimally invasive techniques like laparoscopic surgery are frequently chosen.
  2. Treatment for Endometriosis: To stop adhesions from recurring, the underlying endometriosis must be addressed. Hormonal therapy is one option for treating endometriosis; it suppresses hormones, reduces inflammation, and treats symptoms. To eliminate the cause of inflammation and lower the chance of adhesion formation, it may occasionally be advised to remove or ablate endometriotic lesions.

It is crucial to remember that the course of therapy should be customized to the needs of each patient, taking into account the degree of adhesions, the severity of endometriosis, and any possible effects on quality of life and fertility.

Endometriosis and Adhesions: A Complex Interaction

Although endometriosis and adhesions are distinct conditions, they frequently coexist and have complex interactions. While endometriosis can result in tissue damage and inflammation that can contribute to the formation of adhesions, adhesions can exacerbate the symptoms of endometriosis and complicate surgical operations.

To manage the associated discomfort, preserve fertility, and improve overall quality of life, women with endometriosis and adhesions require a correct diagnosis and treatment plan. Medical experts can develop comprehensive therapeutic methods tailored to the patient’s needs by understanding these two conditions’ relationships.


Two distinct illnesses that can have a major effect on a person’s health and quality of life are adhesion and endometriosis. In cases of endometriosis, endometrial-like tissue proliferates extraordinarily, resulting in fibrous scar tissue that may unintentionally stick to other organs. Prolonged pelvic pain; organ displacement; and surgical complications can arise from adhesion formation caused by endometriosis-induced inflammation. For many disorders, selecting the best therapy requires a precise diagnosis and an effective treatment plan that may involve medication and surgery. Knowing the connection between adhesions and endometriosis enables medical professionals to treat patients with greater specialization and comprehensive care, improving their overall health and well-being.


Unraveling the Links Between Endometriosis and Mental Health

Endometriosis is a medical condition often associated with severe pelvic pain and fertility issues. This disease might have significant psychological implications. This article reviews the relationship between endometriosis and mental health, highlighting how the physical symptoms of this disorder can translate into emotional distress.

Understanding Endometriosis

Endometriosis is a prevalent systemic and gynecological condition characterized by the abnormal growth of uterine lining cells, known as endometrium, outside the uterus. These abnormal cell growths can affect various organs, including the ovaries, fallopian tubes, and sometimes even the bladder, intestines, and rectum.

The symptoms of endometriosis include chronic pelvic pain, heavy menstrual periods, pain during sexual intercourse, and infertility. It’s estimated that about one in 10 women of reproductive age experience endometriosis, with the condition mainly impacting women in their 30s and 40s. An estimated 40% of women with infertility have endometriosis.

1- The Pain-Depression Connection in Endometriosis

The chronic pain associated with endometriosis can significantly disrupt a woman’s daily life, causing distress and leading to mental health conditions like depression and anxiety. The persistent pain can trigger feelings of hopelessness and helplessness. The debilitating effects of endometriosis pain can impact work, social interactions, and intimate relationships, contributing to feelings of isolation and lowered self-esteem.

2- Psychological Toll of Challenges of Endometriosis Diagnosis

One of the significant mental health challenges associated with endometriosis comes from the often lengthy and distressing diagnostic process. It’s not uncommon for women to experience symptoms for several years before receiving a diagnosis. Such delays in diagnosis, often due to the normalization of symptoms by healthcare professionals, can exacerbate the psychological distress associated with the condition.

Moreover, women with endometriosis often report feeling dismissed or misunderstood by healthcare professionals, which can further impact their mental health. A lack of understanding and acknowledgment of the chronic pain experienced by these women can lead to feelings of invalidation and frustration.

3- The Impact of Endometriosis on Relationships

The physical symptoms of endometriosis can significantly influence a woman’s relationships. Painful intercourse, one of the common symptoms of the condition, can cause strain in intimate relationships, leading to feelings of guilt, resentment, and anxiety. On top of that, infertility challenges can also be a complex issue in relationships. Furthermore, individuals with endometriosis might have constant chronic pain and reduced energy for participation in events. This lack of energy and presence can majorly impact a person’s relationships. These factors’s deteriorating effects on relationships can further exacerbate mental health conditions like depression and anxiety.

4- Endometriosis and Work-Life

The impact of endometriosis extends to a woman’s professional life. The heavy menstrual bleeding and severe pain associated with the condition can make maintaining a regular work schedule challenging. This work-life issue can lead to feelings of guilt and stress, further contributing to the development of mental health conditions.

5- Racial and Ethnic Differences in Endometriosis and Mental Health Impact

There’s limited research on racial and ethnic differences in endometriosis and its mental health impacts. However, a review study found that compared with white women, black and Hispanic women were less likely to be diagnosed with endometriosis. This lack of diagnosis will make the whole treatment and diagnosis process longer, which will result in more adverse mental health impacts.

6- Treatment Options and Their Psychological Implications

While there’s no definitive cure for endometriosis, various treatment options can help manage the symptoms. These include over-the-counter pain medications, hormone therapies, and, in severe cases, surgical treatments. However, the effectiveness of these treatments can vary, and the prospect of long-term management can lead to feelings of anxiety and depression.

Furthermore, some treatments, particularly surgical ones, can have physical side effects that can impact a woman’s body image, leading to further psychological distress.

7- The Role of Support and Therapy

Support groups, counseling, and cognitive-behavioral therapies can play a significant role in managing the emotional distress associated with endometriosis. These strategies can provide patients with some help tools to cope with their physical symptoms, as well as the emotional toll of living with endometriosis.

Concluding Remarks

The links between endometriosis and mental health are complex and deeply personal. Recognizing the psychological implications of endometriosis is a critical step in providing comprehensive care to individuals affected by this condition. By acknowledging the psychological stress associated with this condition, healthcare providers can positively impact the mental health outcomes of women living with endometriosis. Patients with endometriosis should seek help not only for their physical symptoms but also for any emotional distress they may be experiencing. Doing so might improve their quality of life and overall well-being.



Is Endometriosis an Autoimmune Disease? An In-depth Analysis


Endometriosis is a chronic and often debilitating condition that affects around 1 in 10 women in the US. It is characterized by the growth of endometrium-like tissue outside the uterus, often resulting in severe pain and fertility issues. Despite extensive research, the root cause of endometriosis remains unclear. Recent studies, however, have pointed to a potential interplay between endometriosis and autoimmunity, prompting questions about whether endometriosis could be an autoimmune disease.

Understanding Endometriosis

Endometriosis is a complex condition with a wide range of symptoms, varying from person to person. The endometriosis tissue, which is similar to the tissue that lines the uterus, can grow in several places outside the uterus, such as the ovaries, abdomen, and bowel. This misplaced tissue can bleed and become inflamed, leading to symptoms such as:

  • Severe cramps
  • Chronic pelvic pain
  • Nausea or vomiting
  • Heavy menstrual flow
  • Pain during sexual intercourse
  • Bowel or urinary problems
  • Infertility

The Immune System and Autoimmunity

To understand the potential link between endometriosis and autoimmunity, it’s crucial to first understand what autoimmunity means. The immune system, which is designed to protect the body against harmful pathogens, can sometimes mistakenly attack its own cells, tissues, or organs. This misguided immune response leads to autoimmune diseases, which can cause a wide array of symptoms depending on the part of the body affected. Examples of autoimmune diseases include Celiac disease, Rheumatoid Arthritis, and Multiple Sclerosis.

Endometriosis and Autoimmunity: The Connection

Although endometriosis is not officially classified as an autoimmune disease, research has suggested a possible link between the condition and problems with the immune system. Endometriosis may cause inflammation and an imbalanced immune response, which could potentially trigger the onset of an autoimmune disease. Alternatively, an existing autoimmune disease could exacerbate the symptoms of endometriosis.

Autoimmune Disorders Linked to Endometriosis

Several autoimmune disorders have been partially linked to endometriosis, including:

  • Multiple Sclerosis (MS)
  • Sjögren’s Syndrome
  • Lupus
  • Inflammatory Bowel Disease (IBD)
  • Celiac Disease
  • Rheumatoid Arthritis
  • Hypothyroidism
  • Addison’s Disease

Endometriosis: Not Officially an Autoimmune Disease

While there are clear links between endometriosis and certain autoimmune diseases, it’s important to note that endometriosis is not officially classified as an autoimmune disease. The exact cause of endometriosis remains unknown, and more research is needed to fully understand the complex interplay between endometriosis and the immune system.

Endometriosis: Immune System Dysfunction and Inflammation

Research has found evidence of immune system dysfunction in individuals with endometriosis. This includes elevated levels of inflammation and disturbances in the function of certain immune cells. This immune dysfunction could potentially contribute to the development and progression of endometriosis.

The Impact of Autoimmunity on Endometriosis Severity

Recent studies suggest that the presence of a co-existing autoimmune disease may be an indicator of more severe stages of endometriosis. This may be due to the additional inflammation and immune system dysfunction caused by the autoimmune disease, which could exacerbate the symptoms and progression of endometriosis.

Autoimmune Treatments for Endometriosis

Current treatments for endometriosis primarily focus on managing symptoms and preventing disease progression, as there is currently no cure. These treatments include hormonal medications, pain relievers, and surgery. While treatments for autoimmune diseases typically involve suppressing the immune system, these treatments have not been found to be effective for endometriosis. However, research is underway to explore potential immunotherapy treatments for the condition.

Endometriosis and Other Health Risks

Endometriosis is associated with several other health risks beyond autoimmune diseases. For instance, endometriosis may also be linked to asthma, allergies, and some cardiovascular diseases.

Endometriosis and Cancer

There is some evidence to suggest that endometriosis may be linked to certain types of cancer. Specifically, endometriosis may increase the risk of developing ovarian cancer and a specific type of breast cancer.

Conclusions and Future Directions

The potential link between endometriosis and autoimmunity presents a complex avenue for future research. While more studies are needed to fully understand this connection, the current findings could have significant implications for the diagnosis and treatment of endometriosis. By better understanding the role of the immune system in endometriosis, researchers may be able to develop more effective treatments and potentially even discover a cure for this debilitating condition.



Understanding Endometriosis and Stomach Cramps

Endometriosis is a medical condition that affects approximately 10% of women globally. Its symptoms can be debilitating and significantly impact the quality of life of those affected. One of the most commonly reported symptoms of endometriosis is stomach cramps. This article delves into the relationship between endometriosis and stomach cramps, unraveling the causes, symptoms, and available treatment options.

What is Endometriosis?

Endometriosis is a health disorder that occurs when tissue similar to the uterus’s endometrium begins to grow in areas outside the uterus. These areas may include the ovaries, fallopian tubes, the lining of the pelvic cavity, and, in some cases, the bowels and bladder.

What is Endo Belly?

One term that has gained popularity in endometriosis discussions is “endo belly.” This term refers to the painful abdominal bloating often associated with endometriosis. The bloating, which can be severe, results from inflammation, growths, gas, or other digestive issues related to endometriosis.

Causes of Endo Belly

The exact cause of endo belly still needs to be fully understood. However, several factors have impacted this symptom. The endometrial-like tissue behaves similarly to the endometrium: it thickens, breaks down, and bleeds with each menstrual cycle. However, since this tissue cannot exit the body, it becomes trapped, leading to inflammation and irritation. Over time, this can cause scar tissue to form, leading to various symptoms, including bloating and fluid retention.

Symptoms of Endo Belly

The primary symptom of endo belly is severe bloating, particularly during or just before the menstrual period. The abdomen may fill with air or gas, causing it to appear larger and feel stiff or tight to the touch. This bloating may last for a few hours to a few weeks. Other symptoms that may accompany endo belly include:

  • Nausea and vomiting
  • Gas pain
  • Constipation or diarrhea
  • Abdominal discomfort, pain, and pressure

How Endometriosis Causes Stomach Cramps

The stomach cramps associated with endometriosis are often severe and debilitating. These cramps are not merely due to the menstrual cycle but are a direct result of the endometrial-like tissue growing outside the uterus. This tissue resembles the endometrium, building up and breaking down each menstrual cycle. But because this tissue is outside the uterus and cannot exit the body, it gets trapped. This trapped tissue leads to inflammation and irritation, which can cause severe stomach cramps.

Symptoms of Stomach Cramps Due to Endometriosis

The main symptom associated with endometriosis-induced stomach cramps is severe pain, particularly during the menstrual period. This pain can be so intense that it disrupts daily activities and significantly impairs the individual’s quality of life. The pain often worsens throughout the day and can be so severe that the person may not be able to button their pants or may even appear as though they are pregnant.

Treatment for Endometriosis and Stomach Cramps

There are several treatment options available for managing endometriosis and its associated stomach cramps. Treatment choice often depends on the severity of the symptoms, the person’s age, and their future pregnancy plans. The treatment options include:

  • Over-the-counter Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or aspirin, may be recommended to manage inflammation and reduce pain.
  • Prescription Hormonal Medications: Hormonal pills or devices may help to regulate symptoms.
  • Endometriosis Surgery: In severe cases, surgery may be the best option for long-term pain relief. This surgery involves removing the endometriosis and scar tissue from the pelvic and abdominal organs.

When to Consult a Doctor

It’s essential to consult an endo specialist if you’re experiencing severe stomach cramps, mainly if they’re associated with your menstrual cycle. Early diagnosis and treatment can significantly improve your quality of life and prevent potential complications, such as infertility.


Endometriosis and stomach cramps are closely linked. The condition can lead to severe stomach cramps that can significantly impair the quality of life of those affected. However, you can manage the symptoms effectively with proper diagnosis and treatment. Suppose you’re experiencing severe stomach cramps, especially if they’re associated with your menstrual cycle. In that case, it’s essential to consult a healthcare provider for a proper diagnosis and treatment plan.



Understanding Bladder Endometriosis and Its Treatment

Bladder endometriosis is a medical condition that affects a significant number of women worldwide. It involves the growth of endometrial-like tissue on or in the bladder. This article aims to provide an understanding of bladder endometriosis, how it is diagnosed, and the surgical procedures involved in its treatment.

What is Bladder Endometriosis?

Bladder endometriosis is a subtype of endometriosis, a condition in which cells similar to those that make up the lining of the uterus (endometrium) grow outside of it. In bladder endometriosis, these cells grow in or on the bladder. This can lead to various symptoms, including urinary frequency, pain during urination, and even blood in the urine.

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Epidemiology and Etiology

Bladder endometriosis is relatively uncommon, occurring in approximately 1-2% of all women with endometriosis. It is most frequently diagnosed in women of reproductive age, with an average age of diagnosis around 35 years. Studies have suggested that heritability may play a role in the development of bladder endometriosis, with some women having a family history of the condition.

The exact cause of bladder endometriosis is still being researched. However, four main theories have been proposed:

  • The embryonal theory suggests that bladder endometriosis originates from Müllerian remnants in the vesicouterine/vesicovaginal septum.
  • The migratory or metastatic theory suggests it is an extension of an adenomyotic nodule of the anterior uterine wall.
  • The transplantation theory posits that it results from the implantation of regurgitated endometrium.
  • The iatrogenic theory suggests it occurs after pelvic surgery, such as cesarean delivery or hysterectomy.

Symptoms of Bladder Endometriosis

The symptoms of bladder endometriosis can vary from person to person, but often include one or more of the following:

  • Frequent urination: The need to urinate often is a common symptom.
  • Dysuria: This is a term for pain or discomfort during urination.
  • Hematuria: This refers to blood in the urine, which may be visible or detected on a urine test.
  • Lower abdominal pain: Some patients may experience pain in the lower abdomen, often worsening during menstruation.
  • Recurrent urinary tract infections: Some women may have frequent UTIs.

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Diagnosis of Bladder Endometriosis

Diagnosing bladder endometriosis can be a complex process, as the symptoms can mimic other conditions such as recurrent cystitis or bladder infections. Various diagnostic modalities are used in the preoperative assessment of bladder endometriosis. These include:

  • Transabdominal and transvaginal ultrasound: These are the initial investigations of choice for suspected bladder endometriosis due to their immediate availability and easy access.
  • Magnetic resonance imaging (MRI): This imaging technique can not only delineate the morphologic abnormalities of bladder endometriosis but can also potentially identify other common sites.
  • Cystoscopy: This procedure allows doctors to view the inside of the bladder and urethra using a thin, lighted instrument.
  • CT urogram or MRI urogram: These tests involve injecting intravenous contrast material (a type of dye) into the urinary bladder to obtain images of the urinary tract.

Treatment of Bladder Endometriosis

The treatment of bladder endometriosis typically involves surgery, as medical management is often not effective for this condition. There are several surgical options, including:

  • Transurethral resection: This procedure involves the removal of the endometriotic tissue through the urethra using a special instrument.
  • Partial cystectomy: This procedure involves the removal of a part of the bladder that is affected by endometriosis.
  • Laparoscopic surgery: This is a minimally invasive procedure where small incisions are made in the abdomen to remove the endometriotic tissue.

It’s important to note that the choice of treatment depends on various factors, including the size and location of the endometriotic lesions, the woman’s age, and the presence of other associated conditions.

Long-term Outcomes and Recurrence

Studies have shown that surgical treatment of bladder endometriosis can lead to good results in terms of pain relief and improvement in urinary symptoms. However, endometriosis is a chronic condition, and there is a risk of recurrence. The overall recurrence rate of symptoms is about 30% for combined therapies and about 35% for hormonal treatment alone. Regular follow-up visits are essential to monitor for any signs of recurrence and to manage any ongoing symptoms.

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Bladder endometriosis is a challenging condition that requires a comprehensive approach to diagnosis and treatment. It is crucial for women to be aware of the symptoms and to seek medical advice if they are experiencing any urinary problems or pelvic pain. With appropriate treatment, most women with bladder endometriosis can achieve significant relief from their symptoms and improve their quality of life.



Does Gastrointestinal Endometriosis Cause Infertility

Gastrointestinal endometriosis is a condition that poses numerous health challenges to women, and one of the most concerning questions revolves around its potential impact on fertility. The primary focus of this article is to address the question:

Does gastrointestinal endometriosis cause infertility?

We will dissect this issue by exploring the available medical and scientific evidence.

Understanding Endometriosis and its Symptoms

Endometriosis can manifest with various symptoms, although not all women may experience them. Some common symptoms include:

  • Painful periods: Women with endometriosis often experience more intense pelvic pain and cramping before and during their menstrual cycle.
  • Chronic lower back/abdominal pain: Another hallmark of endometriosis is persistent pain in the lower back or abdomen.
  • Infertility: Endometriosis has been associated with fertility problems, making it more challenging for some women to conceive.
  • Excessive bleeding and spotting: Women with endometriosis may experience heavy bleeding during their periods or irregular bleeding between periods due to the presence of adenomyosis.
  • Pain during or after intercourse: Endometrial tissue growths can cause pain during sexual intercourse, which can have a significant impact on a woman’s quality of life.
  • Gastrointestinal issues: Endometriosis affecting the intestines can lead to symptoms such as painful bowel movements, diarrhea, constipation, and stomach issues like nausea.
  • Fatigue: Chronic fatigue is a common complaint among women with endometriosis, which can be attributed to the physical and emotional toll of dealing with the condition.

Endometriosis and Fertility

The relationship between endometriosis and fertility has been a subject of continuous research. Women with endometriosis, particularly moderate to severe forms, often face fertility challenges. However, it’s important to note that endometriosis does not automatically lead to infertility. Many women with endometriosis can and do conceive naturally or with the help of fertility treatments.

How Endometriosis Impacts Fertility

The mechanism through which endometriosis affects fertility is complex and multifaceted. Here are some ways it can potentially interfere with conception:

  • Anatomical Distortions: Endometriosis can cause adhesions or scar tissue formation, leading to a distortion of pelvic anatomy. This can block the fallopian tubes or alter the position of the ovaries, hindering the meeting of sperm and egg.
  • Inflammatory Environment: Endometriosis creates an inflammatory environment in the pelvic region, which might harm the quality of eggs or sperm and hinder their movement.
  • Impact on the Endometrium: Some studies suggest that endometriosis may affect the lining of the uterus (the endometrium), making it less receptive to an implanting embryo.

Gastrointestinal Endometriosis and Infertility: Is there a Connection?

When it comes to the specific question – does gastrointestinal endometriosis cause infertility – the answer is not as straightforward as one might hope. While endometriosis is known to affect fertility in general, the impact of gastrointestinal endometriosis on fertility is less clear.

Evidence suggests that endometriosis involving the bowel or bladder can be more challenging to treat and may require more complex surgical procedures, which could potentially affect reproductive function. However, it’s also important to remember that the presence of gastrointestinal endometriosis does not necessarily mean that a woman will experience fertility problems. However, the inflammation and molecular impacts of endometriosis might still increase the risk of fertility problems.

Treating Gastrointestinal Endometriosis

Medical Treatment

The first line of treatment for endometriosis often involves hormone therapy, such as birth control pills or progestin-based contraceptives, which work by managing symptoms and manipulating hormones. However, these medications do not improve fertility.

Surgical Treatment

Surgery to remove endometriosis patches can potentially improve fertility, especially in cases of moderate to severe endometriosis. However, surgical treatment of gastrointestinal endometriosis can be complex and may carry a higher risk of complications. Depending on the extent of the disease, it may involve resection of a portion of the bowel or bladder.

The Path to Pregnancy with Endometriosis

Surgical treatment can increase the chance of natural and assisted fertility. However, in many cases the patient still needs further support and treatment.

Fertility Treatments

For women with endometriosis who are struggling to conceive, assisted reproductive technologies (ART) such as in-vitro fertilization (IVF) may be an option. While women with severe endometriosis may have a lower success rate with IVF than other women, many are still able to achieve a successful pregnancy with this treatment.

Surrogate pregnancy

There are some options to seek help from other women’s bodies and eggs if necessary and desired.

Maintaining Hope

The journey of dealing with endometriosis and its potential impact on fertility can be emotionally challenging. However, it’s important to maintain hope. Many women with endometriosis, including gastrointestinal endometriosis, are able to conceive and have healthy pregnancies, whether naturally or with the help of fertility treatments.

Final Thoughts

In conclusion, while gastrointestinal endometriosis can pose challenges, it can impact fertility by inflammation and molecular pathways. Each case of endometriosis is unique, and the impact on fertility can vary greatly from one individual to another. If you’re dealing with endometriosis and are concerned about your fertility, it’s important to seek guidance from a healthcare provider who can provide individualized advice based on your specific situation.

Remember, understanding your condition and exploring your options can empower you to make the best decisions for your health and fertility journey. So, while gastrointestinal endometriosis can pose hurdles, they are not insurmountable. With the right treatment and support, the dream of parenthood can still be a reality for many women living with endometriosis.



How to Prevent Endometrioma Cysts

Endometrioma cysts, often dubbed as ‘chocolate cysts’ or “endometrioma”, pose a significant health issue for many women worldwide. Understanding how to prevent endometrioma cysts is crucial for maintaining optimal reproductive health. This comprehensive, empathetic guide will walk you through the essentials of endometrioma prevention, demystifying complex medical terms and offering practical advice.

Understanding Endometrioma

Endometrioma, a form of endometriosis, is a condition where tissue similar to the lining of the uterus grows outside the uterus, primarily on the ovaries. This growth often results in cysts filled with blood and tissue products, referred to as ‘chocolate cysts’ due to their dark, chocolate-like appearance. Understanding this condition is the first step in learning how to prevent endometrioma cysts.

Symptoms of Endometrioma

Endometrioma can manifest in a variety of symptoms, some of which are debilitating. Common symptoms include severe menstrual cramps, chronic pelvic pain, discomfort during intercourse, painful bowel movements or urination during menstruation, and fertility issues. In some cases, endometrioma may be asymptomatic, discovered only during a routine check-up or fertility assessment.

Causes of Endometrioma

The exact cause of endometrioma remains a subject of ongoing research. Some theories suggest retrograde menstruation, genetic factors, hormonal imbalances, and immune system dysfunctions. Surgical procedures in the abdominal area may also inadvertently transport endometrial tissue to other parts of the body, leading to endometrioma.

Who is at Risk?

While any woman who menstruates can develop endometrioma, certain factors increase the risk. These include a family history of endometriosis.

How is Endometrioma Diagnosed?

Doctors diagnose endometrioma through several methods, including pelvic examinations, imaging tests like ultrasounds or MRIs, and laparoscopy – a surgical procedure that allows for the visual inspection of pelvic organs. A definitive diagnosis often requires a biopsy, where a small sample of tissue is examined under a microscope.

Why Endometrioma Causes Health Problems

Endometrioma can lead to several health problems, including persistent pain, inflammation, and fertility issues. These cysts can grow, bleed, and cause scarring, leading to complications such as blocked fallopian tubes, adhesions (tissues that bind organs together), and issues with the intestines and bladder.

Preventing Endometrioma: An Overview

While endometrioma cannot be primarily prevented, certain interventions can reduce the risk of progression and recurrence after surgery. These interventions mainly focus on removing the endometriomas through surgery, lowering estrogen levels in the body, and increasing the impact of progesterone-like hormones.

Hormonal Control

Hormonal birth control methods, such as pills, patches, or rings with lower doses of estrogen, can help regulate the menstrual cycle and slow the progression of endometrioma. Intrauterine devices (IUDs) that release hormones may also be beneficial in reducing pain and bleeding.

Lifestyle Factors

Maintaining a healthy lifestyle can influence natural estrogen levels and potentially reduce the risk of endometrioma regrowth and progression. Regular exercise helps decrease body fat, which in turn lowers estrogen levels. Limiting alcohol and caffeine intake can also help, as excessive consumption of either can raise estrogen levels.

Medical Management

For those not trying to conceive, hormonal birth control is often the first line of treatment to manage symptoms.

Surgical Treatment

Excision surgery is usually considered the gold standard and the only treatment that truly removes the endometrioma lesions. The procedure involves removing the endometrioma while preserving as much healthy ovarian tissue as possible. Following surgery, hormonal treatment is typically resumed unless pregnancy is desired.

Complementary and Alternative Medicine (CAM) Therapies

In addition to conventional treatments, some individuals find relief from endometrioma symptoms through complementary and alternative medicine (CAM) therapies. These can include acupuncture, chiropractic, dietary changes, herbs, or supplements. It’s essential to discuss these approaches with your healthcare provider to ensure they’re safe and suitable for your specific needs.

In conclusion, while endometrioma cannot be prevented, understanding the condition, its risk factors, and potential treatments allows women to better manage their reproductive health. Regular check-ups, open communication with healthcare providers, and proactive lifestyle changes are all crucial in dealing with endometrioma and mitigating its effects on one’s life.


Chocolate Cysts: Everything You Need To Know

Management of ovarian endometrioma


Ureteral Endometriosis : Can Endometriosis Spread to the Ureter

Endometriosis is a chronic condition that affects approximately 10-15% of women between 15-50 and other genders as well. This medical condition, characterized by endometrial-like tissue outside the uterus, can impact various body parts. One of the lesser-known facts about endometriosis is its potential to spread to the urinary system, specifically the ureter. This article aims to shed light on the question: “Can endometriosis spread to the ureter?” and delve into the intricacies of this complex issue.

Prevalence of Ureteral Endometriosis

Ureteral endometriosis is a form of urinary tract endometriosis (UTE), which is a rare manifestation of deep infiltrating endometriosis (DIE). Ureteral endometriosis can be either extrinsic, where endometriosis lesions occur outside the ureter causing it to compress, or intrinsic, which happens within the muscular, inner layers of the ureter.

While UTE affects between 0.3% and 12% of endometriosis cases and between 20% and 52.6% of those diagnosed with DIE, ureteral endometriosis is even rarer. Within the entire urinary system endometriosis, the prevalence of ureteral endometriosis is approximately 10%.

Causes of Ureteral Endometriosis

As the exact cause of endometriosis itself is not fully understood, pinpointing the cause of ureteral endometriosis is even more complex. Theories that attempt to explain the origin of ureteral endometriosis include stem cells, immune factors, and retrograde menstruation. In some women, UTE might also be iatrogenic, resulting from previous Caesarean sections.

Read More: Can Endometriosis on Ureter Cause Kidney Shooting Back Pain?

Symptoms Linked to Ureteral Endometriosis

Symptoms of UTE often overlap with those of peritoneal endometriosis. Women with UTE typically experience pelvic pain and dysuria (pain with urination). They may also suffer from frequent urinary tract infections, changes to urination frequency, and hematuria (blood in the urine). However, distinguishing this pain from the one that arises as a result of other forms of pelvic endometriosis is difficult.

Ureteral endometriosis is very rare, with an estimated prevalence of 0.1%. Up to 50% of women with ureteral endometriosis are asymptomatic, 25% have colicky pain, and 15% have gross hematuria. Tissue biopsy and histopathological examination are the gold standard methods for the diagnosis of ureteral endometriosis.

Read More: Can Endometriosis Cause Bowel Issues?

Diagnosing Ureteral Endometriosis

Diagnosing ureteral endometriosis can be quite challenging. It is, therefore, important to consult a specialist who can listen to and understand your symptoms. The initial stages of diagnosis of endometriosis affecting any area include taking the patient’s medical history, followed by pelvic examination and imaging techniques such as ultrasound, sonohysterography, or magnetic resonance imaging (MRI).

Intravenous pyelogram (IVP) is a good imaging technique to predict intrinsic forms of ureteral endometriosis. IVP also helps to evaluate ureter structure after treatment. MRI and Transabdominal ultrasonography can help visualize ureter structure and obstruction in the pelvic region.

Laparoscopic excision surgery followed by histological examination is the gold standard for confirming endometriosis in the urinary tract.

Read More: Can Minimal Endometriosis Cause Infertility

Treating Ureteral Endometriosis

The aim of ureteral endometriosis treatment is to remove endometriosis lesions in the urinary tract and preserve renal function. In cases of mild ureteral endometriosis, medical management, such as combined oral contraceptives, progestin, and aromatase inhibitors, may help with symptoms. However, this is not a permanent solution, and disease progression is expected, so surgical methods are the best option.

The primary treatment for ureteral endometriosis is excision surgery. Although successful medical treatment outcomes have been reported in the literature, medical treatment alone cannot revert the fibrosis resulting from ureteral endometriosis that leads to ureter obstruction.


Ureteral endometriosis, though rare, can cause serious complications, including the potential loss of renal function. Clinical suspicion and preoperative assessment may assist in diagnosis and allow for a multidisciplinary pre-consultation. The laparoscopic surgical approach is based on the extent of the disease and its localization and can be carried out successfully by a highly skilled surgeon.

In conclusion, if there is no other obvious etiology for the presence of unilateral hydroureteronephrosis in women in their reproductive age, the diagnosis of endometriosis should be considered. Early detection and treatment of ureteral endometriosis are essential to prevent severe complications, including the potential loss of kidney function.


Ureteral Endometriosis


How to Treat Deep Infiltrating Endometriosis

Endometriosis, bad enough when endometrial-like cells grow outside the uterus and on the surface of other organs, has an even more troubling variant called Deep-Infiltrating Endometriosis (DIE).  This is a severe form of endometriosis defined by these abnormal cells burrowing or invading deeper into tissues and affected organs, like the bowel and bladder.  Generally, the depth cutoff to fit this category is more than 5mm below the tissue surface.  This guide will shed some light on how we treat and potentially cure deep infiltrating endometriosis in the future. At this time, a long-standing cure is still a stretch, even for superficial endometriosis.  

Understanding Deep Infiltrating Endometriosis

The good news is that this condition is relatively rare, affecting only about 1% of women of reproductive age and only 20% of those with endometriosis.  The bad news is that molecular data suggests it may be a premalignant disease, along with endometrioma type. However, this is still undergoing research, and the malignancy potential remains low.  However, when genetic mutations are shared with an aggressive disease like cancer, this may help explain why endometrioma and DIE types of endo are more likely to cause more local anatomic distortion and harm with pain and subfertility impact, as well as increased metastatic potential (i.e., spread to other parts of the body even if there is no associated cancer). 

Anatomic Comparison of Endometriosis Types

Based on the anatomical location of endometriosis within the pelvic and abdominal cavities, there are three major types of endo:

  • Superficial endometriosis (Peritoneal endometriosis or PEM): Lesions appear on the surface of organs outside the endometrium. Generally, but not always, they cause the least amount of tissue damage and distortion. 
  • Ovarian endometriomas (OE): Dark cysts due to old collected blood, also called chocolate cysts, develop in or on the ovaries due to endometriosis.
  • Deep infiltrating endometriosis: The most severe form, where the endometrial-like tissue invades deeper into the pelvic organs, wreaking more havoc.

Anatomic locations and clinical degree of disease form the basis for most of the staging systems that are currently used.  This is extremely “old school,” and we are about to step into a new age where molecular insights will help with diagnostics and treatment options because abnormal molecular pathways can be targeted with precision therapies.  

Molecular Comparison of Endometriosis Types

This is an evolving hot topic of research in endometriosis, which goes well beyond comparisons based on hormonal factors like receptor activity, up and down-regulation, and relative progesterone resistance.  It is too early to classify different types of endo by this gene mutation molecular pathway metric, but what is known so far might already help with recurrence and cancer risk mitigation.

What we know is as follows:

  • Endometriosis overall (PEM, OE, and DIE types) is a disease of genetic and molecular heterogeneity,  meaning multiple genes are affected. Some of these are mutations exactly like those found in cancer, even if no cancer is present or even destined to develop. This means endo may not be one disease entity between different individuals but rather different ones with varying degrees of aggressiveness. On the other hand, in any given individual, there is research data to support “clonal” molecular signature similarities between all three types of endo, meaning one type (e.g., PEM) advances or progresses to the other (OE or DIE).  
  • Mutations of interest include ARID1A, PIK3CA, KRAS, and PPP2R1A, among others
  • Endometrioma type carries the highest risk of malignant degeneration, and ARID1A is considered to be one of the most important driver mutations to clear cell cancer.  
  • DIE type has a wider range of mutations and is at a lower risk of malignant degeneration, but these mutations may contribute to its more aggressive behavior. 
  • OE-type risk for malignant degeneration may be higher than that for DIE because the molecular micro-environment differs between these two, with the ovaries possibly being more “permissive” to malignant changes.  This does not negate the aggressive, invasive, and potentially metastatic nature of DIE in the absence of cancer. 
  • Gene mutation expression varies based on epigenetic influences, including diet, lifestyle, toxin exposure, concurrent disease states, mind-body influence, etc. 

What does this all mean in summary?  Multiple genes are mutated in endometriosis, some of which may or may not lead to a low risk of cancer development but can dictate how aggressive endo types, especially DIE and OE,  can be in an individual.  These gene mutations can be suppressed or aggravated by epigenetic influences that you have some control over.  Evolving research is helping uncover diagnostic and prescription molecular treatment options based on all of this.   

Identifying Symptoms of Deep Infiltrating Endometriosis

The symptoms of DIE are similar to general endometriosis but usually more severe. They may include:

  • Severe pelvic pain
  • Painful urination (dysuria) of bleeding in the urine (hematuria)
  • Painful menstruation (dysmenorrhea)
  • Genital pain before, during, or after sex (dyspareunia)
  • Digestive discomfort and rectal bleeding
  • Distant symptoms like pain with breathing, related to possible diaphragm involvement

Causes and Risk Factors of Deep Infiltrating Endometriosis

Notwithstanding recent research advances, the exact cause of endometriosis, including DIE, is unknown.  A family history of endo and/or cancer are important to consider.  It is not likely that a single cause will be uncovered because of the probable multifactorial nature of endo.  However, molecular research is taking this to a different level. 

Diagnosing Deep Infiltrating Endometriosis

Since deep infiltrating endometriosis is an advanced form of endometriosis, its diagnosis can be challenging. Usually, multiple diagnostics are used, including medical history, physical examination, histological examination after surgery or upon biopsy (e.g., C-section scar endo), minimally invasive surgery, ultrasound, and MRI.  A 3-Tesla (“3T” for short) MRI is probably the most accurate modality, but it still has many shortcomings.  In other words, it can be helpful in planning for surgery but should not be used to determine definitively if DIE is present or not. It is as good as it gets but is imperfect, missing up to 20% of DIE. 

In many, if not most, cases, the diagnosis will only be apparent and confirmed at the time of surgery.  Since it is impossible to accurately predict the full extent of endo before surgery, this is the main reason that it is very prudent to pick the most skilled and experienced surgeon you can find. The more symptomatic you are, the more this is critical to your success. A botched surgery does not make it easier the second time around, and it exposes you to an increased risk of major complications.  

Treatment Options for Deep Infiltrating Endometriosis

Medical Treatments

Medical treatments for DIE are extremely limited and basically non-existent.  This is because the deep invasive infiltration of disease leads to scarring or fibrosis as your body tries to “wall off” or isolate  this disease and heal.  Any known medication cannot eliminate fibrosis.  What we are left with are pain relievers and hormonal options that are used in all forms of endo, for symptomatic relief and possibly some suppressive effect.

Integrative options are also an option for symptomatic relief, just as they are for any type of endo.  This includes mind-body-based biofeedback, nutrition, botanicals, essential oils, acupuncture and acupressure, electrical stimulation (TENS), etc.  It is best to formulate an integrative strategy with a relevant practitioner.  

Pelvic floor physical therapy (PFPT) is, of course, central to a treatment plan as well.  However, depending on lesion location, this should be undertaken with some caution due to possible disruption of deep lesions with internal therapies, making surgery potentially less effective.  A teamwork approach should be conducted to evaluate the best strategy.  

Surgical Treatments

Surgical excision of DIE lesions and associated fibrosis is by far the best path forward in most cases where DIE is anticipated and/or already diagnosed from prior surgery.  The usual admonitions of excision superiority over ablation are even more critical here because ablation or fulguration is totally useless for lesions of uncertain depth. Also, with ablation, there is an elevated risk of damaging tissues like the rectum, bladder, and ureters. 

A master surgeon is best equipped for DIE, and, in the author’s opinion, these types of cases should be performed robotically because of the far superior optics and wristed robotic instruments.  Further, the surgeon should either be able to handle bowel, bladder, and ureters, including reimplantation where required, or have a well-integrated team ready to participate in a planned fashion.  The problem is that it is hard to tell what will be required before surgery. Still, the best efforts through imaging-based mapping and attention to symptoms should be made to adequately prepare for resection/excision of anything found.   

DIE most definitely does not mean an automatic hysterectomy recommendation.  However, if childbearing is complete, this may need to be discussed for risk vs. benefit to remove all diseased tissue.  Similarly, the closer to menopause, the more disease and the higher the risk of malignancy due to family history or genetic testing, the more it is prudent to talk about the risk vs. benefit of ovarian conservation.  This should be highly individualized and thoroughly discussed for the best outcome. 

Considerations in Surgical Management

Indocyanine Green (ICG) Fluorescence

Indocyanine green (ICG) fluorescence imaging allows surgeons to visualize the details of the ureters and safely remove the maximum amount of infiltrating endometrial tissue without damaging the urinary tract.  It is also helpful to determine if a bowel segment that has been operated upon retains good blood supply and viability.  This helps avoid complications.  

Stenting During Partial Cystectomy or Ureteral Reimplantation

During bladder surgery for urinary endometriosis, surgeons can place stents (tiny plastic catheters) to help protect the ureters (the delicate tubes through which urine travels from the kidneys to the bladder) from further damage or to enhance healing after reimplantation.  

Pathology Evaluation

Other than standard pathology evaluation, research evidence suggests several newer assessments might be considered in DIE and OE.  Specifically, the more the disease looks clinically aggressive, the more the pathologist should ensure that there is no clear cell cancer component.  Beyond that, even with no evidence of cancer, the tissue specimens removed can be assessed for “mitotic index,” meaning whether the pathologist sees many dividing cells.  This is more often seen in aggressive disease, even in the absence of cancer.  This, in turn, may lead to consideration of some degree of well-tolerated hormone suppression (e.g., micronized progesterone) to potentially reduce recurrence risk. Finally, there are immunohistochemical (IHC) stains for some molecular abnormalities that gene mutations can spawn (e.g., ARID1A).  This is not readily available but can be considered, especially in a situation where cancer risk is elevated.  In the future, as discussed above, these aberrant molecular pathways will be targeted with precision therapies.  

Endometriosis and Fertility

Endometriosis, including DIE, can impact fertility. Consequently, surgeons should employ as many atraumatic surgical techniques as possible to avoid injuring delicate structures in the reproductive system and improve the chances of pregnancy.  This is optimized with the robotics platform. 


Deep infiltrating endometriosis adds a layer of complexity to the management of endo.  Surgery is the optimal therapy, followed by supportive care and strategies to mitigate recurrence if possible. Malignant degeneration is uncommon but possible, which means that, especially with a family history of cancer, genetics testing should be considered.  The more complex, the more the need for an endometriosis expert master surgeon in your corner. If the cancer risk is elevated for any of the reasons noted in this article, a gynecologic oncologist should be considered at least as a consultant.  


The Diagnosis and Treatment of Deep Infiltrating Endometriosis

Molecular analysis suggests oligoclonality and metastasis of endometriosis lesions across anatomically defined subtypes – ScienceDirect


How Common is Infertility with Endometriosis

Endometriosis, a medical condition affecting women globally, often poses a significant question:

how common is infertility with endometriosis? This article aims to shed light on this critical question, discussing endometriosis and its relationship with fertility issues, the possible causes and treatments, and the hope that exists for women battling both endometriosis and infertility.

Understanding Endometriosis

Endometriosis is a chronic disorder characterized by the growth of endometrial-like tissue (the lining of the uterus) outside the uterus, inducing a chronic inflammatory reaction. This misplaced tissue can be found on the ovaries, fallopian tubes, and even on the bladder or intestines. The growths can lead to complications, including the formation of scar tissue and cysts, causing pain and potentially affecting fertility.

Read More: Can Endometriosis Be Treated Without Surgery? – Endometriosis Supportive Therapy

Prevalence of Endometriosis

Endometriosis affects an estimated 10–15% of women between 15-50. However, the prevalence dramatically rises to about 25%–50% in women with infertility. Despite the well-supported association between endometriosis and infertility, a causal relationship is yet to be definitively established.

Endometriosis and Infertility: The Connection

Endometriosis can impact fertility in multiple ways, leading to the following complications:

  • Impact on Gametes and Embryos: The increased number of inflammatory cells in the peritoneal fluid of women with endometriosis can damage the oocytes (eggs) and sperm and even have toxic effects on the embryo.
  • Impairment of Fallopian Tubes and Ovarian Function: Endometriosis can lead to pelvic adhesions, blocked fallopian tubes, and damaged ovaries, which can hinder the process of ovulation and egg release, thus affecting fertility.
  • Endometrial Receptivity: The chronic inflammatory state induced by endometriosis can impair endometrial receptivity, affecting the implantation of a pregnancy.

Read More: Can Minimal Endometriosis Cause Infertility

Endometriosis-Associated Infertility: Treatment Approaches

The treatment for endometriosis-associated infertility usually involves a combination of medical and surgical interventions. The choice of treatment depends on several factors, including the age of the woman, the severity of the symptoms, the desire for pregnancy, and the extent of the disease.

Medical Treatment

Medical treatments for endometriosis aim to suppress the growth of endometriosis tissue and relieve symptoms. These treatments include hormonal therapies such as birth control pills, gonadotropin-releasing hormone (GnRH) agonists, and progestins. However, these treatments do not improve fertility rates and are typically used to alleviate pain and other symptoms. They are temporary solutions.

Surgical Treatment

Surgical treatment aims to remove endometrial tissue and restore normal pelvic anatomy. Surgical options include laparoscopy, a minimally invasive procedure. Studies have shown that surgical treatment can improve fertility rates, especially in women with severe endometriosis.

Assisted Reproductive Technology (ART)

In cases where medical and surgical treatments are unsuccessful, assisted reproductive technologies (ART) such as in vitro fertilization (IVF) may be considered. IVF involves the extraction of eggs from the ovaries, which are then fertilized with sperm in a laboratory. The resulting embryos are then transferred back into the uterus.

The Hope for Women with Endometriosis and Infertility

Despite the challenges posed by endometriosis, it’s crucial for women to know that having this condition does not necessarily mean they cannot get pregnant. With the right treatment approach, many women with endometriosis can successfully conceive and carry a pregnancy to term.

In conclusion, understanding how common infertility is with endometriosis is essential for providing effective treatment and support to women dealing with this condition. While endometriosis can indeed impact fertility, it’s important to remember that it’s not the end of the road. With advances in medical technology and treatments, many women with endometriosis are able to overcome their fertility challenges and fulfill their dreams of motherhood.

Read More: Life After Endometriosis Surgery: A Comprehensive Guide



Does Endometriosis Cause Bowel Problems

Endometriosis, a chronic medical condition that affects up to 10% of women worldwide, has a significant impact on various aspects of a woman’s life, including her bowel health. This article will explore the question:

“Does endometriosis cause bowel problems?”

and delve into the symptoms, causes, diagnosis, and treatment of this condition.

What is Endometriosis?

Endometriosis is a medical condition in which tissue resembling the endometrium, the lining of the uterus, grows outside of the uterus. This tissue can grow on various organs, including the ovaries, fallopian tubes, bladder, and even the bowel.

Endometriosis and Bowel Problems

Endometriosis can affect the bowel in various ways, leading to numerous digestive issues. Specifically, endometriosis can grow on or inside the bowel walls, causing symptoms that are often mistaken for other conditions like Irritable Bowel Syndrome (IBS).

Superficial and Deep Bowel Endometriosis

Bowel endometriosis can present in two forms:

  • Superficial Bowel Endometriosis: This is when endometriosis is found on the surface of the bowel.
  • Deep Bowel Endometriosis: This form of endometriosis penetrates the bowel wall.

In some cases, rectovaginal nodules can start as superficial endometriosis and progress to infiltrate the bowel wall.

Read More: Can Endometriosis Cause Bowel Issues?

Recognizing the Symptoms

The symptoms of bowel endometriosis are similar to those of IBS. However, they can vary with the menstrual cycle, worsening in the days before and during a period. Some common symptoms include:

  • Pain with defecation (dyschezia)
  • Deep pelvic pain during sex (dyspareunia)
  • Rectal bleeding during a period

If you experience these symptoms, it’s crucial to discuss them with your doctor. They may choose to use several techniques for diagnosis, such as a vaginal examination, ultrasound, sigmoidoscopy, laparoscopy, CT, or MRI scan.

Bowel Endometriosis: Causes and Risk Factors

While the definitive cause of endometriosis remains unknown, several potential contributing factors include hormonal imbalances, immune system problems, and genetic factors. Researchers have also found links to genes and stem cells, inflammation, and estrogen levels.

Read More: What Does Bowel Endometriosis Feel Like? Understanding the Pain and Symptoms

Diagnosing Bowel Endometriosis

Diagnosing bowel endometriosis can be challenging due to its similarities with other conditions like IBS. In addition to a physical examination and medical history review, doctors may suggest imaging tests such as transvaginal or transrectal ultrasound, magnetic resonance imaging (MRI), laparoscopy, or barium enema.

Treatment Options for Bowel Endometriosis

The treatment for bowel endometriosis typically involves a combination of painkillers, hormone treatments, and surgeries, depending on the severity of the symptoms. Surgery is usually recommended for bowel endometriosis, with the surgical options varying based on the severity of the condition and the areas affected.

There are three main surgery options for bowel endometriosis:

  • The affected segment of the bowel is removed, and the bowel is rejoined (re-anastomosis).
  • For smaller areas of endometriosis, the disc of affected bowel is cut away, followed by the closure of the hole in the bowel.
  • Affected areas can be “shaved” off the bowel, leaving the bowel intact.

Post-Surgery Recovery and Follow-up

Recovery after any surgery varies depending on the individual. After laparoscopic bowel surgery, you can generally expect to go home within four days. Bowel function may be altered after surgery, particularly with a full resection (re-anastomosis). This does improve over time, although watching your diet to see which food aggravate or improve the situation may be helpful.

The Impact of Delayed Treatment

If bowel endometriosis is not treated properly and promptly, the disease may progress, and quality of life significantly decreases. Small lesions on the bowel can eventually progress and become full-thickness lesions that cause obstruction and may require major bowel surgery.

The Importance of Specialist Care

Because bowel endometriosis deals with your gastrointestinal system, it’s usually not solely treated by a general gynecologist. A collaborative care approach between an endometriosis expert, gastroenterologist, and/or general surgeon may be necessary to treat your bowel endometriosis from all angles.

Read More: Finding an Excision Specialist: What you Need to Know


Understanding the link between endometriosis and bowel problems is vital for improving diagnosis and treatment outcomes. If you’re experiencing symptoms of bowel endometriosis, it’s important to discuss them with your doctor and consider seeing a specialist. In doing so, you’ll be taking an important step towards managing your symptoms and improving your quality of life.


Endometriosis and constipation


Endometriosis Treatment: Can Endometriosis Be Treated Without Surgery?

Endometriosis is an extremely painful chronic condition, which often also leads to infertility or subfertility, that affects about ten percent of women worldwide. It is characterized by growth of endometrial-like tissue, which normally lines the inside of the uterus, outside of the uterus on pelvic organs, the abdomen, bowel, and beyond. This tissue is not the same as the endometrium, characterized by very different behavior and unique molecular profiles.  

Eventually, personalized “theranostic” (therapy and diagnostic) tools will exploit these unique molecular profiles and lead to far better diagnosis, therapy and monitoring approaches.  Research is accelerating in this area, which is already very pervasive in other diseases such as cancer and various immuno-inflammatory conditions.   Meanwhile, the only therapies that are available to actually treat endometriosis, not just masking of symptoms, are hormonal options and excisional surgery.  However, there are major limitations to the argument that hormonal therapies work very well to treat endo rather than simply reduce symptoms.  That leaves surgery.

So, in a word, “can endometriosis be treated without surgery?”, the answer is a resounding NO!  That is not to say that hormonal and other treatments, including anti-inflammatory and perhaps anti-histamine agents (e.g. Zyrtec), both mainstream and integrative-holistic, don’t help. They might.  Let’s unpack this a little bit to give you a roadmap of the options.  

Understanding Endometriosis

The exact cause of endometriosis is technically unknown, but we know it is influenced by genetic, genomic, hormonal, immunologic and environmental epigenetic factors.  In other words, it is “multi-factorial”. This means the reason you may have endo could be different from why your friend or even your sister does.  Endo can also behave very differently because different factors are probably in play in different people. This makes a “standard treatment” hard, if not impossible, to recommend to any given patient.  This is changing with the advent of endometriosis bio-molecular pathway research, which will lead to highly individualized targeted treatments. But this is not part of what is available today. 

Diagnosis of Endometriosis

Diagnosing endometriosis is very challenging, because the symptoms can mimic other conditions. This is part of the reason that diagnosis is often delayed by 5-10 years and intentional or inadvertent gaslighting is rampant, depending on which specialist was consulted.  The doctor may be looking at you through a general practice medical lens, or intestinal, urologic, neurologic or other lenses in forming their opinions.   

Rule # 1 is to listen to the patient.  This is almost never done to an appropriate extent.  Why? Because today’s medical system limitations often lead to five-to-ten-minute visits with a semi-interested and overworked provider who is likely under-informed regarding endometriosis.  

When rule #1 is broken, an appropriate evaluation and testing is not likely to be done. Ideally, a clinical suspicion leads to testing that may include ultrasound or MRI, various blood tests, testing for associated conditions and so on.  None of these will reliably lead to a diagnosis of endo but can lead to appropriate specialist referrals to get to the root cause of pain, such as endo. 

Rule #2 in medicine, in general, is to get a diagnosis before recommending treatment.  This is because treatments can be ineffective when treating the wrong condition or, worse, can lead to complications and side effects.  Unfortunately, in the author’s strong opinion, this is often violated specifically in endometriosis treatment.  A common standard is to offer hormonal therapy to patients to see if it might work because the diagnosis might be endometriosis and endo is, in part, fueled by hormones. This may or may not be reasonable depending upon individual circumstances and choices. 

This brings us to rule #3, that we’ll cover next, which proposes that patients should be offered treatment options to select from after informed consent about the potential risks vs the potential benefits based on the best possible scientific evidence.  This is not always done very well and certainly depends on the “trust factor” with your selected specialist(s), since scientific evidence is subject to interpretation.  Most patients do not realize this.    

Conventional Treatment of Endometriosis

Traditional treatment for endometriosis often involves medication or surgery. Medications can include anti-inflammatory pain relievers and hormonal therapies.  In the near future medications will include targeted biomolecular non-hormonal therapies, but they are not here yet.  Pain relievers are mainly a symptom reducing band-aid and are not intended to treat, so we will not discuss them here either.  They can certainly help in overall management, but we will focus on “treatment” in this article.  

Hormones aim to either shut down ovarian function (in other words, cut off estrogen) or at least regulate the menstrual cycle, and progesterone analogs, to potentially reduce the growth of endometriosis tissue. 

Surgery is used for definitive diagnosis of endo as well as treatment by removing any lesions or implants that are found.  In some cases, the two modalities can be used hand in hand, but the order in which they are used, and the nature of the proposed hormonal therapy are important considerations.  

Hormonal Treatment

International guidelines are very confusing and inconsistent regarding hormonal therapy for endometriosis. Because of this, recommendations can vary between practitioners.  We won’t delve into all these options here, but the following are excellent summary articles on this important topic. 

The important points to consider are as follows:

  1. The ONLY way currently to definitively diagnose endometriosis is through biopsy, usually performed during surgery.
  2. Starting treatment that can cause extreme side effects and potential long-term harm without first getting a definitive diagnosis seems imprudent.  So, if a practitioner offers hormones because they “think” you have endo based on history, examination and perhaps some scans, at least get a second opinion from an endometriosis specialist.  This approach is within international guidelines but can cause you a world of misery and potential harm if not managed in expert hands. 
  3. Hormone therapy for endo boils down to either reducing estrogen levels or eliminating estrogen altogether or increasing progestational agent levels to try to medically eliminate endo lesions. Reducing estrogen levels is not possible since there are different types of estrogen, different sources of estrogen and endo lesions themselves can influence local production of estrogen. 
  4. Endometriosis cells differ from endometrial cells that are found in the uterus by being relatively resistant to synthetic progestin or natural micronized progesterone therapy. 
  5. Hormonal therapy is known to reduce pain when endometriosis is the cause. However, studies have shown that pain relief is possible but hormonal therapy fails to significantly retard the growth of endometriosis tissue when objectively tested in pathology laboratories.  Further, hormonal therapy cannot eliminate scar tissue or fibrosis caused by endo and this fibrosis by itself can be a cause for pain.
  6. While unproven, under some circumstances it may be prudent to use less toxic hormonal therapy options to potentially reduce the risk of endo recurrence after surgery.  

Surgical Treatment 

When symptoms, history, physical exam, scans and laboratory evidence all point to endometriosis as a strong possibility to be the root cause of pain, and/or infertility, minimally invasive surgery should be considered to find out for sure.  If endo is diagnosed, then medical hormonal therapy may make sense as part of a highly individualized treatment plan under the guidance of an endo specialist. 

The caveat to considering endometriosis surgery is that there are, of course, potential risks and complications even though it is minimally invasive.  These risks can be minimized in the hands of an expert surgeon, but they should be considered in a risk-benefit discussion.  

More importantly, assuming you have identified an expert endo excision surgeon, surgery is the cornerstone to current effective treatment.  While incompletely proven, for many reasons, it appears that excision of endo lesions and scar tissue (fibrosis) rather than burning them away (fulguration) is a better and safer approach.  To discover more about surgical considerations, consider the following articles. 

Integrative Holistic View of Endometriosis

Since the cause of endo is incompletely understood, but highly multifactorial, and because the reason endo is present in any given individual may vary, either surgery or hormonal therapy or both may fail.  Failure is relative. In other words, failure may be defined as no immediate pain improvement, persistent subfertility, or it may mean recurrence years later.  These are very different scenarios, requiring different approaches.  Also, it’s important to consider whether or not associated conditions have been addressed, such as SIBO or other microbiome irregularities, other inflammatory immune-modulated disease and so on.  Finally, pelvic floor physical therapy is not just a symptom band-aid but a critical co-treatment for pelvic floor function before and after surgery. These topics are all beyond the scope of this article, but you can discover more by reading the following articles. 

If expert excision surgery and supportive hormonal therapy, when used, fails to alleviate pain then supportive pain management can still improve quality of life.  This can be mainstream pain and anti-inflammatory medications like non-steroidal anti-inflammatory (NSAID), nerve block injections, electrical stimulation modalities and/or more holistic approaches including acupuncture, acupressure, mind-body biofeedback approaches such as HeartMath, herbals, aromatherapy and more.  

Kicking it up a notch, here is something you do not see covered much other than in a very superficial manner.  It is not rocket science but is not simplistic at the potential treatment level either.  However, it is something you can implement in a proactive way at any point in your journey.  Specifically, this is the impact of nutrition and lifestyle choices, as well as well-selected and targeted supplements, but drilled down a lot further than simply eating right, exercising and de-stressing.

Upcoming bio-molecular therapies will target specific biological pathways that we are now beginning to better understand.  Many pathways are already identified, many not.  The problem is that there are no mainstream medical therapies, yet which can target these pathways safely and effectively.  We know from other related genomically modulated inflammatory diseases, like cancer and auto-immune disorders, that these treatments take a while to develop and offer safely.  Meanwhile, many of the genomic, metabolic and epigenetic abnormalities that influence endo are known or at least partly known.  With few exceptions, while it is too early to safely use pharmaceutical agents to modulate these abnormalities, nutrients, specific exercise, toxin avoidance, and even state of mind can affect the same pathways abnormalities without risk.  

Nutrigenomics and Epigenetics


How do toxins or stress adversely affect your health, while healthy diet and exercise positively influence your health? In large part, relatively new sciences like metabolomics and genomics, and their derivatives, explain this.  You are born with your genes and, so far, you can’t alter that deck of cards.  Some genes may be “bad” and increase your risk of endo, as well as other diseases. However, not everyone with some bad genes develops disease.  The most famous examples are identical twins who inherited the exact same genetics yet might look a little different (e.g. eye or hair color) and often get different diseases.  Why? 

Anything and everything you eat, drink, get exposed to via skin or breathing, or even think about or emote, can affect your genes through epigenetics.  This means these substances and neurochemicals, good or bad, can turn genes on and off.  Of course, it is infinitely more complex than that and multiple genes affect one process in many cases. However, you can actively modulate your inflammatory and oxidative state.  Do we know what veggie or what thought or what toxin turns what specific gene on or off?  No.  But we do know how these gene-controlled pathways synergize and work together to create health or facilitate disease.    


Surgery is a cornerstone to definitive diagnosis of endo and serves as very important part of treatment.  The path to success is a correct diagnosis, attention to detail and a highly individualized treatment plan.  This can only be carried out in consultation with endometriosis specialists in medical and surgical management.  

Unfortunately, it is not easy to find someone or a team that can fit your needs, but it is a crucial step forward to seek out the best you can.  The more complex your situation (e.g. possible advanced disease or repeat surgery) the more you need an excision surgeon with master surgeon skills.  Ideally you want a specialist who is not only a surgeon but also capable of guiding you through any additional treatment options you may need, mainstream and holistic.  While a master excision surgeon and integrative endo specialist is hard to come by, many have a team that can fulfill your needs.


Endometriosis: Etiology, pathobiology, and therapeutic prospects

Brassica Bioactives Could Ameliorate the Chronic Inflammatory Condition of Endometriosis

Diet and risk of  endometriosis in a population-based case–control study

Emerging Drug Targets for  Endometriosis

The effect of dietary interventions on pain and quality of life in women diagnosed with  endometriosis: a prospective study with control group

Updated Post: July 09, 2024


Can Endometriosis Grow Inside the Bladder

Endometriosis, a medical condition that affects many women worldwide, is often associated with the reproductive system. However, this disorder can manifest in other regions of the body, leading to a pertinent question:

Can endometriosis grow inside the bladder?

In this article, we will explore the nature of endometriosis, its ability to affect the bladder, the related symptoms, causes, diagnosis, and available treatment options.

Understanding Endometriosis

Endometriosis is a gynecological condition where cells similar to the ones lining the uterus, known as endometrial-like cells, grow outside of the womb. These cells can attach themselves to various organs such as the ovaries, fallopian tubes, and in rare instances, the bladder. This phenomenon is known as bladder endometriosis.

Read More: Endometriosis and Inflammatory Bowel Disease: Distinguishing the Differences

Bladder Endometriosis: An Overview

Bladder endometriosis is a specific form of endometriosis where endometrial-like cells grow inside or on the surface of the bladder. These cells respond similarly to hormones as the cells within the womb, causing them to build up, break down, and bleed. However, being outside of the uterus, these cells have no way of exiting the body, leading to inflammation, pain, and scar tissue.

Bladder endometriosis is considered a rare form of the disorder, affecting only about 1 to 2% of patients with endometriosis. However, for those suffering from deep endometriosis (DE), a severe form of the condition, the prevalence increases to nearly 50%.

There are two types of bladder endometriosis:

  • Superficial Endometriosis: Endometrial-like cells are found on the outer surface of the bladder.
  • Deep Endometriosis: Endometrial-like cells infiltrate the bladder lining or wall. This infiltration can cause a nodule, potentially affecting the ureter.

Read More: What Does Bowel Endometriosis Feel Like? Understanding the Pain and Symptoms

Recognizing the Symptoms of Bladder Endometriosis

The symptoms of bladder endometriosis can vary, often aligning with the menstrual cycle and intensifying during or just before a period. However, many women may remain asymptomatic until the disease has progressed significantly.

Common symptoms of bladder endometriosis include:

  • Bladder irritation
  • Urgency to urinate
  • Pain when the bladder is full
  • Occasional presence of blood in the urine during menstruation
  • In some cases, pain in the area of the kidneys

Identifying the Root Causes of Bladder Endometriosis

The exact cause of bladder endometriosis remains unknown. However, several theories have been proposed, including:

  • Early Cell Transformation: Cells leftover from embryonic development may transform into endometrial-like cells.
  • Surgery: Endometrial cells may spread to the bladder during pelvic surgeries, like a cesarean delivery or hysterectomy.
  • Hematogenous/Lymphatic Spread: Endometrial-like cells might travel through the blood or lymph system to the bladder.
  • Genetic Factors: Endometriosis has been observed to run in families, indicating a possible genetic link.

Diagnosing Bladder Endometriosis

Bladder endometriosis is diagnosed through a comprehensive evaluation involving a physical examination, medical history, and various diagnostic tests. These tests may include:

  • Vaginal examination
  • Ultrasound
  • Urine sample analysis
  • Cystoscopy and Laparoscopy
  • CT and/or MRI scan

Bladder Endometriosis Treatment Options

The primary aim of bladder endometriosis treatment is to control symptoms and inhibit the growth of endometrial-like cells. Treatment options include:


Hormone therapy can slow the growth of endometrial-like cells, relieve pain, and help preserve fertility.


Surgery is typically required for bladder endometriosis. The surgical options can vary depending on the severity and area affected. The areas affected by endometriosis can be excised to remove them.

Complications and Prognosis

If left untreated, bladder endometriosis could lead to kidney damage. However, surgery can prevent this complication. The condition doesn’t directly affect fertility, but if endometriosis is present in other parts of the reproductive system, conceiving might be challenging.

Endometriosis, including its bladder variant, is a chronic condition that can impact daily life. Yet, it can be effectively managed with proper treatment and a supportive healthcare team.

Read More : Life After Endometriosis Surgery: A Comprehensive Guide

Final Thoughts

So, to answer the question, Can endometriosis grow inside the bladder? — yes, it can. However, through increased awareness, early diagnosis, and effective treatment strategies, bladder endometriosis can be managed, improving the quality of life for those affected.


Bladder Endometriosis symptoms

Endometriosis Symptoms And Treatments


Do Endometriomas Automatically Make You Stage 4?

Endometriosis, a complex and often painful condition, is characterized by the growth of endometrial-like tissue outside the uterus. This tissue, which differs molecularly and in behavior from the lining of the uterus, can cause severe discomfort and various health complications. One such complication is the formation of endometriomas, sometimes referred to as “chocolate cysts”, which predominantly affect the ovaries. They’re named for their dark, chocolate-like appearance, resulting from the accumulation of old blood within the cyst.

But does the presence of endometriomas automatically classify a patient as having stage 4 (also designated Stage IV) endometriosis? This primer delves into the stages of endometriosis, the nature of endometriomas, and the relationship between the two.

Understanding Endometriosis and Its Stages

Endometriosis is categorized into four stages according to the American Society of Reproductive Medicine (ASRM), with each stage reflecting the location, extent, and superficial vs deep endometriosis implants, presence and severity of adhesions, and the presence and size of ovarian endometriomas.  The current revised ASRM system (rASRM) was adopted in 1996 and remains the most common staging system.  Unfortunately, there is a lot of inter-observer variation, so reproducibility of the score is poor.  It also is limited because it mixes visual staging and actual biopsy proven staging.  So, one surgeon might call it one stage and another surgeon may arrive at a different stage.  In addition, rASRM stages do not correlate well with degree of pain and does not fully consider presence and location of deeply infiltrating endometriosis (DIE).  

For all of the above reasons, other staging systems have been introduced.  The ENZIAN system, which more robustly considers the location and depth of DIE, was intended to supplement the rASRM system but due to numerous misunderstandings it is not widely used.  The endometriosis fertility index (EFI) focused mainly on predicting pregnancy rates. The American Association of Gynecological Laparoscopists (AAGL) proposed a comprehensive system to try to address pain, infertility/subfertility, and surgical excision difficulty. However, it was only recently published in 2021, continues to have limitations of not addressing upper abdominal and extra-abdominal disease, and is not yet widely accepted.

So, we are left with the rASRM system in terms of best communicating surgical outcomes, treatment planning and comparing results.  The Stages are based on a numerical score and are as follows:

Stage I: Minimal Endometriosis

In stage I, there are only a few small clumps of endometriosis tissue, also known as implants. These may be found in the tissue lining the abdomen or pelvis. 

Stage II: Mild Endometriosis

In stage II, there are more implants than in stage I, which may be either superficial or deep, with mild adhesions. Stage II is typically characterized by more extensive endometriosis with deep implants present.

Stage III: Moderate Endometriosis

In stage III, deep implants of endometriosis tissue are present. Adhesions may be dense rather than filmy and thin. As a result, endometriosis at this stage is more widespread than in stage II.

Stage IV: Severe Endometriosis

Stage IV, or severe endometriosis, is typically associated with numerous deep endometriosis plaques, large endometriotic cysts on one or both ovaries and many dense adhesions. There is usually also extensive scar tissue in the abdomen and signs of intense inflammation and scarring or fibrosis.

Read More: Can Endometriosis Cause Bowel Issues?

The Nature of Endometriomas

Endometriomas are endometriosis cysts that primarily affect the ovaries. Endometriomas can occur on one ovary or both and affect between 20-40% of patients with endometriosis, many of whom also have stage III-IV disease. The origin of endometriomas is incompletely known, just like endometriosis in general, but likely multifactorial in principle. 

Endometriomas and Stage 4 Endometriosis: The Connection

The question is, “Do endometriomas automatically make you stage 4?” The answer is not straightforward. The presence of ovarian endometriosis or an endometrioma of course contributes to the staging of endometriosis. Each ovary can contribute between 1 and 20 points, varying based on tiny implants to endometriomas greater than three centimeters in size.   However, the presence of endometriomas alone does not automatically classify a patient as having stage 4 endometriosis, which requires 40 or more points.  In addition to ovarian endometrioma,  presence or absence of surrounding adhesions also contributes to the point total. Also, larger endometriomas are often associated with extensive deep pelvic disease.  So, in general, small endometriomas may not mean Stage 4.  But larger ones are quite likely to mean Stage 4 disease is present.  

Read More: What Does Bowel Endometriosis Feel Like? Understanding the Pain and Symptoms

Treatment Options for Stage 4 Endometriosis and Endometriomas

The treatment of stage 4 endometriosis and endometriomas is complex and highly individualized. It depends on various factors, including the patient’s symptoms, age, desire for pregnancy, and overall health.

Treatment options for stage 4 endometriosis can include a combination of hormonal therapy, pain management, and surgery. While hormonal therapy may help control pain it is highly unlikely to shrink endometriomas, let alone resolve them, or effectively treat endometriosis.  This is due to the relative resistance of endometriosis to progesterone and progestins and incomplete dependence on estrogen.  There are major potential health risks and this should be part of the discussion with your chosen endometriosis specialist.  Pain management strategies include over-the-counter and prescription medications, as well as physical modalities like pelvic floor therapy and transcutaneous electrical nerve stimulation (TENS) units.  While this can help manage chronic pain associated with the condition this does not treat the root cause, which is endometriosis and resulting fibrosis.

Minimally invasive surgery under the care of an extremely well trained surgeon is the cornerstone of advanced endometriosis treatment.   This is not surgery that should be undertaken by novices or most general gynecologists.  The reason is mainly due to the fact that anatomy can be severely distorted, making surgery very challenging in terms of achieving excision while limiting complications which can be life threatening or at least very morbid. 

Specifically regarding endometriomas, endometriomas require excision, not drainage.  Draining is very ineffective and the endometrioma can soon recur.  Ideally, any surgical spillage should be minimized because it is not just old blood but also potentially endo-related stromal stem cells, which can implant and grow elsewhere.  Overall, the planning and timing of surgery varies significantly.  Often decisions have to be made based on whether or not fertility is the main concern or pain, or both in equal degrees.  Surgical planning is complex and requires a master surgeon for optimal outcomes.  Especially for the management of Stage 4 endometriosis and endometriomas a highly trained and skilled endometriosis specialist and surgeon is mandatory for your success. 

Read More: Life After Endometriosis Surgery: A Comprehensive Guide


Risk factors for coexisting deep endometriosis for patients with recurrent ovarian endometrioma

Diagnosis and management of endometriosis


Endometriosis-Related Infertility – Minimal Causes

Endometriosis, a common gynecological condition, has been frequently associated with infertility. However, the question remains: can minimal endometriosis cause infertility? This comprehensive article aims to delve into the connection between endometriosis, particularly in its minimal stage, and fertility issues.

Defining Endometriosis

Endometriosis is a medical condition characterized by the growth of endometrium-like tissues outside the uterus. These tissues can adhere to various pelvic structures like the ovaries, fallopian tubes, and even the intestines and bladder, causing irritation, inflammation, and scar tissue formation.

Stages of Endometriosis

Endometriosis is categorized into four stages:

  • Stage I (Minimal): Small endometriotic implants with no scar tissue.
  • Stage II (Mild): More extensive implants, involving less than 2 inches of the abdomen, without scar tissue.
  • Stage III (Moderate): Severe endometriosis with deep implants and possible formation of endometriotic cysts or ‘chocolate cysts’ in the ovaries.
  • Stage IV (Severe): Numerous endometriotic implants, possibly large endometriotic cysts in the ovaries, and scar tissue formation around the reproductive organs.

Read More: Understanding How Endometriosis Can Cause

The Connection Between Endometriosis and Infertility

It’s estimated that 30% to 50% of women with endometriosis may experience infertility. Even in cases of minimal or mild endometriosis, the disease may still impact fertility in numerous ways, including:

  • Distorted pelvic anatomy due to scar tissue and adhesions
  • Inflammatory response causing a hostile environment for eggs, sperm, and embryos
  • Altered immune system functionality
  • Changes in the hormonal environment affecting egg quality and embryo implantation

However, it’s essential to note that endometriosis does not necessarily equate to infertility. Many women with endometriosis, even in severe stages, can conceive naturally or with fertility treatments.

Exploring the Question: Can Minimal Endometriosis Cause Infertility?

The impact of minimal endometriosis on fertility is a contentious subject. The disease, even at its earliest stage, can cause inflammation and subtle changes in the pelvic environment, potentially affecting fertility. However, many women with minimal endometriosis conceive without issues, leading some researchers to suspect that other factors, possibly genetic or immunological, might be at play in cases of endometriosis-associated infertility.

Diagnosing Endometriosis

Diagnosing endometriosis can be challenging, as many women with infertility migh experience no symptoms. The gold standard for diagnosis is a surgical procedure known as laparoscopy, allowing the doctor to visually inspect the pelvic organs for endometriotic lesions and scar tissue, and take samples for histopathology.

Read More: Life After Endometriosis Surgery: A Comprehensive Guide

Evaluating Fertility

Before initiating any fertility treatment, a comprehensive fertility evaluation is recommended. This includes hormonal and blood tests, an assessment of ovarian reserve, a sperm analysis for the male partner, and possibly a laparoscopy to confirm the presence and extent of endometriosis.

Read More: Pelvic Floor Physical Therapy: What you Need to Know

The treatment approach for endometriosis-related infertility is multifaceted, depending on the stage of endometriosis, the woman’s age, and the presence of other fertility factors.

Surgical Treatment

For women with Stage I or II endometriosis, surgical removal of endometriotic tissue may improve pregnancy rates. However, for women aged 35 or older, other fertility treatments might be recommended in addition to surgery.

Medical Treatment

Medical treatments aim to suppress endometriosis growth by reducing estrogen levels. However, these treatments, including hormonal contraceptives and Gonadotropin-Releasing Hormone (GnRH) agonists, prevent pregnancy during use.

Assisted Reproductive Technology (ART)

In cases where pregnancy does not occur naturally or following surgery, ART methods such as Intrauterine Insemination (IUI) or In Vitro Fertilization (IVF) may be recommended. The success rates of these treatments vary depending on the woman’s age, ovarian reserve, and specific fertility issues.

Conclusion: Can Minimal Endometriosis Cause Infertility?

While minimal endometriosis can potentially affect fertility, it does not guarantee infertility. A comprehensive evaluation and personalized treatment plan can help women with endometriosis, even at minimal stages, to conceive successfully. However, further research is needed to fully understand the complex relationship between endometriosis and fertility.



Diaphragmatic Endometriosis: An In-Depth Analysis

Diaphragmatic endometriosis is a chronic health condition that manifests when tissues akin to the endometrial lining start to grow outside the uterus. This exogenous growth of endometrial-like tissue can be found in various areas such as the ovaries, fallopian tubes, and bladder. However, endometriosis can also occur in less common areas like the diaphragm, organs in the upper abdomen, like the stomach, in the retroperitoneum like the lymph nodes and kidneys, and so on.  Of these uncommon findings, finding some amount of endo on the diaphragm is perhaps most common. 

Understanding the Diaphragm

The diaphragm is a large, dome-shaped muscle located beneath the lungs, responsible for the crucial function of respiration. Acting as a separation between the abdominal and thoracic (chest) cavities, its involuntary contraction and relaxation facilitate the breathing process. The diaphragm also has openings that allow important structures such as the esophagus and major blood vessels to pass through.

What is Diaphragmatic Endometriosis?

In most cases, diaphragmatic endometriosis affects the right side of the diaphragm. The endometrium-like tissue that builds up on the peritoneal surface of the diaphragm reacts to the menstrual cycle’s hormones in the same way it does in the uterus, which can cause a range of symptoms in the affected individuals.

Read More: Understanding How Endometriosis Can Cause

Symptoms of Diaphragmatic Endometriosis

The most common symptoms of diaphragmatic endometriosis include pain in the chest, upper abdomen, right shoulder, and arm. This pain typically occurs around the time of your period and may get worse when you take deep breaths or cough. In rare cases, if it grows through the diaphragm and involves the lungs, it can lead to a collapsed lung.  This is known as catamenial pneumothorax. However, diaphragmatic endometriosis can often be asymptomatic while only small superficial implants are present.  Hence, surgery usually involves at least looking at the diaphragms to document if there are any endo implants even if there are no symptoms in that area. 

Causes of Diaphragmatic Endometriosis

The exact causes of diaphragmatic or other types of endometriosis remain unknown.  However, it is plausible that endo cells from the pelvis can travel throughout the abdomen and up into the diaphragm. What makes them implant and grow there is unknown.  Alternatively, there are other possible etiologies, such as lymphatic or blood stream spread to this area or direct transformation of stem cells or growth of embryologic remnants into endometriosis implants.  This is all likely facilitated or repressed by genetic and genomic molecular signalling that is only now coming to be appreciated and unraveled.  

Read More: What Does Bowel Endometriosis Feel Like? Understanding the Pain and Symptoms

Diagnosis of Diaphragmatic Endometriosis

Diagnosing diaphragmatic endometriosis can be challenging. Diagnosis often involves a combination of medical history, physical examination, and imaging tests such as a CT (computed tomography) scan or MRI (magnetic resonance imaging).

The most reliable way to diagnose diaphragmatic endometriosis is via minimally invasive laparoscopic or robotic surgery. Ideally, the surgeon who is excising endo in the pelvis can also remove diaphragmatic implants or have a surgeon available as part of the team, who can do so. In the much rarer event that endo is suspected to be inside the chest and/or growing on or in the lungs, a thoracic surgeon should be consulted.

Treatment of Diaphragmatic Endometriosis

Surgery is the main treatment for diaphragmatic endometriosis and this can usually be accomplished using minimally invasive laparoscopic or robotic surgery.  Again, the excision surgeon or surgical team should be capable of removing endo from the diaphragms.  

In some cases, endo is not suspected to be growing on the diaphragm.  In that case, if the surgery cannot be safely accomplished by the surgeon or surgeons on the team, it is best to back out and not cause more harm than good.  The diaphragm is very thin and it is rather easy to enter the chest as part of the excision.  In expert hands, that is not a problem. However, going one step beyond diaphragmatic endo, if it is unclear whether or not the endo may be crossing into the chest cavity it is best to back out, re-evaluate with proper imaging and consultation and perform the surgery with a thoracic surgeon at a later date.  

Complications of Diaphragmatic Endometriosis

In relatively rare cases, endometriosis of the diaphragm can lead to defects or holes forming in the diaphragm. Endo can then grow into the chest cavity and possibly involve the lungs. This can lead to life-threatening complications such as a collapsed lung during your period (catamenial pneumothorax) or significant bleeding into the chest, also compressing the lung.  

Read More: Can Endometriosis on Ureter Cause Kidney Shooting Back Pain?


In conclusion, while it is relatively uncommon, endometriosis can indeed spread to your diaphragm. Under more rare circumstances it can even grow into the chest and lungs.  Expert endometriosis consultation and care is always prudent.  But if you are experiencing upper abdominal or chest symptoms as discussed this this article, it become crucial.  



Can Ureteral Endometriosis Cause Kidney Shooting Back Pain?

Endometriosis is a common gynecological condition that affects many women during their reproductive years. While it typically manifests in the pelvic region, in some instances, it may invade other organs, including the urinary system. This article explores the question: Can endometriosis on the ureter cause kidney shooting back pain?

About Endometriosis

Endometriosis is a chronic disease characterized by the presence of endometrial-like tissue outside the womb. This could include the ovaries, fallopian tubes, and the lining of the pelvic cavity. In some extreme cases, endometrial tissue may also affect organs outside the pelvic cavity, such as the bladder, bowel, or kidneys.

Read More: Understanding Endometriosis: Unveiling the Common Symptoms and Their Impact

Understanding Ureteral Endometriosis

Ureteral endometriosis is an uncommon manifestation of the disease, accounting for about 1% of all endometriosis cases. It involves the ureters, the tubes that transport urine from the kidneys to the bladder. This condition can lead to urinary tract obstruction, resulting in hydronephrosis, which is the swelling of a kidney due to a build-up of urine.

The Kidney-Endometriosis Connection

The kidneys can be impacted when one or both of the ureters become affected by endometriosis. The section of the ureter that is usually affected sits below the pelvic area.

Symptoms of Kidney Endometriosis

Kidney endometriosis can be asymptomatic for several years. If a person who has undergone surgery to treat endometriosis has ongoing urinary problems such as pain and infections, it may suggest the presence of urinary tract or kidney endometriosis. Symptoms may include:

  • Pain in the lower back that gets worse with a monthly menstrual cycle. That pain can also extend down through the legs.
  • Blood in the urine that can co-occur with the menstrual cycle
  • Difficulty urinating
  • Recurrent urinary tract infections

Read More: Understanding How Endometriosis Can Cause

Diagnosis of Ureteral Endometriosis

The diagnosis of ureteral endometriosis relies heavily on clinical suspicion. As a result, they often misdiagnose patients with kidney cancer. This can lead to patients not receiving treatment on time, or receiving the wrong kind of treatment.

Read More: Life After Endometriosis Surgery: A Comprehensive Guide

Treatment Options

Kidney endometriosis can lead to kidney damage and even kidney failure if left untreated. However, the best approach is to treat the condition by removing endometriosis lesions with minimally invasive laparoscopic surgery.

The Silent Threat of Kidney Failure

One of the most concerning aspects of ureteral endometriosis is the silent threat of kidney failure. It is estimated that as many as 25% to 50% of nephrons are lost when there is evidence of ureteral endometriosis, and 30% of patients will have reduced kidney function at the time of diagnosis.

Impact on Kidney Health

The good news is that if one kidney isn’t functioning due to endometriosis, you can survive on the other kidney. So, if you find out you only have one fully-functioning kidney, it’s essential to take care of it.


In conclusion, while endometriosis is typically a pelvic condition, it can venture beyond and affect the urinary system, including the kidneys. This can lead to severe complications, including kidney failure. Therefore, it’s crucial for women with endometriosis to be aware of the potential symptoms and seek medical advice if they experience any signs of kidney problems. The early detection and treatment of ureteral endometriosis are crucial to preserving kidney function and overall health.


Endometriosis: Perilous impact on kidneys


iCareBetter Launches Center For Endometriosis Long-Term Care

iCareBetter Launches  Center For Endometriosis Long-Term Care

Based on patients’ needs and considering the lack of appropriate endometriosis care, iCareBetter launches Endometriosis Centers for long-term care. The centers’ focus will be long-term endometriosis care before and after excision surgery. We will collaborate closely with excision surgeons, physical therapists, and other providers on iCareBetter to offer long-term multidisciplinary care to endometriosis patients. We believe that excision surgery is the gold standard of treatment for endometriosis, and we also believe that patients need an ongoing care plan and monitoring after excision surgery, even if the best surgeons in the world do it.

This is Dr. Saeid Gholami, the founder of iCareBetter. I have an important announcement to make today. But first, let me take you on a journey with me through the last three and a half years. 

Phase I – it starts with surgery. 

In my exposure to endometriosis patients as a medical student and then as a primary care doctor, I have always tried to find a solution to identify trusted resources for patients. A few years ago, right at the beginning of the pandemic, while the world was going upside down, I started working with a team of the best endometriosis surgeons and advocates to create a vetting system to find and introduce skilled excision surgeons. The vetting was based on a New England Journal of Medicine article and assessed surgical videos in a double-blind process.

This vetting made some people uncomfortable. However, the vetting confirmed the skills of the best surgeons in the world and introduced some new excision surgeons with a limited chance to prove themselves in a space where everyone claimed expertise without proof. This led to a transparent process that let patients make informed decisions about their excision surgeons. This innovation put us on the map and made us a significant platform in the endometriosis world. 

Phase II – add multiple disciplines 

After successfully launching video vetting for surgeons, we sought other opportunities to support endo patients. Our conversations with patients taught us that the community needs vetted physical therapists (PT) who understand endometriosis and its complex care requirements. Therefore, we introduced the iCareBetter Physical Therapy vetting and built a network of PTs. Our list of PTs kept growing, and after two years, many advocates and patients are using it daily and promoting the importance of physical therapy for endometriosis patients. The PT directory has been very helpful for patients, and we have over 120 physical therapists in almost all the US states. And thousands of patients have used iCareBetter to find a PT to help with their endometriosis.

Similarly, we added urologists, dietitians, and pain specialists so patients can use iCareBetter for most of their endo-related issues.

Phase III – Artificial Intelligence for endometriosis

Right after the launch of Chat-GPT and the excitement around artificial intelligence (AI), we launched an AI-powered chat tool called endometriosis.AI. This created massive excitement, and many patients started using it. As a result, we ran out of server capacity within three days after launch and had to shut it down to avoid going into debt for server costs. As I am speaking with you, thousands of patients have used it and keep using it to acquire information about endometriosis. With the launch of, we made endometriosis the first disease community to have its specialized AI discussion. This was in sharp contrast with the history of endometriosis, which is always among the last diseases to be considered in other situations, such as surgical tools, medications, and others.

Moreover, we have published hundreds of articles and interviews to create an education hub for endometriosis.

We currently have over 200 providers in our network, and 30,000 patients use our services each month.

I am incredibly proud of what we have achieved.


iCareBetter Clinic

Phase VI – Begins iCareBetter Centers for Long-Term Care.

One question that patients commonly asked us was, “Where can I go before surgery or after surgery for long-term care?” 

We searched the medical community for the right centers to help with this long-term care. Our non-negotiable criteria were simple: These centers should not dismiss patients and avoid putting endo patients on hormones as “the cure for endo.” 

To my frustration and shock, no center expressed interest in seeing more endometriosis patients. We even purchased the emails of ten thousand OBGYNs in the US and invited them to join our network and support endo patients. Not even one ObGyn responded positively to the invite to see more endometriosis patients. Except for our excision surgeons, no one wanted to deal with endometriosis patients in their practice. It was a heartbreaking realization for all of us.

From a patient’s perspective, they need a care team that is in their corner and does not get tired of them after four or five visits because the pain is still there. A team that sits and thinks with the patient and tries to problem-solve with the patients as a team member. This team should map out the options, what has been tried, and what is left to be tested. A team that patients can go to four weeks, four months, or four years after surgery to complain that the pain is back.” This team, instead, thoroughly evaluates patients for other pain generators or a recurrence of endometriosis. A care team that believes in patients and helps them connect with the right specialist for their gastrointestinal, urinary, neurological, and other symptoms. 

We tried several solutions to create this care team with other centers and groups, but there was a complete lack of interest and empathy, as it has always been with endometriosis. Therefore, we decided to build these centers ourselves. With that, I am proud to announce that we are launching the first iCareBetter Endometriosis Center in sunny California. It will be at 6621 Bay Laurel Place, Suite A, Avila Beach, CA 93424. We plan to open the next centers in CA and other states.

The centers’ focus will be long-term endometriosis care, so we will collaborate closely with excision surgeons, physical therapists, and other providers on iCareBetter to offer long-term multidisciplinary care to endometriosis patients. We believe that excision surgery is the gold standard of treatment for endometriosis, and we also believe that patients need an ongoing care plan and monitoring after excision surgery, even if the best surgeons in the world do it. iCareBetter centers will be the long-term care center for patients before and after excision surgery.

Our first center in Central California will be ready to see patients on February 20th, and we will offer in-person and virtual services. The next ones are being prepared, and we will announce their launch soon. If you want to ensure you secure your place before we run out of space, join the waitlist by filling out the form below. Also, if you want to be among the first ones to know about iCareBetter centers when we come to your area, please use the link below to add your name to the waitlist.



Understanding the Pain and Symptoms of Bowel Endometriosis

Endometriosis is a condition affecting roughly 11% of women worldwide, predominantly those of reproductive age. An even more specific form of this ailment is bowel endometriosis, which impacts around 5% to 12% of those diagnosed with endometriosis. In this comprehensive guide, we delve into the intricacies of bowel endometriosis, exploring what it feels like, the symptoms, causes, diagnosis, and treatment options.

What is Bowel Endometriosis?

Bowel endometriosis occurs when endometrial-like tissue, which typically grows inside the uterus, begins to develop on or inside the bowel walls. This can lead to a range of gastrointestinal symptoms, often causing significant discomfort and negatively impacting the quality of life.

Read More: Understanding Bowel Endometriosis

Where Does Bowel Endometriosis Occur?

The condition predominantly affects the rectum and sigmoid colon, with approximately 90% of bowel endometriosis cases directly involving these regions. However, the appendix, small intestine, stomach, and other parts of the large intestine can also be affected.  In many cases, bowel symptoms occur because of the mere presence of intensely inflammatory endo lesions on the peritoneum in the pelvis and abdomen and not even involving the bowel directly with implants. 

Symptoms of Bowel Endometriosis

The symptoms of bowel endometriosis often mimic common gastrointestinal disorders, including small intestinal bacterial overgrowth (SIBO), making it difficult to diagnose. They can range from mild to severe, and often fluctuate depending on the menstrual cycle. 

Common Symptoms

Common symptoms may include:

  • Abdominal pain, particularly in the lower quadrants
  • Bloating, often referred to as “endo belly”
  • Changes in bowel movements, including constipation or diarrhea
  • Nausea and vomiting
  • Pain during bowel movements, which might increase during menstruation
  • Rectal bleeding

Non-Bowel Symptoms

In addition to bowel symptoms, individuals with endometriosis might experience:

  • Chronic pelvic pain
  • Difficulties with fertility
  • Painful sexual intercourse
  • Pain during urination
  • Pelvic heaviness
  • Fatigue
  • Impaired psychological well-being

Causes of Bowel Endometriosis

The exact cause of bowel endometriosis remains unknown. However, Mullerianosis of embryogenic origin and retrograde menstruation are two often-quoted theories. Mullerianosis of embryogenic origin suggests that developmental abnormalities lead to cells being present in atypical locations which later turn into endometriosis.  This includes potential genetic, genomic and immunologic influencing factors.  Retrograde menstruation proposes that period blood flows upward towards the Fallopian tubes and into the pelvis instead of out through the vagina, potentially leading to endometriosis. Given that most women experience retrograde menstruation, and only 10% or so experience endometriosis, this theory is antiquated and has been challenged because of this disconnect.  Far more likely, some combination of embryologic, molecular, immunologic and genetic factors are in play and this can vary between individuals.  

Read More: Can Endometriosis Cause Bowel Issues?

Diagnosis of Bowel Endometriosis

Diagnosing bowel endometriosis is a complex process. It often requires a combination of a good evaluation of symptoms history, physical examination, imaging techniques like ultrasound or MRI, and sometimes minimally invasive laparoscopic or robotic surgery. However, diagnosis could be delayed due to its symptom similarity with other gastrointestinal diseases.  Imaging can only help with diagnosis and potential mapping for surgery.  It is absolutely not reliable enough to exclude the diagnosis of endo


Misdiagnosis is common in bowel endometriosis, with many patients being misdiagnosed with irritable bowel syndrome (IBS) or other gastrointestinal disorders. Therefore, a high index of suspicion is necessary for diagnosis, and any bowel symptoms correlated with the menstrual cycle should be critically evaluated.

The Role of Minimally Invasive Surgery

Surgery with biopsy is considered the “gold standard” in diagnosing endometriosis, including bowel endometriosis. It provides a more accurate diagnosis and gives healthcare providers an exact idea of how much scar tissue and endometrial-like tissue they’re dealing with. Ideally, the surgeon should be prepared to perform a therapeutic surgery at the same time as a diagnosis.  However, a bad surgery is worse than no surgery if the surgeon is unprepared and performs some variation of fulguration (burning) of endometriosis lesions as opposed to proper excision of the lesions or implants.  If diagnostic surgery uncovers a situation where the surgeon is unprepared to properly perform therapeutic excision it is better to back out and refer to an appropriate surgeon. 

Treatment of Bowel Endometriosis

Treatment for bowel endometriosis often involves surgery, as medical management has generally been deemed ineffective for these specific lesions. The chosen surgical method depends on the extent of the condition. In many cases, hormonal options may also be recommended after surgery to reduce recurrence risk.  The better the surgery the less likely this would be required but there are exceptions.   

Surgical Treatment

The surgical treatment of endo usually involves removing all of the peritoneal lesions by an excisional technique. In deeply infiltrating endometriosis, the approach may vary based on the involvement of the rectal wall or the mesentery, which is where the blood vessels to the rectum are located. The treatments for bowel endometriosis include shaving, nodulectomy, disc resection, and bowel resection.  The surgeon should be capable of performing any of these procedures as needed at the time.  In some cases this may be the main excision surgeon, if they have bowel surgery training and hospital prvileges, and in other cases, this may be another surgeon who is part of the backup team.   In the latter situation, it is best if the possibility of bowel surgery and options are addressed before surgery and not as an emergency during surgery, when appropriate surgeons may not be readily available.  

Lifestyle Changes

Alongside medical treatment, lifestyle changes can aid in managing bowel endometriosis symptoms. Some patients find that certain foods or lifestyle habits, such as stress or irregular sleep, may trigger their symptoms. Keeping a journal to track triggers and consulting with a healthcare provider or nutritionist when making dietary changes can be beneficial.

Read More: How to Treat Bowel Endometriosis: A Comprehensive Guide

Coping with Bowel Endometriosis

Living with bowel endometriosis can be challenging, but with the right diagnosis, treatment, and management, individuals can lead fulfilling lives. It’s essential to communicate openly with healthcare providers about symptoms and concerns, as this can aid in diagnosis and treatment planning.

In conclusion, bowel endometriosis is a painful and often misunderstood condition. Increased awareness and understanding of the disease can help in early diagnosis, effective treatment, and improved quality of life for those affected. If you suspect you might have bowel endometriosis or are experiencing any of the symptoms mentioned, do not hesitate to seek medical advice.


Surgical Outcomes after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis


How to Treat Bowel Endometriosis: A Comprehensive Guide

Bowel endometriosis, a complex and severe variant of endometriosis, is a condition best navigated with a deep understanding of its details. This guide aims to shed light on the various aspects of bowel endometriosis, from its origins to symptoms, diagnostic approaches, and treatment options, to empower those affected.

What is Bowel Endometriosis?

Endometriosis, a chronic health disorder predominantly affecting women in their reproductive years, is characterized by the growth of endometrial-like tissue, which usually lines the uterus in regions outside the uterus. This misplaced tissue prompts an inflammatory reaction, leading to distressing symptoms. When this aberrant tissue growth takes place on or inside the bowels, the condition is referred to as bowel endometriosis.

How Common is Bowel Endometriosis?

While the exact prevalence of bowel endometriosis remains uncertain, it’s estimated to occur in 5-15% of all endometriosis cases. Predominantly, it manifests on the rectum or sigmoid colon but can also affect the appendix or small intestine.

Read More:

Recognizing the Symptoms

Symptoms of bowel endometriosis may not always be apparent, especially in the early stages of the disease. However, as the condition progresses, women may experience discomfort associated with their menstrual cycle, sexual intercourse, bowel movements, and even infertility.

Symptoms commonly associated with bowel endometriosis include:

  • Painful Bowel Movements: This is often accompanied by constipation or diarrhea.
  • Rectal Bleeding: This symptom, which is more uncommon, usually occurs during menstruation.
  • Infertility: Some women may experience difficulty conceiving.
  • Pelvic Pain: Chronic pelvic pain is a common symptom associated with endometriosis, often more severe during menstruation or ovulation.
  • Painful Intercourse: This is often due to the endometriosis lesion causing a distortion of the pelvic anatomy.

It’s important to note that bowel endometriosis can sometimes mimic symptoms of other gastrointestinal conditions, like irritable bowel syndrome (IBS), making it challenging to diagnose.

Diagnosing Bowel Endometriosis

A comprehensive diagnosis of bowel endometriosis usually involves a combination of physical examination, medical history analysis, and advanced imaging techniques. The diagnostic process may include:

  • Physical Examination: This includes a manual check for growths in the rectum or vagina.
  • Imaging Tests: These can include ultrasound, MRI, colonoscopy, and barium enema.
  • Laparoscopy: This surgical procedure is considered the gold standard for diagnosing endometriosis, as it allows for visual examination of the uterus, ovaries, and other pelvic structures. And surgeons can take samples for histopathology evaluations.

Read More: Understanding Bowel Endometriosis

Treating Bowel Endometriosis: An Overview

Treatment for bowel endometriosis is complex and multifaceted. It requires a personalized approach, taking into account the severity of the disease, the patient’s age, fertility goals, and personal preferences. The primary treatment options include:

  • Hormonal Therapy: This involves medications that control estrogen levels, which can influence the progression of endometriosis. These medications can help manage pain and other symptoms.
  • Pain Management: Over-the-counter or prescription nonsteroidal anti-inflammatory drugs (NSAIDs) may be recommended to help alleviate pain.
  • Surgery: Surgical interventions aim to remove as much endometrial tissue as possible while preserving organ function.

Surgical Treatment Options

Surgery is typically the primary treatment for bowel endometriosis, particularly for severe cases. The goal of surgery is to remove endometrial implants without compromising the functionality of the organs involved. There are three main surgical options:

  • Segmental Bowel Resection: This involves removing the section of the bowel affected by endometriosis and reconnecting the healthy portions. This option is often recommended for larger areas of endometriosis.
  • Rectal Shaving: This procedure involves shaving off the endometriosis from the top of the bowel without removing any portion of the intestines. It’s often used for smaller areas of endometriosis.
  • Disc Resection: In this procedure, a surgeon cuts out a small disk where the endometriosis lesions appear and then closes the remaining hole.

Understanding the Risks of Surgery

Surgery for bowel endometriosis is a complex procedure associated with certain risks. These can include short-term complications such as infection, leakage of bowel content during the postoperative healing phase, peritonitis, and septicaemia. Long-term risks might include bowel dysfunction, characterized by frequency, urgency, and incontinence.

Read More: Finding an Excision Specialist: What you Need to Know

Hormone Treatment Options

Although hormonal treatments cannot halt the progression of endometriosis, they can help manage symptoms. Hormonal treatments for bowel endometriosis can include birth control pills, progestin injections, or, less favorably, gonadotropin-releasing hormone (GnRH) agonists.

Read more: What are the long-term side effects of Lupron?

Managing Symptoms and Quality of Life

Bowel endometriosis can significantly impact the quality of life of those affected. However, with appropriate treatment and management strategies, many women affected by this condition can lead fulfilling lives. Communication with your healthcare team, lifestyle modifications, and psychological support can all contribute to improving the quality of life.


Understanding how to treat bowel endometriosis is crucial for managing this complex and often painful condition. With the right approach, it’s possible to mitigate symptoms, improve fertility outcomes, and enhance the quality of life for those affected. If you suspect you have bowel endometriosis, it’s important to speak with a healthcare provider who can guide you through the diagnostic process and treatment options. With the right knowledge and resources, you can navigate this challenging condition and find a path to improved health and well-being.


Bowel Endometriosis


Can Endometriosis Cause Bowel Issues?

Endometriosis is a common but often under-recognized condition, primarily affecting women between 15-50. It results from the growth of tissue similar to the endometrium (the lining of the uterus) outside the uterus. This article explores the question: Can endometriosis cause bowel issues?

Understanding Endometriosis

Endometriosis is a condition where tissue, similar to the kind that lines the uterus (the endometrium), grows outside the uterus. This condition usually affects the ovaries, fallopian tubes, and the tissue lining the pelvis. However, in some cases, it can also affect other organs, including the bowel.

Endometriosis and Bowel Involvement

When endometriosis affects the bowels, it typically occurs in two forms:

  • Superficial: The endometriosis tissue is located on the surface of the bowel.
  • Deep: The endometriosis tissue passes through the bowel wall.

In both cases, doctors usually find a small mass of tissue, known as a lesion, on the bowel wall. More rarely, these lesions can penetrate into the muscular layer of the bowel.

Read More: Endometriosis and Inflammatory Bowel Disease: Distinguishing the Differences

Causes of Endometriosis

While the definitive cause of endometriosis remains unknown, several contributing factors have been identified. These include hormonal imbalances, immune system problems, and genetic factors.

Symptoms of Bowel Endometriosis

The symptoms of bowel endometriosis can vary, depending on the location and size of the lesion, and how deep it is within the bowel wall. These symptoms often mimic those of irritable bowel syndrome (IBS), but there are key differences.

Some of the common symptoms include:

  • Trouble pooping or loose, watery stools (constipation or diarrhea)
  • Pain during bowel movements
  • Menstrual discomfort
  • Painful sex
  • Difficulty getting pregnant (infertility)
  • Blocked bowel (this is a rare symptom)

Diagnosing Bowel Endometriosis

Diagnosing bowel endometriosis can be challenging due to its similarities with other conditions. However, if you have other endometriosis symptoms, such as painful periods, painful sex, lower back pain, or abdominal bloating and discomfort, it’s critical to talk to your doctor.

Read More: Understanding Bowel Endometriosis

Misdiagnosis of Bowel Endometriosis

Unfortunately, bowel endometriosis is often misdiagnosed as irritable bowel syndrome or other gastrointestinal diseases. This is because the symptoms of bowel endometriosis can mirror those of IBS, Crohn’s disease, and appendicitis.

Read More: Finding an Excision Specialist: What you Need to Know

Treatment for Bowel Endometriosis

Treatment for bowel endometriosis is usually tailored to the patient’s symptoms and medical history. The most common treatments include surgery, hormone treatments, and counseling.

Coping with Bowel Endometriosis

Bowel endometriosis is a challenging condition to live with. It not only affects your physical health but also your mental well-being. Many patients have found some symptom relief through lifestyle changes, including dietary adjustments and regular exercise.

The Importance of Early Detection

Given the potential complications of bowel endometriosis, early detection and treatment are crucial. If you experience bowel issues alongside painful menstruation, it’s essential to consult with a healthcare professional.


The question, “Can endometriosis cause bowel issues?” is undoubtedly answered with a resounding yes. However, with timely detection, appropriate treatment, and necessary lifestyle changes, it’s possible to manage the symptoms and lead a healthy life.

Additional Information

This article is a comprehensive exploration of how endometriosis can impact bowel health. It’s essential to remember that while this condition can cause significant discomfort and health issues, effective treatments are available. If you suspect you have endometriosis, don’t hesitate to reach out to a healthcare provider.



Endometriosis Diet: Low FODMAP, a Comprehensive Guide

‍The Low FODMAP Diet, a revolutionary approach for managing symptoms associated with Irritable Bowel Syndrome (IBS), has gained substantial recognition and popularity in recent years. Developed by researchers at Monash University, this diet has offered hope to many individuals suffering from IBS, a common gastrointestinal disorder that affects the digestive system. So how can it help those with endometriosis? This article will focus on the diet itself, but a relatively recent systematic review of dietary approaches and endometriosis showed that the low FODMAP diet was most helpful in managing symptoms in those with endometriosis that complained of gastrointestinal symptoms and had good follow through in individuals who tried it. 

Understanding the Low FODMAP Endometriosis Diet

FODMAP is an acronym that stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols. These are certain types of carbohydrates that are either poorly absorbed or not absorbed at all in your intestines and can trigger symptoms in individuals with IBS.

What are FODMAPs?

FODMAPs are naturally occurring sugars found in a wide range of foods and food additives. When consumed, these sugars move slowly through the small intestine, attracting water. As they reach the large intestine, they are fermented by gut bacteria, resulting in gas production. This extra gas and water cause the intestinal wall to stretch and expand, which can cause pain and discomfort, especially in people with IBS.

Types of FODMAPs

Here are the different types of FODMAPs and examples of foods where they can be found:

  • Oligosaccharides: These include Fructans and Galacto-Oligosaccharides (GOS) found in foods such as wheat, rye, onions, garlic, and legumes.
  • Disaccharides: Lactose is a disaccharide found in dairy products like milk, soft cheeses, and yogurts.
  • Monosaccharides: Fructose is an example, found in honey, apples, and high fructose corn syrups.
  • Polyols: These include Sorbitol and Mannitol, found in some fruits, vegetables, and used as artificial sweeteners.

Exploring the Impacts of FODMAPs

When FODMAPs are consumed, they move slowly through the small intestine, attracting water. As they reach the large intestine, gut bacteria use these FODMAPs as a fuel source, fermenting them and producing gas. This process is normal but can cause problems in people with IBS due to issues with motility (the speed at which contents move through the intestines) or a highly sensitive gut wall.

FODMAPs are found in a variety of foods, such as fruits, vegetables, bread, cereals, nuts, and legumes. It’s impossible to guess the FODMAP content of a food without careful laboratory analysis. Monash University has developed a mobile phone app, the Monash University FODMAP Diet App, which uses a simple traffic light system to indicate whether foods are low, moderate, or high in FODMAPs.

High FODMAP Foods and Low FODMAP Alternatives

Here’s a table showing some high FODMAP foods and their low FODMAP alternatives:

High FODMAP FoodsLow FODMAP Alternatives
Vegetables: Artichoke, Asparagus, Cauliflower, Garlic, Green Peas, Mushrooms, Onion, Sugar Snap PeasAubergine/Eggplant, Beans (Green), Bok Choy, Green Capsicum (Bell Pepper), Carrot, Cucumber, Lettuce, Potato, Zucchini
Fruits: Apples, Apple Juice, Cherries, Dried Fruit, Mango, Nectarines, Peaches, Pears, Plums, WatermelonCantaloupe, Kiwi Fruit (Green), Mandarin, Orange, Pineapple
Dairy & alternatives: Cow’s Milk, Custard, Evaporated Milk, Ice Cream, Soy Milk (Made from Whole Soybeans), Sweetened Condensed Milk, YoghurtAlmond Milk, Brie/Camembert Cheese, Feta Cheese, Hard Cheeses, Lactose-Free Milk, Soy Milk (Made from Soy Protein)
Protein sources: Most Legumes/Pulses, Some Marinated Meats/Poultry/Seafood, Some Processed MeatsEggs, Firm Tofu, Plain Cooked Meats/Poultry/Seafood, Tempeh
Breads & Cereals: Wheat/Rye/Barley Based Breads, Breakfast Cereals, Biscuits and Snack ProductsCorn Flakes, Oats, Quinoa Flakes, Quinoa/Rice/Corn Pasta, Rice Cakes (Plain), Sourdough Spelt Bread, Wheat/Rye/Barley Free Breads
Sugars, Sweeteners & Confectionery: High Fructose Corn Syrup, Honey, Sugar Free ConfectioneryDark Chocolate, Maple Syrup, Rice Malt Syrup, Table Sugar
Nuts & Seeds: Cashews, PistachiosMacadamias, Peanuts, Pumpkin Seeds/Pepitas, Walnuts

Who Should Follow a Low FODMAP Endometriosis Diet?

The Low FODMAP diet is specifically designed for individuals with medically diagnosed IBS. It is not recommended for people to self-diagnose and start this diet without the proper medical guidance. There are many conditions with symptoms similar to IBS, such as coeliac disease, inflammatory bowel disease, endometriosis, and bowel cancer. Therefore, it is crucial to get a clear diagnosis of IBS from a medical doctor before starting this diet.

The Purpose of a Low FODMAP Endometriosis Diet

The Low FODMAP diet is essentially a three-step diet used to manage symptoms of IBS, which can include abdominal pain, bloating, wind (farting) and changes in bowel habit (diarrhea, constipation, or both). The main goals of this diet are:

  • Understand which foods and FODMAPs you tolerate and which ones trigger your IBS symptoms.
  • Determine whether your IBS symptoms are sensitive to FODMAPs.
  • Implement a less restrictive, more nutritionally balanced diet for the long term that only restricts foods that trigger your IBS symptoms.

How to Follow a Low FODMAP Diet

The Low FODMAP diet is a three-step diet, typically encompassing the following steps:

Step 1: Follow the Monash University Low FODMAP Diet by replacing high FODMAP foods in your diet with low FODMAP alternatives. This step usually lasts for 2-6 weeks.

Step 2: Continue your low FODMAP diet and complete a series of ‘FODMAP challenges’ to identify which FODMAPs you tolerate and which trigger symptoms.

Step 3: Relax dietary restrictions as much as possible, reintroduce well-tolerated foods and FODMAPs to your diet, and establish a ‘personalized FODMAP diet’ for the long term.

It is recommended to follow a Low FODMAP diet under the guidance of a dietitian who has specialty skills in managing IBS and using a FODMAP diet. Monash University’s FODMAP Dietitian Directory can be a useful resource to find such dietitians.

The Effectiveness of Low FODMAP Endometriosis Diet Combined with Other Therapies

The Low FODMAP diet has shown promising results in managing IBS symptoms. However, in some cases, the diet alone may not be sufficient, and other therapies may be required. One such therapy that has shown positive results in treating IBS is Gut Focused Hypnotherapy.

Understanding Gut Focused Hypnotherapy

Gut Focused Hypnotherapy is a type of treatment where patients are asked to visualize their gut as a perfectly slimy set of passages where all the digesting food slips through smoothly. This treatment has been proven to reduce symptoms of IBS by 70% in patients.

Combining Low FODMAP Diet and Gut Focused Hypnotherapy

Researchers at Monash University conducted a study combining the Low FODMAP diet and Gut Focused Hypnotherapy. The study resulted in a significant improvement in the overall and individual gut symptoms of the participants by the end of the six-week study.

Comparing the Low FODMAP Diet with Other IBS Diets

When comparing the Low FODMAP diet with other diets for IBS, it has been noted that the Low FODMAP diet seems to be superior to a gluten-free diet for patients with non-celiac gluten sensitivity. This is likely due to the comprehensive approach of the Low FODMAP diet, which considers all types of carbohydrates that could potentially trigger IBS symptoms.

The Low FODMAP diet has been shown to be effective in managing IBS symptoms, with studies showing improvement in pain, discomfort, bloating, and other GI symptoms. However, it is essential to follow this diet under the guidance of a trained dietitian and in conjunction with other therapies if necessary. As with any diet, the Low FODMAP diet should be personalized to fit the individual’s needs and tolerance levels.

If  you are suffering from IBS-like symptoms and you have endometriosis or are just starting in your journey for a diagnosis, it may be worth seeking out professional guidance to see if the low FODMAP diet may be helpful. As a reminder – it is not going to treat your endometriosis and is used primarily for symptom management. It does not replace seeking out the root cause of both endometriosis and your GI dysfunction. 

Disclaimer: This article is intended for informational purposes only and is not a substitute for professional medical advice. Always consult your doctor or a dietitian before making any changes to your diet.



Molina-Infante, J., Serra, J., Fernandez-Banares, F., & Mearin, F. (2016). The low-FODMAP diet for irritable bowel syndrome: Lights and shadows. Gastroenterol Hepatol, 39(2), 55-65.


Understanding How Endometriosis Can Cause

Bowel Problems

Endometriosis, a common health concern among women, can manifest itself in various ways, one of them being bowel problems. But how exactly can endometriosis cause bowel problems? This article will take you through the intricate connection between endometriosis and bowel problems, the symptoms to look out for, diagnostic procedures, and potential treatments.

What is Endometriosis?

Endometriosis is a health condition where the tissue similar to the type that lines the uterus, known as the endometrium, grows outside the uterus. This condition predominantly affects the reproductive organs such as the ovaries, fallopian tubes, and the external part of the uterus. However, it can also extend to other parts of the body including the bowels, rectum, and other pelvic organs.

Understanding Bowel Endometriosis

Bowel endometriosis is a form of endometriosis that affects the gastrointestinal tract, specifically the bowels. It can appear in two forms: superficial (on the surface of the bowel) and deep (penetrating the bowel wall).

Read More: Understanding Bowel Endometriosis

Symptoms of Bowel Endometriosis

The symptoms of bowel endometriosis can vary widely depending on the location of the lesion, its size, and how deep it is in the bowel wall. Some women may experience no symptoms. However, common symptoms include:

  • Difficulty in passing stool or loose, watery stools (constipation or diarrhea)
  • Pain during bowel movements
  • Menstrual discomfort
  • Painful sexual intercourse
  • Difficulty in conceiving (infertility)
  • Blocked bowel (a rare symptom)

It is noteworthy that these symptoms can often mimic other conditions like irritable bowel syndrome (IBS), but the two conditions are distinct. One distinguishing factor is that with bowel endometriosis, symptoms often worsen before and during the menstrual period.

Read More: Endometriosis and Painful Intercourse: Is it Really Just Endometriosis?

Causes of Bowel Endometriosis

The exact cause of bowel endometriosis is still under study. However, several factors have been linked to its occurrence. These include genetic predisposition, inflammation, and levels of estrogen, a female sex hormone.

The Prevalence of Endometriosis

Endometriosis affects approximately 10%-12% of women of childbearing age. The condition is often diagnosed in women who are in their 30s, although it can occur at any age.

Diagnosing Bowel Endometriosis

The diagnosis of bowel endometriosis starts with the doctor asking about your symptoms and medical history, followed by a physical examination of your pelvic area. The doctor may also recommend imaging tests to get more information on the location and size of any cysts or tissue damage related to endometriosis. These tests include:

  • Transvaginal or transrectal ultrasound: This procedure involves the insertion of a wand-like device into your vagina or rectum. This device releases sound waves that create images of your organs.
  • Magnetic resonance imaging (MRI): An MRI test provides detailed images of your organs and tissues using a magnetic field and radio waves.
  • Laparoscopy: This surgical procedure involves making a small incision near your belly button and inserting a thin viewing tool called a laparoscope.
  • Barium enema: This type of X-ray is used to see changes or defects in your large intestine (colon).
  • Colonoscopy: They pass a tube with a camera on its tip through the anus into the colon to directly visualize the wall and take samples from inside the colon.

Read More: Colon Chronicles: Delving into Bowel Endometriosis

Treating Bowel Endometriosis

The treatment plan for bowel endometriosis will be personalized, taking into account your symptoms, medical history, age, and reproductive plans. Treatments can include:

  • Surgery: The aim of surgery is to remove as many lesions as possible while preserving your organs and overall health.
  • Hormone treatments: These medications control estrogen levels which can worsen the symptoms of bowel endometriosis.
  • Counseling: Given the ongoing nature of bowel endometriosis and its impact on both physical and mental health, counseling may be recommended to provide emotional support.

The Prognosis for Bowel Endometriosis

There is currently no cure for endometriosis. However, treatments like surgery and hormone therapy can help manage the symptoms. It is also important to note that symptoms could return if treatment is halted, or they could recur on their own, especially in cases with deep lesions.

Endometriosis is a complex condition that can cause bowel problems and other health issues. If you suspect you have endometriosis and are experiencing bowel problems, it’s important to consult with a healthcare provider. Early diagnosis and treatment can help manage symptoms and improve your quality of life.


Bowel Disease



Anti-Mullerian Hormone & Endometriosis – What’s The Connection?

Endometriosis has been associated with a marker called Antimullerian hormone (AMH), which is a pivotal marker of ovarian reserve, and is commonly measured in women with endometriosis specifically in relation to fertility. There is debate among the community that your AMH level is what it is and it cannot change. I would challenge this notion though as I have seen people with endometriosis have significant increases after proper excision surgery, which is a point of debate. Recently, I had another patient send me lab work that demonstrated what some may call a low AMH, has confirmed endometriosis, but likely a surgery that was incomplete and is continuing to suffer ongoing symptoms. Though I have seen this change in my patients, I recognize this is only a small fraction of the people suffering, so it was time to review what the research says. This article aims to provide a review of the various studies conducted on this critical subject, exploring how endometriosis and AMH interact, the effect of surgical intervention on AMH levels, and the subsequent impact on fertility.

The Antimullerian Hormone (AMH): A Brief Overview

AMH, a hormone playing diverse roles during embryonic development and puberty, is produced by ovarian follicles smaller than 8 mm, hence linking ovarian reserve to AMH levels in the blood. The normal range for AMH hovers between 1 and 4 ng/mL. However, women’s AMH levels greatly vary based on factors like age, ethnic background, lifestyle, and genetics. Additionally, someone at the low end of range may still suffer problems despite them being “in range.” 

AMH Testing in Reproductive Health

AMH testing is a crucial tool for evaluating female fertility. It can assist in:

  1. Assisting with understanding the prognosis of a woman’s response to assisted reproduction techniques (ART) such as in vitro fertilization (IVF)
  2. Confirming other markers of menopause
  3. Providing a more comprehensive evaluation when certain conditions are confirmed or suspected such as polycystic ovarian syndrome (PCOS), premature ovarian failure, and endometriosis

Endometriosis and AMH Levels

Endometriosis is a common culprit behind infertility, affecting nearly half of the women suffering from this ailment. This infertility arises from various factors, including inflammation in the reproductive tract, scar tissue-induced decreased blood supply to the ovaries, and pelvic anatomical distortions. Research reveals a significant correlation between endometriosis and lower than average AMH levels.

Some argue that surgical intervention of endometriosis often leads to a reduction in AMH levels, though many of us in the community may argue that this is a more nuanced topic and this highly depends on the skill of the surgeon, something that is often overlooked in endometriosis research.  Various studies have attempted to decipher the impact of endometriosis surgery on AMH levels and fertility outcomes. A retrospective study conducted in 2016 found that preoperative AMH levels did not influence pregnancy rates after surgery. This is consistent with the literature we have on surgical impact, and thus the need for better research in the future. In my experience, this is the opposite of what I have seen, as many of us have seen when people get to the right surgeon. 

Laparoscopic Cystectomy on AMH Levels

Laparoscopic ovarian cystectomy, a common surgical procedure to treat endometriomas, has been associated with decreased ovarian reserve. A study in 2019 demonstrated significantly lower AMH levels in women who underwent laparoscopic endometrioma cystectomy, especially in cases with bilateral cysts larger than 7 cm and stage 4 endometriosis. 

Considerations: I want to highlight that we do not know the skill of the surgeon, but we do know that the skill of the surgeon matters. That being said, large endometriomas can often overtake ovarian tissue which is what happened to Christina. Hear her story here. This is why it is extremely important to find a knowledgeable surgeon that you feel comfortable with. If you need help finding a surgeon, you can start here. 

Laparoscopic Endometriosis Surgery on AMH Levels

A literature review and meta-analysis of 19 studies conducted between 2010 and 2019 on the impact of laparoscopic endometriosis surgery on AMH levels post-surgery revealed a decline in AMH levels, extending beyond six months post-surgery. This decline was more pronounced in cases where surgery was performed on both sides of the body, compared to a single side.

Again, I would argue that we consider the quality of the research and the skill of the surgeon. Remember, ablation is different from excision and this may be another factor that is skewing results. I repeat this because, like many of us in the community, this is not our experience, thus I often read research with these things in mind. If many others in the community are also seeing this, there must be more to consider than what is presented. The bottom line is that we need better research. 

AMH Levels Post-Surgery for Endometrioma

Several studies have observed that laparoscopic ovarian cystectomy results in a significant and progressive decrease in AMH levels post-surgery. However, other studies have noted that this decrease may only be temporary, with levels potentially returning to normal within a year. Another factor to consider is when the AMH was measured post-surgery and what other factors may have impacted the levels! 

Certain studies have observed a temporary decrease in AMH levels following endometrioma ablation. However, this decrease did not persist beyond six months in most cases, suggesting a potential recovery of ovarian reserves. 

Several studies have compared the decrease in AMH levels following ovarian cystectomy and endometrioma vaporization. The general consensus suggests a higher postoperative decline in AMH levels following cystectomy compared to vaporization, particularly in bilateral endometrioma cases.

This caught my attention and highlights my thoughts on how the surgery (excision) is being performed as to not compromise ovarian tissue. Using ablation, which is what the CO2 laser is referring to, may not compromise the ovarian tissue, but it also may not treat the disease. Paul Tyan, MD discusses this complex topic in our interview which you can find here. 

The combined technique, involving partial cystectomy and ablation, has been shown to have less detrimental effects on the ovary, resulting in a lesser decline in AMH levels post-surgery.

The role of endometriosis surgery in improving pregnancy rates remains a topic of debate. Some studies suggest that surgery might improve the success rates of fertility treatment, while others highlight the risk of ovarian damage due to surgical intervention.

In conclusion, the Antimullerian hormone is a vital marker for assessing the impact of endometriosis and its surgical intervention on ovarian reserve and fertility. Understanding the complex relationship between AMH levels, endometriosis, and surgical intervention along with identifying gaps in the research can help medical professionals devise more effective treatment strategies, improve the quality of research studies which ultimately improves patient outcomes.

IRelated Reading:

  1. Does Endometriosis Cause Infertility? Covering the Basics
  2. Endometriosis and Pregnancy: Natural, Medical, & Surgical Options



Endometriosis and Inflammatory Bowel Disease: Distinguishing the Differences

Exploring the complex world of health and medical conditions can sometimes feel like navigating through a labyrinth. The similarities between certain conditions often blur the lines, making it challenging for individuals and even healthcare professionals to differentiate between them. This is notably true in the case of endometriosis and inflammatory bowel disease (IBD), two disorders that share several overlapping symptoms and characteristics. We’ve recently been discussing endometriosis and the bowel, this article aims to shed light on these conditions, highlighting the differences, similarities, and the challenges faced in their diagnosis.

Symptoms of Endometriosis

The signs and symptoms of endometriosis can vary greatly, making it a complex disease to diagnose. Some of the most common symptoms include dysmenorrhea (painful periods), dyspareunia (painful intercourse), chronic pelvic pain, and gastrointestinal symptoms like diarrhea, constipation, and abdominal pain. Because endometriosis symptoms often overlap with GI symptoms, getting a diagnosis in general can be tricky, but especially if it may be impacting the bowels which is estimated in about 5-12% of cases, whereas approximately 90% of those with endometriosis suffer from gastrointestinal symptoms. In many cases, these symptoms can be mistaken for other conditions, leading to delays in diagnosis.

Inflammatory Bowel Disease: An Overview

Inflammatory bowel disease (IBD) is an umbrella term that encompasses two chronic autoimmune disorders: ulcerative colitis (UC) and Crohn’s disease (CD). These conditions are characterized by the chronic inflammation of the gastrointestinal tract, which can lead to a wide range of symptoms, including abdominal pain, diarrhea, weight loss, and fatigue.

The prevalence of IBD is highest in Europe, with reported cases reaching up to 505 per 100,000 for UC in Norway and 322 per 100,000 for CD in Italy. Like endometriosis, IBD can significantly impact an individual’s quality of life, necessitating long-term management strategies to control symptoms and prevent complications.

The Overlap: Endometriosis and IBD

Interestingly, endometriosis and IBD share several common traits, including immune dysregulation and overlapping clinical manifestations like abdominal pain and bowel-related symptoms. This overlap often poses a significant diagnostic challenge, as endometriosis can mimic IBD or vice versa, leading to delays or indeterminate diagnosis.

In fact, endometriosis has often been termed as having “IBD-like” features due to the similarities in symptoms and underlying pathophysiology. This has led to substantial interest in the potential link between these conditions, with several studies investigating the co-occurrence of endometriosis and IBD.

To understand the potential link between endometriosis and IBD, numerous studies have been conducted, ranging from case reports and clinical series to epidemiological research. These studies have reported varying results, further highlighting the complexity of these conditions and the challenges associated with their diagnosis and management.

Case Reports and Clinical Series

Many case reports have been published that highlight the diagnostic challenges associated with endometriosis and IBD. For instance, several cases have been reported where an initial diagnosis of CD was later revised to intestinal endometriosis upon histopathological examination. Similarly, other case reports have documented instances where an initial diagnosis of UC was later confirmed to be appendiceal endometriosis.

Conversely, there have also been cases where an initial diagnosis of endometriosis was later revised to be CD upon histopathological examination. Additionally, several case reports have documented instances where both CD and endometriosis were diagnosed in the same patient.

Epidemiological Studies

In addition to case reports and clinical series, several epidemiological studies have investigated the co-occurrence of endometriosis and IBD. One such study, a nationwide Danish cohort study, reported a 50% increase in the risk of IBD in women with endometriosis compared to the general population. This increased risk persisted even more than 20 years after a diagnosis of endometriosis, suggesting a genuine association between the two conditions..

Another study, a retrospective cross-sectional study conducted in Israel, found that 2.5% of patients with endometriosis also had a diagnosis of IBD, compared to 1% in the general population. A recent Italian case-control study found that among 148 women with endometriosis, five had IBD, although this did not reach statistical significance.

The Challenge of Temporality

One of the critical aspects of evaluating the association between endometriosis and IBD is the issue of temporality, or the order in which the conditions are diagnosed. Many studies do not provide information on the temporal sequence of endometriosis and IBD, which poses a significant challenge in determining a cause-effect relationship between the two conditions.

Furthermore, the diagnosis of endometriosis often faces delays, with an average delay of seven years estimated between the onset of symptoms and definitive diagnosis. This delay further complicates the evaluation of the temporal relationship between endometriosis and IBD.

Distinguishing Between Endometriosis and IBD

Given the overlapping symptoms and shared characteristics of endometriosis and IBD, distinguishing between these conditions can be challenging. Both conditions can result in similar symptoms, such as abdominal pain and bowel-related symptoms, which can lead to misdiagnosis or delayed diagnosis.

In cases where endometriosis and IBD coexist, the symptoms can be atypical and cyclic, and fibrosis caused by chronic inflammation can lead to obstruction of the intestinal lumen. Therefore, it’s essential for healthcare professionals to consider both conditions when evaluating patients with such symptoms.

In cases of intestinal endometriosis, endoscopic biopsies may reveal IBD-like lesions. However, these lesions may represent an epiphenomenon of endometriosis rather than a true IBD. Hence, patients with concurrent IBD and endometriosis should be adequately followed up for the reassessment of IBD diagnosis over time.

The Role of Treatment in the Risk of IBD

The treatment of endometriosis could potentially influence the risk of developing IBD. For instance, oral contraceptives are a common treatment for endometriosis, and a meta-analysis of 14 studies suggested an increased risk of IBD among users of oral contraceptives. Additionally, non-steroidal anti-inflammatory drugs (NSAIDs), often used for pain relief in endometriosis, have been reported to increase the risk of IBD.

The Need for Further Research

Though existing research has shed some light on the association between endometriosis and IBD, there is still much to uncover. Further research is needed to better understand the temporal relationship between endometriosis and IBD in cases of co-occurrence and identify predictors that could be useful for evaluation and management of these patients.

Understanding these conditions and their potential links can not only improve diagnostic accuracy but also inform treatment strategies and improve the quality of life for those affected.

Distinguishing between endometriosis and inflammatory bowel disease can be a challenging task due to the overlapping symptoms and shared characteristics of these conditions. However, understanding the nuances of these conditions and the potential links between them can lead to improved diagnostic accuracy and more effective treatment strategies. As research progresses in this area, we hope to gain a better understanding of these complex conditions and continue to improve the lives of those affected.

Related Reading:

  1. Finding an Endometriosis Specialist: Your Guide to Effective Treatment
  2. Unraveling the Connection Between Endometriosis and Autoimmune Diseases


  1. Parazzini F, Luchini L, Vezzoli F, Mezzanotte C, Vercellini P. Gruppo italiano perlo studio dell’endometriosi. Prevalence and anatomical distribution of endometriosisin women with selected gynaecological conditions: results from amulticentric Italian study. Hum Reprod 1994;9:1158–62.
  2. Bulun SE. Endometriosis. N Engl J Med 2009;360:268–79. 
  3. Weed JC, Ray JE. Endometriosis of the bowel. Obstet Gynecol 1987;69:727–30.
  4. Molodecky NA, Soon IS, Rabi DM, Ghali WA, Ferris M, Chernoff G. Increasing incidence and prevalence of the inflammatory bowel diseases with time, based on systematic review. Gastroenterology 2012;142:46–54.
  5. Nielsen NM, Jorgensen KT, Pedersen BV, Rostgaard K, Frisch M. The co-occurrence of endometriosis with multiple sclerosis, systemic lupus erythematosus and Sjogren syndrome. Hum Reprod 2011;26:1555–9.

Rediscovering Life After Endometriosis Surgery: Tips and Strategies for a Full Recovery

Endometriosis surgery, typically excision of endo implants and related fibrosis, using minimally invasive laparoscopy or robotic surgery, significantly impacts women’s health and recovery journey. Here’s an enhanced guide to life post-surgery, incorporating tips to improve physical and mental healing towards lasting thrivorship

Understanding Endometriosis and Its Surgical Treatment

Endometriosis involves the growth of tissue similar to the uterine lining outside the uterus, creating pain and sub-fertility.  Thankfully, minimally invasive surgery requires only small incisions through which a camera and instruments can be placed.  This is the gold standard for diagnosing and treating endometriosis and has revolutionized the healing process and length of time to full recovery. (Ferrero et al., 2018).

The Recovery Period

Recovery from laparoscopic or robotic minimally invasive surgery varies based on the extent of endometriosis and overall health. Typically, full recovery involves several weeks to a few months. Patients might experience tiredness initially and are advised to consume soft foods, stay hydrated, and take fiber supplements to avoid constipation, especially when using narcotic pain relief. It’s crucial to initially avoid strenuous activities but engage in light walks to promote healing.  This reduces the risk of venous clots in the legs but avoids complications like hernias through the incisions.  

How long you should take off work depends on the extent of the surgery, physical job demands, and any known medical co-existing conditions that might slow the healing process, such as diabetes. Discuss this with your surgeon before the procedure to set realistic expectations.

Enhanced Recovery Tips:

  • Balanced Nutrition: Within limits of allergies and food intolerance which may be specific to you, the following is a generic prudent healing plan:
  1. Protein: Lean meats, fish, eggs, tofu, and legumes help repair tissues.
  2. Fruits and Vegetables: Rich in vitamins, minerals, and antioxidants to reduce inflammation.
  3. Whole Grains: Brown rice, quinoa, and whole wheat bread for energy and fiber.
  4. Healthy Fats: Avocados, nuts, seeds, and olive oil for inflammation control.
  5. Hydration: Plenty of water, green and herbal teas.
  • Bromelain Supplements: Bromelain, an enzyme found in pineapples, can reduce inflammation and promote healing by minimizing post-surgical scarring (Walker et al., 2018).
  • Arnica: Homeopathic arnica can help reduce bruising and swelling, and may reduce pain as well. 
  • Vitamin C and Zinc: Essential for tissue repair and immune function.
  • Probiotics: Support gut health, which can be disrupted by surgery, antibiotics used around the time of surgery, and pain medications.
  • Red Light Therapy: Otherwise known as photobiomodulation, this modality can exert and anti-inflammatory effect, reducing prolonged inflammation and thereby can promote healing.  Keep in mind, acute inflammation is part of normal healthy healing, so it may be prudent to avoid this for at least a month postop. (Hamblin MR)

Physical Health Post-Surgery

Post-surgery, physical health generally improves, with reduced bodily pain and better physical functioning. However, side effects like hot flashes can occur, particularly if the ovaries are removed or compromised and/or hormonal treatments are part of the post-surgery plan. Regular follow-ups are essential to monitor recovery and address any complications promptly.  This is a highly individualized situation, so work with an expert before and after surgery. 

Pain Management:

  • Heat Therapy: Use heating pads to alleviate abdominal pain.  Be careful not to burn skin by not using something like a towel between the heat source and the skin.  
  • TENS Units: Transcutaneous Electrical Nerve Stimulation can help manage pain by sending small electrical pulses to the affected areas.
  • Acupuncture: Can relieve pain and promote healing.

Mental Health Post-Surgery

Mental health is a crucial aspect of recovery. Enduring a chronic condition like endometriosis can lead to anxiety and depression. Therefore, incorporating mental health support into post-surgery care can be vital. Many women report improved emotional well-being post-surgery, but not all.  So ongoing support may be necessary to manage any lingering psychological effects (Stratton et al., 2020).

Mental Health Tips:

  • Therapy and Counseling: Cognitive-behavioral therapy (CBT) can be effective.
  • Mindfulness and Meditation: Practices like yoga and meditation can help manage stress and improve mental clarity.
  • Support Groups: Joining endometriosis support groups can provide emotional support and practical advice.

Fertility and Family Planning

Fertility and family planning are significant concerns for many women with endometriosis. Studies show that surgery could double the spontaneous pregnancy rate in people with mild endometriosis. Those with moderate to severe endometriosis also have improved spontaneous birth rates after the laparoscopic removal of endometrial-like lesions.

However, even after successful surgery, some women may struggle with fertility issues. It is essential to have a candid discussion about fertility and family planning with your healthcare provider before surgery.

Financial Considerations

Endometriosis surgery can be financially burdensome. Many specialists are out-of-network, leading to high out-of-pocket costs in many, but not all, cases. It’s best to discuss potential expenses with your insurance provider and surgeon’s office beforehand. Additionally, explore options like payment plans or grants for financial support. 

Managing Recurrence

Despite effective surgery, endometriosis can recur. Studies indicate a 51% recurrence rate within ten years.  However, it can be in the 5-10% range if complete excision of visible implants is possible.   This may require additional interventions that are often hormonally based but can also be integrative and holistic to some degree. Risk factors for recurrence include age, ovarian endometriosis, incomplete removal of lesions, and the initial surgeon’s expertise. Regular monitoring and follow-up surgeries may be required to manage recurrences effectively. It is very prudent to find the most experienced and highly trained surgeon possible.  Here is a review of what you should be looking for in selecting a surgeon. 

Prevention Strategies:

  • Hormonal Treatments: Birth control pills, gonadotropin-releasing hormone (GnRH) agonists, and other hormonal therapies can help prevent recurrence but may also carry significant and prolonged side effects.  In general, the least potentially harmful option should be considered first and this should be highly individualized with your endo expert and/or reproductive endocrinologist.  
  • Lifestyle Modifications: Maintaining a healthy diet, avoiding toxins and regular exercise can support overall health and reduce the risk of recurrence by modulating and more efficiently eliminate excess estrogen in your system.
  • Anti-inflammatory Diet: Incorporate foods rich in omega-3 fatty acids and antioxidants to reduce inflammation. It is best to craft a personalized plan with a nutrition expert. 

Holistic Approaches:

  • Herbal Supplements: Consider supplements like turmeric, which has anti-inflammatory properties.
  • Aromatherapy: Essential oils like lavender and peppermint can aid in relaxation and pain relief.


Quality of life after endometriosis surgery involves a multifaceted approach to physical and mental health, fertility, and financial planning. By understanding the recovery process and incorporating comprehensive care strategies, women can optimally navigate their post-surgery journey.  Work with an endometriosis expert.  


  1. Ferrero S, Evangelisti G, Barra F. Current and Emerging Treatment Options for Endometriosis. Expert Opin Pharmacother. 2018;19(11):1109-1125. doi:10.1080/14656566.2018.1507067.
  2. Vercellini P, Buggio L, Frattaruolo MP, Borghi A, Dridi D, Somigliana E. Medical treatment of endometriosis-related pain. Best Pract Res Clin Obstet Gynaecol. 2018;51:68-91. doi:10.1016/j.bpobgyn.2018.06.001.
  3. Zondervan KT, Becker CM, Missmer SA. Endometriosis. N Engl J Med. 2020;382(13):1244-1256. doi:10.1056/NEJMra1810764.

Updated Post: July 09, 2024


Colon Chronicles: Delving into Bowel Endometriosis

In our recent blog, we highlighted the significance of addressing bowel endometriosis, a condition prone to misdiagnosis. Whether individuals have struggled with lifelong bowel issues or are suddenly facing disruptions, determining what’s considered normal can be perplexing. The “normal” range spans anywhere from three times a day to as infrequent as three times per week. In many sources, the focus is typically limited to frequency and to some degree consistency; however, there’s an overall scarcity of information on what defines normalcy. 

ICYMI: Understanding Bowel Endometriosis

This ambiguity is particularly challenging for those with endometriosis, where gastrointestinal symptoms vary widely, making it tough to discern what’s amiss. About 90% of endometriosis cases involve some form of gastrointestinal symptoms, often leading to an IBS (irritable bowel syndrome) diagnosis, which essentially offers a label for persistent symptoms without an identifiable cause. The usual next step in diagnostics is often a colonoscopy, a key tool for identifying or ruling out certain diseases. This article explores the nuances of bowel endometriosis, with a primary focus on the role and precision of colonoscopy in diagnosing this condition.

Bowel endometriosis is considered to be deep infiltrating endometriosis and can lead to a variety of symptoms which we discussed in the previous blog, but is often concerning if not diagnosed timely and may risk more complex surgeries including resection if the disease is not properly addressed. 

Related Reading: How to Get an Endometriosis Diagnosis

The Role of Colonoscopy – Is it helpful?

A colonoscopy is a diagnostic procedure commonly used to examine the inner lining of the large intestine (colon and rectum). It involves the use of a long, flexible tube called a colonoscope, which has a small camera attached to its end. This tool allows physicians to visualize the interior of the colon to identify any abnormal conditions or changes.

In the context of bowel endometriosis, a colonoscopy can potentially detect signs of endometrial tissue growth within the bowel. However, its effectiveness and accuracy in diagnosing this condition have been subjects of ongoing research and debate. Aside from its ability to detect endometriosis, there is also consideration of the provider performing the procedure and their level of knowledge of endometriosis. 

The use of colonoscopy in diagnosing bowel endometriosis has been a topic of considerable discussion among medical professionals. Given the invasive nature of the procedure and the often non-specific symptoms of bowel endometriosis, the role and necessity of colonoscopy in its diagnostic process have been questioned.

However, several case studies and research findings suggest that colonoscopy can indeed play a crucial role in identifying bowel endometriosis. In particular, it has been found to be effective in detecting endometriosis growth in the bowel, with certain colonoscopic findings such as eccentric wall thickening, polypoid lesions, and surface nodularities often being associated with endometriosis.

Evaluating the Accuracy of Colonoscopy for Diagnosing Bowel Endometriosis

While the potential of colonoscopy in detecting bowel endometriosis has been recognized, its accuracy in doing so has been the subject of extensive research. A number of studies have sought to evaluate the sensitivity, specificity, and predictive values of colonoscopy in diagnosing this condition.

One such study was conducted by Milone M et al., who performed a prospective observational study that included women diagnosed with deep pelvic endometriosis. The study aimed to evaluate the accuracy of colonoscopy in predicting intestinal involvement in deep pelvic endometriosis.

The results of the study suggested that colonoscopy did have the potential to detect bowel endometriosis, with a number of cases accurately diagnosed through the procedure. However, the overall sensitivity, specificity, and predictive values of colonoscopy were found to be variable, indicating room for improvement in its diagnostic accuracy.

In another study conducted by Marco Milone and his team, the researchers also found that while colonoscopy could indeed identify bowel endometriosis, its accuracy was not optimal. The study elucidated that the presence of colonoscopic findings of intestinal endometriosis in deep pelvic endometriosis was quite low, indicating that routine colonoscopy may not be justified for all women with deep pelvic endometriosis.

A Case Study: Bowel Endometriosis and Colonoscopy

To illustrate the potential role of colonoscopy in diagnosing bowel endometriosis, let’s consider a case study involving a 45-year-old woman who presented with abdominal pain in her left lower quadrant. This woman underwent a colonoscopy, which revealed a submucosal tumor-like lesion in her sigmoid colon.

Upon further examination using magnifying endoscopy, the lesion was found to contain sparsely distributed round pits – a finding that was suggestive of endometrial glands and stroma (the histological definition of endometriosis). This discovery led to a biopsy of the lesion, the results of which confirmed the presence of intestinal endometriosis.

This case study serves to highlight how colonoscopy, when combined with other diagnostic methods like magnifying endoscopy and biopsy, can aid in the detection and diagnosis of bowel endometriosis.

The Future of Bowel Endometriosis Diagnosis

While the role and accuracy of colonoscopy in diagnosing bowel endometriosis have been explored, research in this area is ongoing. The development and refinement of diagnostic methods are crucial for improving the detection and treatment of bowel endometriosis.

In parallel with the innovations in medical technology, new diagnostic methods such as magnifying chromoendoscopy, target biopsy, and virtual colonoscopy are being explored and studied for their potential to improve the accuracy of bowel endometriosis diagnosis. These advancements, coupled with a deeper understanding of the condition, may pave the way for more accurate and less invasive diagnostic options in the future.

Bowel endometriosis is a complex condition that can significantly impact the quality of life of those affected. While colonoscopy can play a role in its diagnosis, its effectiveness and accuracy are subject to continuous research and improvement. Exploring new diagnostic methods and refining existing ones are crucial steps toward enhancing the detection and treatment of this condition. As we continue to learn more about bowel endometriosis and its nuances, we can hope for more efficient and accurate diagnostic tools in the future.

Related Reading:

  1. Endo-Fighting Microbiome Optimization: Research-based Tips
  2. Endometriosis and the Microbiome: Insights and Emerging Research


  1. Walter SA, Kjellström L, Nyhlin H, Talley NJ, Agréus L. Assessment of normal bowel habits in the general adult population: the Popcol study. Scand J Gastroenterol. 2010;45(5):556-566. doi:10.3109/00365520903551332
  2. Habib, N., Centini, G., Lazzeri, L., Amoruso, N., El Khoury, L., Zupi, E., & Afors, K. (2020). Bowel Endometriosis: Current Perspectives on Diagnosis and Treatment. Int J Womens Health, 12, 35-47. 
  3. Milone, M., Mollo, A., Musella, M., Maietta, P., Sosa Fernandez, L. M., Shatalova, O., Conforti, A., Barone, G., De Placido, G., & Milone, F. (2015). Role of colonoscopy in the diagnostic work-up of bowel endometriosis. World J Gastroenterol, 21(16), 4997-5001. 
  4. Tomiguchi, J., Miyamoto, H., Ozono, K., Gushima, R., Shono, T., Naoe, H., Tanaka, M., Baba, H., Katabuchi, H., & Sasaki, Y. (2017). Preoperative Diagnosis of Intestinal Endometriosis by Magnifying Colonoscopy and Target Biopsy. Case Rep Gastroenterol, 11(2), 494-499. 


Understanding Bowel Endometriosis

Bowel Endometriosis is a debilitating chronic health condition that affects a significant number of women worldwide. This disease is characterized by the growth of endometrial-like tissue outside the uterus, specifically on or inside the bowel walls. The condition often presents with varying gastrointestinal symptoms like painful bowel movements, constipation, and diarrhea, making it difficult to diagnose.

What is Bowel Endometriosis?

Bowel Endometriosis is a specific form of endometriosis that involves the intestines. In this condition, cells similar to those that line the uterus start growing on the bowel or even penetrate into the bowel wall. This growth can lead to painful and uncomfortable symptoms, particularly during a woman’s menstrual cycle.

Prevalence and Affected Areas

Bowel Endometriosis is a subset of a larger condition, endometriosis, affecting 1 in 5 endo patients. The most common sites for bowel involvement are the rectum, appendix, sigmoid, cecum, and distal ileum. It’s also worth noting that bowel endometriosis frequently co-exists with endometriosis in other areas, making it a multifaceted disease that requires comprehensive treatment.

Symptoms of Bowel Endometriosis

Understanding the symptoms of bowel endometriosis can help in early diagnosis and treatment. It’s essential to note that these symptoms often overlap with other gastrointestinal conditions, making it a challenging disorder to diagnose.

Common Symptoms

  • Painful bowel movements: This is one of the most common symptoms of bowel endometriosis. The pain is often described as sharp or cramping and may worsen during menstruation.
  • Constipation and Diarrhea: Changes in bowel habits are another common symptom. Some women may experience constipation, while others may have diarrhea. These symptoms may also worsen during menstruation.
  • Rectal Bleeding: While not as common, some women may experience rectal bleeding, particularly during their menstrual period. A healthcare professional should always evaluate this symptom as it can also be a sign of other serious conditions.
  • Abdominal Pain: Abdominal pain, often worsening during the menstrual cycle, is another common symptom. The pain can range from mild to severe and may be constant or intermittent.
  • Dyspareunia: Dyspareunia, or painful sex, is another symptom that may indicate the presence of bowel endometriosis. This pain often stems from endometriosis lesions in the posterior pelvic compartment peritoneum, an area around the rectum that includes the surface peritoneum, commonly called the pouch of Douglas.

Diagnosing Bowel Endometriosis

Diagnosing bowel endometriosis can be challenging due to the overlap of symptoms with other gastrointestinal disorders. However, several diagnostic tools can aid in the identification of this condition.

Physical Examination and Patient History

A detailed patient history and a thorough physical examination are crucial first steps in diagnosing bowel endometriosis. The doctor will ask about the symptoms, their severity, and if they worsen during menstruation. A pelvic exam may also be performed to check for any abnormalities.

Imaging Tests

Imaging tests, such as transvaginal sonography (TVS) and magnetic resonance imaging (MRI), are commonly used to identify and characterize endometriosis lesions.

TVS is a first-line imaging technique providing detailed dynamic images of the pelvis with minimal patient discomfort. It helps identify all of the bowel’s layers and any potential endometriosis nodules.

MRI, on the other hand, is typically used as a second-line diagnostic tool. It excels in evaluating the extent of the disease and identifying any specific organ involvement and depth of infiltration.

Endoscopy and Biopsy

An endoscopy may also be performed to examine the bowel for any abnormalities. A biopsy can be taken during this procedure to check for the presence of endometriosis cells. However, this method has its limitations as it only provides a superficial sample, and endometriosis usually involves deeper layers of the bowel wall.


Laparoscopy is the gold standard for diagnosing endometriosis. This surgical procedure allows for visual inspection of the peritoneal cavity and can provide a definitive diagnosis. The surgeon can also assess the extent of the disease and its impact on other organs.

Misdiagnosis of Bowel Endometriosis

Bowel endometriosis is often misdiagnosed due to its similar symptoms to other gastrointestinal disorders. This condition is frequently mistaken for irritable bowel syndrome (IBS), Crohn’s disease, and even colon cancer.

It’s crucial for healthcare providers to consider a possible diagnosis of bowel endometriosis in women presenting with gastrointestinal symptoms, especially if these symptoms worsen around the menstrual cycle.

Treatment of Bowel Endometriosis

Treating bowel endometriosis is typically multidisciplinary, involving a team of specialists. It generally involves a combination of medical and surgical therapies.

Medical Therapy

Medical treatments aim to control the symptoms of bowel endometriosis and may include pain relievers, hormonal therapies like oral contraceptives or progestins, and gonadotropin-releasing hormone analogs. These treatments work by reducing inflammation and suppressing the growth of endometrial tissue.

Surgical Therapy

In more severe cases, or when medical therapy is ineffective, surgery may be necessary. The type of surgery will depend on the extent and location of the endometriosis. In some cases, a conservative approach may be used, where the surgeon attempts to remove the endometriosis while preserving as much of the bowel as possible. In other cases, a segment of the bowel may need to be removed.

Laparoscopic Surgery

Laparoscopic surgery is often the preferred method for treating bowel endometriosis. This minimally invasive procedure allows for precise removal of the endometriosis with less damage to surrounding tissue and quicker recovery times. However, it requires a skilled surgeon and may only be an option in some cases.

Read More: Why It’s Important Your OB-GYN Specializes in Endometriosis?

Bowel Endometriosis and Fertility

Research indicates that bowel endometriosis may have an impact on a woman’s fertility. This could be due to the inflammation and scarring caused by the disease, which can interfere with the normal function of the reproductive organs.

In cases where infertility is an issue, assisted reproductive technologies may be considered. However, surgery to remove the endometriosis is often recommended first to increase the chances of a successful pregnancy.

Read More: Does Endometriosis Cause Infertility?


Bowel endometriosis is a complex condition that can significantly impact a woman’s quality of life and fertility. Early diagnosis and effective treatment are crucial to managing this condition and minimizing its effects. Suppose you’re experiencing symptoms of bowel endometriosis. In that case, it’s important to consult with a healthcare provider who is knowledgeable about this condition and can guide you through the diagnosis and treatment process.



Through the Looking Glass: Reflecting on 2023

Embarking on the journey of self-reflection is not just a personal endeavor; for us at iCareBetter, it’s a collective celebration of progress, community, and collaboration. As we bid farewell to 2023, a year marked by challenges and triumphs, it’s time to take a look into the past year and reflect on all that has been accomplished. Join us as we navigate through the areas of growth, community involvement, projects, and meaningful collaborations that shaped our year. In this special blog post, we’re excited to share the insights gained from our podcast endeavors and offer a sneak peek into the thrilling developments that await us in 2024. Let’s rewind, recap, and anticipate the exciting narrative that continues to unfold in the ever-evolving story of iCareBetter.

About iCareBetter

iCareBetter is an innovative platform dedicated to helping patients with endometriosis and chronic pelvic pain find compassionate and skilled experts. All experts on iCareBetter have shown knowledge and expertise in the treatment of endometriosis and chronic pelvic pain.


Our vision is to reduce the symptom-to-effective treatment of endometriosis to less than a year. Studies show that patients with endometriosis spend an average of 7.5 years to have an official diagnosis. Moreover, even after the diagnosis, patients will have to spend several years with multiple failed treatment attempts. After the long delays in diagnosis and treatment, they might be lucky enough to receive effective treatment from an expert.


Our mission is to improve access to high-quality specialized care for those with endometriosis. iCareBetter wants to combat the issue of patients living in confusion, pain, and isolation. To that end, we hope to connect as many patients to the right experts as early as possible. And we hope that this will ensure timely diagnosis and effective treatment.

To read more about why iCareBetter was built and the inspiration behind it, check out our blog here and listen to episode 1 of the podcast here, where Saeid and Jandra give you a behind the scenes look into what inspired them. 

What happened in 2023?

In 2023, iCareBetter grew in many ways, including new avenues to provide education along with collaboration from the community. Here are some of the highlights!

  • We started a podcast! iCareBetter: Endometriosis Unplugged is hosted by Jandra Mueller, DPT, MS a pelvic floor physical therapist and endometriosis patient. The podcast is available on Spotify, Apple Podcasts, and Youtube.
    • We had 19 weekly episodes in season one
    • Listeners joined from all over the world, reaching 22 countries
  • We brought on a team to help with new content on social media creating a more visually appealing platform, community engagement, and followers.
  • We now have 211 providers on our website available and ready to help those suffering from endometriosis and we are continuing to grow!
  • Our blog content is now consistent with twice weekly posts bringing you updates on all things endometriosis. 

What To Expect in 2024 

While 2023 was a big year for iCareBetter, we hope to continue the growth and expand our providers across the globe. Our hope is to increase our collaboration with medical specialists, researchers, and advocates. There are some exciting things to come in 2024 including a new season of iCareBetter: Endometriosis Unplugged as well as some other projects that will be announced in 2024.   

We hope you have found our resources helpful either for yourself or a loved one, and hope you continue to share the love and spread the word about Endometriosis. All of us here at iCareBetter wish you a safe and happy new year. 

Cheers to 2024!

Do you or a loved one have Endometriosis? Here are some blogs that may help you get started on your journey. 

  1. Endometriosis Signs and Symptoms: Everything You Need to Know
  2. Endometriosis Facts & Myths: Dispelling the Misconceptions

Women’s Health Research and the White House Initiative

Merry Christmas and Happy Holidays! It’s time for some good news when it comes to researching ‘women’s diseases.’

Women’s health has long been an area that has been overlooked and understudied in medical research. Despite making up more than half of the population, women have historically been underrepresented in clinical trials and medical studies, leading to significant gaps in knowledge and understanding of women’s health issues. However, recent developments, such as the establishment of the White House Initiative on Women’s Health Research, are changing the landscape and paving the way for a new era of research and innovation in women’s health.

The Historical Underrepresentation of Women in Research

For decades, women’s health needs were considered a low priority in the scientific and medical fields. During the 1970s, when the women’s health movement emerged as part of the larger women’s movement, it became apparent that women were significantly underrepresented in medical and scientific research. At that time, there were few women working in medicine and science, and the lack of representation had serious implications for the understanding and treatment of women’s health conditions.

One significant example of the cautious approach towards including women in research was the Food and Drug Administration’s policy in 1977, which recommended excluding women of childbearing potential from early-stage drug trials. This policy was a response to the tragic consequences of the drug thalidomide, which caused severe birth defects in thousands of babies born to women who had taken the drug during pregnancy. While the intention was to protect women from potential harm, it resulted in a lack of data on how drugs specifically affected women.

The Shift Towards Inclusion and Advocacy

As awareness grew about the exclusion of women from research studies, advocacy groups and activists began to protest for change. They argued that individual women should be allowed to make informed decisions about participating in research and that excluding women limited their access to potentially life-saving treatments. The Public Health Service Task Force on Women’s Health Issues, in their 1985 report, called for long-term research on how behavior, biology, and social factors affect women’s health, further highlighting the need for inclusion.

In response to these concerns, the National Institutes of Health (NIH) established a policy in 1986 that encouraged the inclusion of women in studies. This policy, published in the NIH Guide for Grants and Contracts in 1987, urged researchers to include women and minorities in their studies and provided guidelines for doing so. The policy was further reinforced in 1989 when NIH announced that research solicitations should prioritize the inclusion of women and minorities.

The Founding of the White House Initiative on Women’s Health Research

In 1990, the Congressional Caucus for Women’s Issues requested an investigation into NIH’s implementation of guidelines for the inclusion of women in research studies. The subsequent report by the General Accounting Office (now known as the Government Accountability Office) highlighted inconsistencies in applying the inclusion policy and the need for improved communication. As a result, the Office of Research on Women’s Health (ORWH) was established in 1991 to monitor and promote the inclusion of women in research.

Under the leadership of Dr. Bernadine Healy, the first female NIH Director, the Women’s Health Initiative was launched in 1991. This initiative consisted of clinical trials and an observational study involving over 150,000 postmenopausal women. The trials aimed to investigate the effects of hormone therapy but was stopped due to incorrect interpretation of the data resulting in the majority of women stopping their hormone therapy overnight, literally. We are still dealing with the consequences of this today. 

Legislation and Policies to Ensure Inclusion

While the inclusion of women in research was initially an NIH policy, it became federal law in 1993 through the NIH Revitalization Act. This act included provisions requiring the inclusion of women and minorities in clinical research funded by NIH. The law mandated that NIH ensure the inclusion of women and minorities and that trials be designed to analyze whether variables affect women and minorities differently. It also emphasized that cost should not be a reason for exclusion and called for outreach efforts to recruit diverse populations for clinical studies.

Since the establishment of the ORWH, the office has monitored adherence to inclusion policies and guidelines. Researchers receiving NIH funding are required to report on the sex, race, and ethnicity of participants enrolled in clinical trials. These reports contribute to the ongoing efforts to promote inclusivity and address health disparities among different populations.

Improving Women’s Health Through Research

The White House Initiative on Women’s Health Research, announced by President Biden and led by First Lady Jill Biden, signifies a renewed commitment to advancing women’s health research. The initiative aims to galvanize the federal government, private sector, and philanthropic communities to close research gaps, address health disparities, and pioneer the next generation of discoveries in women’s health.

Under this initiative, concrete recommendations will be delivered to the Biden-Harris Administration within 45 days, outlining actions to improve research on women’s health and maximize investments in this field. Priority areas of focus will be identified to ensure transformative outcomes, ranging from heart attacks in women to menopause and beyond. The initiative also seeks to engage stakeholders from the scientific, private sector, and philanthropic communities to drive innovation and foster collaborative partnerships.

By prioritizing research on women’s health, we can gain a deeper understanding of conditions and diseases that predominantly affect women, such as endometriosis, cardiovascular disease, and Alzheimer’s disease. This knowledge will enable healthcare providers to better prevent, diagnose, and treat these conditions, ultimately improving the lives of millions of women.

The establishment of the White House Initiative on Women’s Health Research and the ongoing efforts to promote inclusion in medical research mark significant milestones in addressing the historical underrepresentation of women in studies. Through policies and legislation, initiatives like the Women’s Health Initiative, and the monitoring of adherence to inclusion guidelines, progress is being made to close research gaps and improve women’s health outcomes.

Research plays a crucial role in understanding the unique aspects of women’s health and developing effective treatments and interventions. By prioritizing and investing in research on women’s health, we can empower women, healthcare providers, and researchers to make informed decisions and advancements that will positively impact the health and well-being of women across the nation. The White House Initiative on Women’s Health Research is a vital step towards achieving this goal and creating a future where women’s health is fully understood, supported, and prioritized.

What you can do! 

The Initiative is accepting written comments and input, we urge everyone to get involved. 

You can send in either a word document or PDF file to

Related reading: 

  1. Endometriosis Signs and Symptoms: Everything You Need to Know
  2. Endometriosis Facts & Myths: Dispelling the Misconceptions
  3. Why was iCareBetter built?



Endometriosis: Is it a Disability?

Endometriosis, a debilitating condition affecting millions of women globally, often prompts questions about its influence on daily life and work ability. This article provides an in-depth analysis of endometriosis, how it affects women’s work ability, and the possibility of qualifying for disability benefits.

Endometriosis is a medical condition that primarily affects women during their reproductive years, and is very prevalent, with over 80 million women diagnosed worldwide, typically between the ages of 20 and 40. Treatments such as surgery and medical management as well as physical therapy can alleviate some symptoms, but there is currently no definitive cure for the disease.

Endometriosis and Disability: An Intricate Relationship

The symptoms of endometriosis vary greatly among individuals. The most common symptom is pelvic pain, particularly during menstruation, sexual intercourse, bowel movements, or urination. Other symptoms include abdominal bloating, nausea, as well as infertility, among other symptoms. 

Endometriosis can significantly disrupt daily functioning due to associated symptoms such as pain, fatigue, and psychological distress especially during one’s menses (period) but is not always confined to that time of the month. Consequently, the disease might qualify as a disability under the Americans with Disabilities Act (ADA) in certain cases. However, it is important to know that the Social Security Administration (SSA) does not automatically classify endometriosis as a disability in endometriosis disability act.

Endometriosis and Social Security Disability Benefits

Qualifying for Social Security disability benefits due to endometriosis is not straightforward. The SSA considers two primary factors when determining if an individual qualifies for SSDI (Social Security disability insurance) or SSI (Supplemental Security Income) disability benefits:

1. Does the individual’s condition meet (or equal) the requirements of a listed impairment?

2. If not, do the symptoms of endometriosis significantly interfere with the individual’s ability to function, to the point where they cannot perform any type of job safely?

Since endometriosis is not listed as a qualifying condition, sufferers cannot automatically meet the first criterion. However, they might still qualify for Social Security disability if their symptoms significantly impede their ability to work, what the SSA calls “substantial gainful activity,” or SGA.

How to Qualify for Social Security Disability for Endometriosis

To qualify for Social Security disability due to endometriosis, it must be demonstrated that the symptoms of the disease prevent the afflicted individual from performing their job. The SSA will then assess if there is any type of job that the individual can safely perform. This evaluation considers medical records, age, work experience and job skills, education, and residual functional capacity (the minimum work that can be expected from an individual).

Applying for Social Security Disability for Endometriosis

Applications for Social Security disability benefits can be made online, through a phone call to the Social Security’s national office, or in person at a local Social Security field office. Winning a disability claim for endometriosis can be challenging, but applicants can seek assistance from an experienced disability attorney or non-attorney representative.

Endometriosis and Employment: A Complex Scenario

While endometriosis can significantly impact an individual’s ability to work, it does not automatically lead to unemployment or early retirement. In fact, many women suffering from endometriosis are able to maintain their employment status, albeit with certain adjustments to accommodate their symptoms.

Work Ability and Endometriosis

A woman’s ability to work can be severely compromised by endometriosis, with the disease often linked to poor work ability at age 46. This decreased work ability can lead to increased absence from work due to health issues. However, despite the increased absenteeism, women with endometriosis often maintain an employment rate comparable to women without the disease. It makes you question why? 

Over the past few years, emphasis has been put on staying home if you are sick, as a safety measure for spreading disease, though many with endometriosis may not be able to afford days off of work either because financially they are unable, or there is worry about saying PTO for an unexpected turn of event such as a necessary surgery, or increased symptoms causing debilitating pain. So we suffer through expecting there to be worse days. Women in general, tend to minimize their own symptoms or question if they are “really that bad” as a result of societal influences.

Endometriosis Disability Act and Retirement

The emergence of disability retirement due to endometriosis is not common. Despite the debilitating symptoms of the disease, the risk of early retirement is not significantly higher for women with endometriosis compared to those without the condition. This finding is encouraging and demonstrates the resilience and determination of women battling this condition. Or, is it that those with endometriosis stay working longer because of the financial need and medical bills?


Endometriosis is a complex and debilitating condition that can significantly impact a woman’s ability to work. However, it does not inevitably lead to unemployment or early retirement per the literature, though that does not mean that those living with the condition are able to work feeling well or without worry about consequences of not working.  With appropriate medical treatment and workplace accommodations, we hope that not only can those with endometriosis keep working, but with a higher quality of life while working. 


  1. The Americans with Disabilities Act
  2. Rossi, H., Uimari, O., Arffman, R., Vaaramo, E., Kujanpää, L., Ala‐Mursula, L., Piltonen, T.T., 2021. The association of endometriosis with work ability and work life participation in late forties and lifelong disability retirement up till age 52: A Northern Finland Birth Cohort 1966 study. Acta Obstetricia et Gynecologica Scandinavica 100, 1822–1829. 


“You Don’t Have Endometriosis” My Story

Many people have been asking about the return of our podcast iCarebetter: Endometriosis Unplugged. We are on a hiatus but thought it may be nice to share some success stories as those were quite popular. As we get the podcast up and running again and more interviews underway, I thought it might be helpful to share my own story, and why I am such an excision surgery advocate, though I understand it does not address everything. When you are told “you don’t have endo” you have two choices – give up and look elsewhere or keep pushing. 

Many of us keep pushing and get pushback about having central sensitization, needing mental health help, or it’s just not the right diet and supplements. Yes, all of those things may be true AND it also may be true that you didn’t have the correct surgery or surgeon. 

The Symptoms 

I was twenty-eight years old when I suddenly started feeling a sharp pain in my lower abdomen, one that was all too familiar in my teen years. I was told by the emergency room doctor shortly after starting my period that the pain I was having was likely due to rupturing cysts, and told my mom I needed to see a gynecologist to talk about birth control options to prevent them from happening. I was thirteen years old at the time, in the emergency room after my mom and brother had to pull me out of the shower because I experienced sudden and severe abdominal pain causing me to not be able to stand up or walk. 

This was 15 years later but all too familiar. I saw my doctor who recommended an ultrasound and was told once again “it was probably a ruptured cyst,” and that I may want to consider birth control pills in addition to my Mirena IUD as it “could be defective,” despite no periods or pregnancy scares over the last two and a half years since I had it replaced. At the same time, I became severely constipated and bloated with anything I ate, as well as feelings of sharp rectal pains and an odd sensation throughout my body, like a tingling or wave of lightheadedness during times I did have an urge to have a bowel movement. This also was very familiar to me but I hadn’t had it in years, it was less like a pain but a very intense uneasiness that made me stop in my tracks and literally pray to God for it to end, which it did, usually within a minute or two. 

After the ultrasound, the addition of Lo Loestrin along with the Mirena IUD, next step was a colonoscopy with no answers except for some relief after three months of barely any movement, and a diagnosis of IBS (irritable bowel syndrome). At this point, I had seen my OBGYN, a GI specialist, a naturopath, and discussed with my PT colleagues, but still no answers. 

I should mention, this all started after the most severe stress I had ever experienced at this point – a divorce. So it was no surprise that throughout all of these visits, it was definitely suggested that this could all be due to stress and anxiety. I knew there was more though, and I was seeking out the help I needed to learn to handle the stressors.  

Trials and Tribulations 

After about two years of trying various diets, food allergy & sensitivity testing, changes in birth control pills, a new GI doctor finally asked if I’d ever been tested for SIBO (small intestinal bacterial overgrowth).  “SIBO? What’s that?” I responded. Sure enough SIBO was in fact part of the problem (both hydrogen and methane positive) and after two rounds of antibiotics, things started to feel somewhat normal, until the UTI-like symptoms began. However, it was not a UTI, I learned that I was experiencing side effects from the birth control pill I had started to control the pain from the cyst ruptures, also known as hormonally mediated vestibulodynia, which we recently wrote about in a previous blog which you can read here

At this point, constipation was still a struggle, but nothing like it was before, the antibiotics helped, the diets helped, everything helped a bit, until it didn’t. The rectal symptoms were recurring, the constipation still a daily struggle and if I had a “bad” diet day, it took almost a week to get back on track. SIBO was recurring, the diets were stressful, the symptoms would fluctuate without a rhyme or reason and then the severe abdominal pain came once again along with a fever and nausea. It was time to go back to the ER. 

The ER Visit

This felt all too familiar, I waited several hours and even overheard the team in triage say “bladder symptoms, probably UTI.” I was finally rolled in and waiting for a CT scan to check for appendicitis. The pain was severe and the only thing that made a dent, and in my fever, was the lovely little morphine button. As soon as it got close to the time to press the button again, fever would spike and pain would come back. 

Good news and bad news. Good news no appendicitis, bad news is in the scan they saw a cyst on my liver and I need more imaging. More imaging was done and they couldn’t say what the cyst was, but this time they saw that I had some swelling in my lung and there was something called ‘atelectasis’ or a partial deflation of my lung. They finally sent me for a pelvic ultrasound and guess what the conclusion was “you probably ruptured a cyst, we see fluid behind your uterus. Have you seen your gynecologist?” 

At this point the fever wasn’t breaking, I had no answers but 10 more problems on the list and they admitted me to hospital where I stayed for four days. 

The Hospital Stay

I was checked by probably every type of specialist within those four days. Hospitalist, GI doc, urologist, immunologist, obgyn, and even infections disease. I had breakouts in hives and rashes because I am very sensitive to most antibiotics, I was in and out of imaging machines, my oxygen levels wouldn’t stay up – likely because of the partial lung collapse, and I had to practice breathing into that plastic thingy (an inspirometer), and on top of it, they diagnosed me with a heart murmur and was told I needed to follow up with a cardiologist for a further workup. 

In the end, they released me because the fever finally broke and my pain subsided and told me “we have no idea, it was probably some virus, follow up with your OBGYN.” 

The OBGYN (actually urogynecologist)

It was after a patient of mine, who had endometriosis, asked me “Do you think you could have endo?” I really never thought about it, my younger sister had endo or was clinically diagnosed with it many many years prior, but I didn’t feel like she did, she had severe period pain, would miss work and school, heavy bleeding, all the endo symptoms and I had GI issues and intermittent severe abdominal pain from rupturing cysts. 

At my appointment, I brought up this question – “how do they KNOW I ruptured a cyst, if it ruptured? She told me that because of the fluid and the symptoms, it was likely that, and that we should see the fluid go away shortly as the body reabsorbs it. I still had my IUD so I wasn’t sure when I was ovulating and she agreed to do weekly transvaginal ultrasounds to monitor. The fluid never went away. 

I had a lovely doctor, and she really helped me get on the right path, though she was not an endometriosis specialist, she was able to take me to surgery. I knew what she could and couldn’t do, and she was very transparent with me about this. By this time, I had done more research and knew there was a very high likelihood I would have to have another surgery – an excision surgery. I was okay with that because I knew what I was going into and knew what the outcomes could be, and it was essentially free, because of that lovely ER visit hitting all of my deductibles and out of pocket maximums. 

Surgery #1 (November 2017)

To keep it short, I was told I didn’t have endo. Despite this, she said that my left uterosacral ligament was ‘very strange’ and she took a biopsy and a sample of the pelvic fluid that never went away. When I got my pathology report back it read:

  • Left Uterosacral Ligament: Fibrotic inflammatory tissue
  • Pelvic Free Fluid: Cells consistent with endometriosis

I was still not given an endometriosis diagnosis after this, and I felt horrible. This was November 2017 and all the tools I had been able to use to manage to some degree, didn’t work. I was so fatigued, my GI symptoms were awful, SIBO came back yet again, and just felt unwell. Everything was difficult but at least I was on the right track. 

Surgery #2 (March 2018)

After having my surgical pictures reviewed by trusted colleagues, and the most painful, but helpful pelvic exam that literally reproduced my symptoms. My doctor told me “this is endometriosis, I can feel nodules.” She assured me that it presents in different ways, and really taught me the difference between the training of endometriosis specialists vs the standard gynecologist. She educated me about the different types of lesions and that not all of them come back as endometriosis because they lack “stroma and glands” but that fibrotic endo is likely what I had, and it can cause problems. This made a lot of sense and in March 2018, I had my second surgery, but this time it was the right one. My pathology report looked quite a bit different this round, and I felt entirely different. 

  • Uterus: globular and soft (possibly adenomyosis)
  • Rectovaginal septum: Peritonealized fibrofatty with focal reactive mesothelial hyperplasia
  • Right Uterosacral Ligament: Peritonealized fibromuscular and fatty tissue
  • Left Uterosacral Ligament: Fibromuscular and fatty tissue with few CD10 positive cells compatible with endometriosis
  • L peritoneum (pelvic sidewall): Fibrofatty tissue with endometriosis with single non-necrotizing granuloma

It was definitely validating seeing this report but it was even better when it just was gone, the inflammation, the pain, much of what I was experiencing was just gone. I now understood what many of my patients had told me. While this is not everyone’s experience, in my personal and professional experience, when you’ve addressed all the various factors, oftentimes the lesions are the last one and there is a vast difference in those who have a true excision surgery versus an incomplete excision surgery or non-excision surgery. Dr. Vasilev just wrote about how to find a specialist and some considerations. 

If you suspect endo is your problem, and you’ve had a surgery though you suspect it may not have been a thorough one, I sincerely urge you to seek a second opinion. I see this all too often, and it saddens me. I understand, because I have been there. The instances I see this the most are the ones who have fibrotic endo and are either told “you don’t have endo” or it’s never even addressed during their surgery because it is not recognized as endo by many doctors.  

The years following…

I did well for about three years, and after a very significant reaction I had, and months of inflammation following, I felt those endo symptoms creep back. The constipation that just felt like something was blocking my intestines from moving and the rectal symptoms, which is called dyschezia, and is one of the clinical manifestations of endometriosis. I had some symptoms that concerned me about thoracic endo, and the other new symptom was that I was getting fevers and flu-like symptoms about 1-2 days before my period that would dissipate on day 3 of my cycle. Because of COVID, and working in healthcare, I was testing frequently, but it was never covid and it would never be more than 48-36 hours. 

I found a wonderful in-network doctor in San Diego, and in February 2022, I had my third surgery (second excision) and there was regrowth of only fibrotic tissue in the rectovaginal septum as well as adhesions attaching my sigmoid colon to the left pelvic side wall. Once again, my symptoms completely resolved following the surgery. 

My story is not a unique one, but I felt it was important to share as I have had this same discussion with others in urging them for a second opinion and sure enough, they DID have endo, they just weren’t listened to, or hadn’t found the right doctor. I get discouraged when I hear people dismiss excision surgery because of the lack of good studies supporting it. The surgery is not the issue, the research is the issue. However, surgery won’t fix or cure all of the issues one may have and while the surgery (I feel) is crucial to most, if not all, people; you still need to be a detective and address ALL of the issues and root problems for the best outcome. 

Check out our podcast iCarebetter: Endometriosis Unplugged, available on Spotify and Apple Podcasts for more personal stories and discussions with experts, and we will see you for more episodes in 2024! 

Related reading:

  1. Endometriosis and Painful Intercourse: Is it Really Just Endometriosis?
  2. Finding an Excision Specialist: What you Need to Know
  3. All You Need to Know About Endometriosis Lesions


Understanding Neuroproliferative Vestibulodynia and the Connection with Endometriosis

A few weeks ago, we delved into the intricacies of vestibulodynia and its potential association with painful intercourse in individuals with endometriosis. We presented an overview of vestibulodynia subtypes in general and discussed one of the more common presentations we see in those with endometriosis – hormonally mediated vestibulodynia which in many is caused from the side effects of the birth control pill, which are offered as first line “treatments” for endometriosis. Today, we will focus on another subtype, neuroproliferative vestibulodynia (NPV), and the fascinating connections are are seeing in these two conditions, including the role of mast cells.  

If you missed our previous discussion on painful sex and vestibulodynia, you can find the detailed information here. 

Recent research endeavors have yielded valuable insights into the fundamental causes of these conditions, unveiling a shared mechanism involving neuroproliferation, characterized by an increase in nerve cells. Furthermore, an elevated presence of mast cells—integral components in immune function—has been observed both in endometriosis tissue and the vestibule of individuals diagnosed with neuroproliferative vestibulodynia (NPV).

Individuals diagnosed with NPV undergo a surgical procedure which is excised to remove the problematic tissue, sound familiar? 

This surgical approach has demonstrated notable success in alleviating pain for individuals affected by NPV. Dr. Paul Yong, an OBGYN, endometriosis surgeon, and researcher based in Canada, addressed the parallels between these two conditions during his presentation titled ‘Neuroproliferative Dyspareunia’ at the ISSWSH’s annual conference in March 2022. Dr. Yong’s insights laid the foundation for subsequent research, with Dr. Irwin Goldstein initiated further exploration earlier this year.  We were lucky enough to be able to speak directly with these two on our podcast iCarebetter: Endometriosis Unplugged, available on Spotify (linked here) and Apple Podcasts.

A Quick Overview


Vestibulodynia is a condition characterized by pain in the vestibule, the area of tissue within the vulva that surrounds the opening of the vagina. This pain can be described as sharp, stinging, burning, or hypersensitive, and can occur spontaneously or be provoked by touch or pressure, and many people will report superficial dyspareunia (or pain upon insertion) which is not limited to penis in vagina sex. Vestibulodynia is a subcategory of a broader condition called vulvodynia, which refers to chronic pain in the vulva.


On the other hand, endometriosis is a condition where tissue similar to the lining of the uterus grows outside the uterus, often causing pain and fertility issues. This condition can cause deep dyspareunia, or pain with deep vaginal penetration. Like vestibulodynia, the pain associated with endometriosis can be chronic and can significantly impact the quality of life.

The Concept of Neuroproliferative Dyspareunia

Both vestibulodynia and endometriosis can lead to pain during sexual intercourse and the term neuroproliferative dyspareunia, is in reference to the source of the pain.  Both tissues have been shown to have neuroproliferation, or increased growth, of nerve endings in the areas affected by these conditions and we are now seeing an aberrant amount of mast cells as well also contributing to inflammation. This overgrowth of nerves, and presence of excessive mast cells, can lead to heightened sensitivity and pain during vaginal penetration, both superficially, as well as deep.

Neuroproliferation in Vestibulodynia

In the case of vestibulodynia, research has shown that there are too many nerve endings in the vestibule tissue. This overgrowth of nerves, or neuroproliferation, is still under investigation. However, it is believed that this could be due to a congenital birth defect, with the excess nerve endings developing very early. There are two types of neuroproliferative vestibulodynia: primary (congenital) and secondary (acquired). In primary vestibulodynia, individuals have experienced pain their entire lives though usually identified shortly after menses or with first attempts at penetration (sex, tampons, speculum exams) while in secondary or acquired vestibulodynia, pain develops later in life usually after an event such as an allergic reaction, chronic yeast infections or other infection, and there has typically been a period of normalcy prior to these event. 

Neuroproliferation in Endometriosis

In endometriosis, nerve fibers have been found around endometriosis lesions in the pelvic peritoneum. These nerve fibers are more numerous in individuals with endometriosis compared to those without the condition. The increase in nerve fibers is believed to be driven by the immune response to infection or allergy, leading to nerve proliferation.

Symptoms of Neuroproliferative Vestibulodynia and Endometriosis

Vestibulodynia Symptoms

People with vestibulodynia typically experience pain at the entrance of the vagina, called the vestibule. This pain can be described in various ways, including as sharp, stinging, burning, or hypersensitive. This pain can also be classified by when it occurs, with provoked vestibulodynia referring to pain that occurs with touch or pressure, while unprovoked pain occurs spontaneously.

Endometriosis Symptoms

In endometriosis, the pain is typically experienced deeper within the pelvis, often during or after sexual intercourse. This deep dyspareunia can also be accompanied by other symptoms, such as painful periods (dysmenorrhea), painful bowel movements, and chronic pelvic pain to name a few. 

For more signs and symptoms, check out our blog Endometriosis Signs and Symptoms: Everything You Need to Know.

Causes of Neuroproliferative Vestibulodynia and Endometriosis

Causes of Vestibulodynia

The exact causes of vestibulodynia are still being investigated. However, research suggests that the overgrowth of nerves in the vestibule tissue could be triggered by signaling from immune cells in the tissue. This could be due to a congenital birth defect, resulting in excess nerve endings developing very early, or it could be an acquired condition, developing later in life possibly due to infection or allergy.

Causes of Endometriosis

The causes of endometriosis are also not fully understood though we have began to shift away from the narrative that it is caused by retrograde menstruation, and towards a genetic basis. We hope that in the future with new research, we will be able to fully understand the cause (or causes) and have optimal treatment methods to address the heterogeneity of this disease. 

You can read more about these theories in our blogs listed below:

  1. The History of Endometriosis: Unraveling the Theories and Advances [or lack thereof]
  2. Is Endometriosis Genetic? Understanding the Genetic Links in Endometriosis.

There has been limited research in the role of mast cells in endometriosis thus far, and Dr. Irwin Goldstein, MD has now successfully demonstrated in a case study of a patient with NPV, her endometriosis pathology also demonstrated similar findings, as well as a biopsy taken of her colon during a colonoscopy. 

Thank you to Paul Yong, MD for this information, here is a comparison of endometriosis and NPV and common mechanisms in each.

PrevalenceApprox 10%Approx 10%
DiagnosisHistological diagnosis(ectopic endometrial-like epithelium/stroma)Clinical diagnosis (but normal vestibular histology consists of epithelium/stroma)

NPV – mast cells and excessive nerve endings
Description of DyspareuniaDeep Superficial 
Nerve DensityIncreased local nerve density compared to controlsIncreased local nerve density compared to controls
NeutrophinsIncreased NGF expression by endometriosis stroma when higher nerve fibersIncreased NGF expression by immune cells in vestibulodynia in areas with more nerve fibers
InflammationIncreased IL-1b expression by endometriosis when higher nerve fibres

Endometriosis stromal cells, when stimulated by IL-1b, increase production of NGF and promote nerve fibre development in a PC12 2q13 polymorphism (adjacent to IL-1 family genes)

Mast cells

Increased IL-1b in tissues in vestibulodynia vs. controls; Not observed in another study (Eva)

Vestibular fibroblasts from patients with vestibulodynia expressed more IL-1b compared to external vulvar fibroblasts and to controlsIL-1b and IL-1R antagonist gene polymorphism

Mast cells




  1. Mwaura, A. N., Marshall, N., Anglesio, M. S., & Yong, P. J. (2023). Neuroproliferative dyspareunia in endometriosis and vestibulodynia. Sex Med Rev. 
  2. Goldstein, S., Yee, A., & Goldstein, I. (2022). Severe Allergic, Inflammatory and Traumatic Reactions of the Vestibule Associated with Acquired Neuroproliferative Vestibulodynia. The Journal of Sexual Medicine, 19(8, Supplement 3), S3.

Bornstein, J., Goldstein, A. T., Stockdale, C. K., Bergeron, S., Pukall, C., Zolnoun, D., Coady, D., consensus vulvar pain terminology committee of the International Society for the Study of Vulvovaginal, D., International Society for the Study of Women’s Sexual, H., & International Pelvic Pain, S. (2016). 2015 ISSVD, ISSWSH, and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia. J Sex Med, 13(4), 607-612.


Finding an Excision Specialist: What you Need to Know

Finding a true excision specialist is difficult for many reasons, including the paucity of skilled surgeons and the financial burden that may come with when you find one that is a good fit for you.  So, the first step is to find the right surgeon and the second step is determining how to navigate the financial implications. It’s important not to do it the other way around because initial botched surgery and treatment can make it that much more difficult to find relief.  Surgery is never easier the second or third time around. 

There are a small handful of carefully monitored sites with very helpful information and a listing of qualified surgeons based mainly on patient outcomes feedback, none better than Nancy’s Nook. While there may be a few others that share patient experiences and some information, most are not well monitored or refereed, and thus, information and surgeon leads must be viewed with caution.  Nancy Petersen has a vested personal interest in endometriosis and a deep understanding of the disease based on her work for many years with Dr. David Redwine, a pioneer in the field.  Thus the information which is refereed by Nancy and her hand-picked editors forms a solid base.  However, patient feedback, while important,  is not the only way to determine who to pick as your surgeon.   

The degree of a surgeon’s true technical skills is not easy to judge,  especially if you are in the majority of not being medically trained yourself.  Review of resumes and asking questions such as where did you go to school or train or how many cases do you do leaves a lot to be desired.  It is simply not an accurate reflection, although knowing the surgeon’s background and pedigree can help.  So, what else can be done to help find the right surgeon for you?  

iCarebetter was created to help those in need find a specialist with a bit more objective information than patient recommendations alone. iCarebetter includes surgeons who are video-vetted by a peer review process.  This means that acknowledged experts review surgical videos submitted by surgeons who wish to be vetted and are objectively either verified or not as possessing a high level of surgical capabilities.  Of course, this does not reflect total patient management and bedside manner and more subjective skills.  However, you want someone who can get the surgery properly done at the highest possible level for your needs. There is something to be said about a surgeon who is not afraid of showing other, perhaps better, surgeons what they’ve got, so to speak.    

Additional related reading: Why was iCarebetter built?

Not too long ago, it used to be that when you showed up to your appointment and asked the surgeon what type of surgery they perform, you typically would hear ablation or excision. More recently, many more have adopted excision as the preferred method, or at least talk that way.  But outcomes are variable among those receiving “excision surgery,” why?  This article will help you better understand some of the key takeaways in finding the right surgeon for you.  Some are simply not at a high enough skill level to help you, and others do not walk the talk. 

Additional related reading: Laparoscopy: A Common Treatment for Endometriosis

Excision vs. Ablation

Excision is the removal of tissue diseased with endo, whereas ablation is the burning or fulguration of endo lesions and surrounding tissue and organs, usually using electrocautery. Research shows both may be effective for superficial endometriosis and not near delicate structures such as bowel and ureters; however, it is usually not possible to accurately determine which are superficial or deep infiltrating lesions based on looking at them.

While some patients do symptomatically improve with ablation surgery, clinically, it is recommended that excision is the preferred method because you really cannot know if a lesion invades deeper into the tissue, until you remove it. It is likely that those who have benefited from ablation surgery probably only had superficial lesions, and those who did not improve likely had more extensive endometriosis that was missed or not fully eradicated. While this is clinically accepted, we need more research to confirm this and show it truly is the preferred method.  The problem with designing an accurate research study for this question is that the skill of surgeons participating in clinical trials is highly variable, so the results can be completely wrong because it almost entirely depends on surgical skill.  More importantly, one size does not fit all, and everyone is different.  Hence, a truly expert surgeon who can determine and act appropriately on findings and nuances is critical to your personal success. 

Important terms and approaches 

  • Wide excision is a term you may hear which means that there is a wide margin of tissue that is removed to ensure that only healthy tissue remains. There is no consensus on this topic. Some surgeons will adopt wide excision, while others will remove the individual lesions, perhaps leaving micro-diseased tissue behind that is difficult to visualize during surgery. These areas may develop endometriosis in the future.  In an expert’s hands, it is a judgment call as to how wide any given area of excision should be.  There is a balance of too much and not enough, and this requires a high level of expertise to optimize benefits and minimize harm.
  • Combination of excision and ablation. The other consideration when it comes to excision surgery is that some surgeons adopt a combination of excision and ablation.  Some tissue will be excised for histological confirmation of the disease, but then many lesions may be ablated instead of excised.  This generally does not make sense unless the surgeon simply does not believe that excision is better.  The only exception is the ablation of tiny lesions on sensitive areas, such as the ovarian surface, where fertility preservation is a concern.
  • Incomplete removal of lesions.  Most general gynecologic surgeons will not be able to excise very many lesions and will handle them by fulguration or ablation.  Some surgeons may be able to excise the majority of lesions but do not have extensive training to remove all lesions.  Hopefully, your surgeon will advise you of their limitations prior to rather than after your incomplete surgery.  However, in some cases, endometriosis is not suspected prior to surgery, and a general gynecologist, who is most often not trained in higher-level excision techniques, is caught by surprise.  In that case it is better to biopsy, prove that endo exists, and refer to a specialist rather than poorly perform an incomplete surgery.

Complete excision, especially in a difficult case where there is a lot of disease or perhaps in case of distorted anatomy due to repeat surgery, will only occur with a surgeon who has been additionally trained not just in MIGS (minimally invasive gynecologic surgery) but in endo excision per se.  The main surgeon has to be an expert because it is never possible to predict how much endo there is, even if imaging scans are negative.  Beyond that, if the main surgeon is not trained to perform bowel or urologic surgery, then a well-coordinated team is mandatory.  The problem is that this coordination is not too tightly organized in many centers.  Ask questions about who can do what, if any required supporting surgeons are in surgery from the beginning or “on call” when needed.  The latter does not often work out too well because of other commitments that might be conflicting.  

What if I Cannot Afford to see an Excision Specialist?

It is true that many of the surgeons that specialize in excision surgery are out-of-network providers. However, in the past couple of years there have been more surgeons that do take insurance and hopefully, with legislative efforts and more education, this trend will continue to grow. 

That being said, there is a good reason why many do not take insurance, and even if you have the option of an in-network provider, it may not be the right surgeon for you. Currently, there is no difference in the coding when undergoing laparoscopic or robotic surgery for endometriosis that discriminates between ablation versus excision. Ablating lesions takes far less skill, time and effort than excision does. Meaning, that an in-network surgeon who performs an ablation surgery that takes one hour will get paid the same as an in-network surgeon who does an excision surgery that takes four hours. Becoming a trained excision specialist costs money to the provider to undergo extra training to be able to perform these types of procedures, and even more training to become an expert in robotics.

Until our payment, insurance, and coding systems catch up to what is required, we will likely not see a dramatic shift in those who take insurance.  

Aside from the financial difference, those who are in-network may not be able to spend the amount of time you may want during office visits to discuss the details of your surgery and your overall case as those who are out-of-network. Out-of-network doctors are usually able to provide longer visits to address your concerns in depth instead of the standard 15-20 minutes you typically get with your regular OBGYN. Some choose cost over this important treatment planning time, but there are many people who value a personalized approach which takes more time over the cost of the surgery.   It is not just excision surgery that will get you to where you want to be, and this personalized treatment planning includes very important discussion about pre-operative and post-operative healing options.  

Whatever you choose, you want to feel comfortable with your surgeon and find the right fit for you. 

Other Considerations: Some Tips on Navigating the System

  • Change your insurance provider.  I know this is easier said than done, but for those with HMOs who are only allowed to stay within a small network, it may be worthwhile to talk to your employer, or partner (if applicable), or do some research on what other insurances are available to you.  PPO plans include their list of in-network providers but also often provide some reimbursement for out-of-network providers, especially if their surgeons are not at the skill level that you need or are not within a reasonable geographic range. Open enrollment is typically once a year, or when you change jobs, or due to other qualifying life-changing events.   So consider this as an option that may allow you to have more latitude and choice when planning for surgery.
  • Work with your insurance company. This does not always work, and is time-consuming, but can have a big payoff at the end. There have been patients who have communicated and worked with their insurance companies when there is no available specialist around to cover your out-of-network provider services. While this has worked for some, be ready for a time commitment and likely many phone calls to get to the person who can help you.  
  • Ask the doctor you have selected.   Some excision specialists have been helping patients with this insurance negotiation conundrum for many years. Because of that, some have teams that help you get an exception and lower your out of pocket costs tremendously.  
  • Adopt a new perspective. Lastly, this will not necessarily save you money, but looking at your surgery as an investment in your health may make it seem more doable. We often do not think twice about financing $30-$40k on a car or the thousands of dollars we spend on “stuff,” but we often hesitate when it comes to our health.  Without health, nothing else matters. For many, excision surgery has been life-changing, and thinking of paying for your surgery as an investment in your health, may be the best thing for you.  Again, while upfront costs may seem high, a concerted effort to find the right surgeon, advocate for yourself, and ideally find a surgeon’s office that can help you negotiate and advocate can lead to lower final out-of-pocket costs than you might think. 

Whatever route you take, it needs to be the best route for you, with a full understanding of the pros and cons. Take your time when finding the right surgeon, and don’t rush into something you are not comfortable with. 

Additional reading: 7 Ways to Prepare For First Endometriosis Specialist Appointment


Current Research in Endometriosis

Endometriosis affects roughly 190 million women and girls (assigned female at birth) worldwide. Despite its significant impact on the health of the individual due to both the disease and overlapping pain conditions, research funding for endometriosis lags behind other common diseases. However, we are starting to see small improvements. For example, in 2020, research funding by the NIH (National Institutes for Health) for endometriosis was 14 million dollars (US) and in 2022 nearly doubled at 27 million, and it is estimated for 2023 and 2024 to be approximately 29 million dollars. 

The economic burden of endometriosis on the U.S. alone, in terms of medical care and lost productivity, is estimated to be around $78-120 billion annually. These figures underscore the urgent need for more research funding and better treatment options for endometriosis. Which is what we have been seeing more recently, research focused on other aspects of the disease and co-morbidities and not just drugs aimed at suppressing hormones. 

Researchers have started to look more broadly and dive deeper into some areas that have only been superficially explored such as the impact of the  microbiome and genetic studies.  While the media has seemed overly excited about the findings and what this  means now, this new research may be the stepping stones we need to better understand the variations of this disease and future treatments for managing endometriosis along with the overlapping symptoms. 

This article aims at reviewing the new research in endometriosis. 

Please note that this is a brief overview of some of the research, not opinions or endorsements from the iCareBetter team. More extensive research is needed in these areas before any conclusions can truly be drawn. 

Here’s what researchers have been studying recently: 

  • Dichloroacetate. Researchers from the University of Edinburgh found that treatment with dichloroacetate reduced the size of endometriosis lesions and decreased lactate production, which has been associated with endometriosis manifestation in earlier studies.
  • Cannabis. The Western Sydney University in Australia is investigating the potential benefits of medical cannabis for endometriosis treatment. The double-blind randomized controlled trial will evaluate whether medicinal cannabis can counter symptoms like pain caused by endometriosis against a placebo. This of course would not be focused on a treatment for endo, but as pain management.
  • Immune system. It’s been recognized for many years that endometriosis and the immune system are intricately linked. Recent studies have found an overexpressed protein on endometriotic cells which may help drug development.  Startup Fimmcyte is developing an antibody that labels endometriosis cells for clearance by the immune system, which could provide a much-needed non-hormonal therapy for women with endometriosis.
  • Pelvic floor therapy. Studies have shown that pelvic floor therapy could be key to tackling endometriosis-induced pain, or identifying overlapping pain conditions. In addition to helping manage chronic pelvic pain, pelvic floor therapy has been effective in relieving pain through exercise,  movements, and manual therapies that target the pelvic area. Read more about pelvic floor physical therapy from our recent blog here.
  • Endometriosis and other inflammatory diseases. Recent research suggests that endometriosis may be linked to other inflammatory and pain-inducing diseases. A study by Celmatix and 23andMe, among others, found that endometriosis may be linked to 11 conditions, including migraine, back, and multisite chronic pain (MCP), and inflammatory conditions like asthma and osteoarthritis.
  • Biotech and Endometriosis. Several ongoing studies aim to improve our understanding of endometriosis at the genetic level. The Research OutSmarts Endometriosis (ROSE) study is investigating the causes of endometriosis and aims to develop improved diagnostics and treatments for women with the condition.

Despite the challenges faced by researchers and patients alike, these recent developments in endometriosis research are a beacon of hope. As our understanding of this complex condition deepens, we edge closer to more effective treatments and perhaps, one day, a cure for endometriosis. One thing is certain though, endometriosis may be due to several factors which may need different targets. The expanding research into these topics may not seem relevant now, but may pave the way to better understanding of the variations of the disease, resulting in a wider array of therapies in addition to surgery for both treatment as well as symptom management.  

Related Reading:

  1. Genetic Study On Patients With Confirmed or Suspected Endometriosis; Next Gen Jane
  2. Unraveling the Connection Between Endometriosis and Autoimmune Diseases
  3. The Hidden Connection Between Endometriosis and Systemic Lupus Erythematosus
  4. Genetics and Epigenetics of Endometriosis: Unraveling the Complex Web of Hereditary Implications


  1. Endometriosis Clinical Trials – Mayo Clinic Research
  2. Giudice, L.C., Horne, A.W. & Missmer, S.A. Time for global health policy and research leaders to prioritize endometriosis. Nat Commun 14, 8028 (2023).

Your Guide to Supporting a Loved One Through the Holidays: The Ultimate Endometriosis Resource List Updated and Revised

The holiday season can be a joyous time filled with festivities, but for individuals navigating the challenges of endometriosis, it can also present unique hurdles. Supporting a loved one with endometriosis during this time involves not only empathy but also understanding the complexities of the disease. To aid both those directly affected and their support systems, a plethora of resources are available, ranging from insightful blogs and informative books to engaging movies and podcasts. These tools not only offer a wealth of knowledge about endometriosis but also provide a platform for individuals seeking a better understanding of the condition or those desiring to support their loved ones effectively. 

In this guide, we will explore a curated selection of resources, offering both emotional support, educational insights, and even some ideas for your holiday shopping list to help individuals navigate the holiday season with a heightened awareness of endometriosis and a supportive approach to those impacted by this often misunderstood condition.

Understanding Endometriosis

For those of you unfamiliar with our blog, endometriosis is a chronic disease that primarily affects women (XX) of reproductive age. It involves the growth of endometrial-like tissue (the tissue that lines the inside of the uterus) outside of the uterus, leading to inflammation and pain, particularly during menstruation, though many other symptoms may be present. 

For more information on symptoms of endometriosis, read our blog 20 Signs and Symptoms of Endometriosis.

Despite being a common condition, endometriosis is often misdiagnosed or overlooked, leading to many women suffering in silence. However, with the right information, supportive community, and access to informed medical providers, it is possible to manage the condition and lead a fulfilling life.

Podcasts on Endometriosis

Podcasts are an excellent way of gaining insights and information about endometriosis in a convenient and accessible format. Here are some podcasts that delve into various aspects of the disease, from personal stories to expert opinions:

  • “iCareBetter: Endometriosis Unplugged”: Hosted by yours truly, is a video podcast (Spotify & Youtube) that focuses on expert interviews and patient stories with a few bonus episodes of specialists who treat conditions that often coexist with those with endometriosis. We have completed season 1 and hope to have season 2 coming in 2024!
  • “In Sixteen Years of Endometriosis”: Hosted by two witty best friends who share their personal journey with the disease, this podcast offers a blend of humor, vulnerability, and accurate information.
  • “The Cycle”: This podcast features stories of people living with endometriosis from around the world, providing practical ways to cope with the disease.

For more podcasts about endo, check out our previous blog here. 

Books about Endometriosis

Reading about endometriosis can provide a comprehensive understanding of the disease. Here are some books written by medical experts and those living with the condition:

  • “Beating Endo: How to Reclaim Your Life from Endometriosis”: Written by Iris Kerin Orbuch, MD, and Amy Stein, DPT, this book provides actionable insights into understanding and managing the disease.
  • “Heal Endo”: By Katie Edmonds, (F)NTP  provides a book that is patient focused with a more indepth understanding of the science balanced by actionable items that range from surgery to dietary and lifestyle changes. 
  • “The Endometriosis Health and Diet Program”: Authored by Dr. Andrew S. Cook, MD, FACOG, and Danielle Cook, MS, RD, CDE, this book focuses on treating endometriosis holistically, offering a comprehensive program tailored to individual needs.
  • “Know Your Endo: An Empowering Guide to Health and Hope With Endometriosis”: Authored by Jessica Murnane, this book provides tools and strategies to manage chronic pain associated with endometriosis.
  • “The Endo Patient’s Survival Guide: A Patient’s Guide to Endometriosis & Chronic Pelvic Pain”: This book by Andrew S. Cook, MD, FACOG, Libby Hopton, MS, and Danielle Cook, MS, RD, CDE, is a companion guide for patients, offering insights into diagnosis, treatment options, and achieving optimal relief.

Videos and Documentaries about Endometriosis

Visual content can help in understanding complex information about endometriosis. Several documentaries and movies have been produced to increase awareness about the disease.

  • “Below the Belt”: A documentary from Shannon Cohn who created “Endo What?” focuses on the journey of several women seeking an endometriosis diagnosis and the challenges they face. “Below the belt” is not only an empowering film for educating the masses, it has become a tool for legislative change. A must see for everyone. 
  • “All about NINA”: A drama highlighting the experience of a woman, Nina Geld, managing her life with endometriosis.
  • “Endo what?”: A documentary featuring women living with endometriosis and experts discussing treatment options.
  • “The painful truth”: This film focuses on endometriosis and adenomyosis, another related condition.
  • “A thousand needles”: A short documentary about the impact of endometriosis on a woman’s life.
  • “End-o”: A short film showcasing the life of a young woman, Jaq, living with endometriosis.
  • “The resilience of women in pain”: This short film focuses on Rose, a woman suffering from endometriosis and chronic illness, and her journey towards resilience.

Your Endo Shopping List: Comfort Tools for Loved Ones

In case you need to do some last minute shopping and want to show your loved ones you understand, here are some essential items that have proven useful for many. While these tools may not be able to stop this awful disease, they may provide some degree of comfort and relief when things get bad. Whether you are prepping for surgery, or just need some handy tools, here are some of my favorite items. 

  • Wedge Pillow. This is a must for those preparing for surgery during recovery. I only found this at my 3rd (and hopefully last) surgery and it was a game changer. When your belly is full of air, tender, and you don’t feel like moving (or sitting up at the very least), this helps to provide relief for recovering in bed or on the couch and is great if you are a side or back sleeper.
  • Heating pads. This is probably the number one item most endo warriors have – likely at home and work. They are always handy to have wherever you are, and for a more personalized gift, ETSY.COM has some amazing endo swag (including heating pads).
  • My Obi Apollo. This is a TENS unit with heat and multiple programs to help with cramps and reduce pain. To learn more about how TENS may be helpful, check out our blog here.
  • Squatty Potty. Everyone should have one. This is the gift that no one really wants, but secretly is so happy when they get one. It is essential for optimal toileting for everyone, but especially if you have endometriosis. Constipation and pelvic floor dysfunction are two issues the majority of those with endometriosis suffer from and this tool can make a world of a difference for toileting…. 

Until recently, endometriosis was not a term most people were familiar with, unless you are suffering. It is amazing how this is shifting and so many more people are familiar with the term, but may not understand how impactful this disease is to one’s life. Finding the right surgeon is key to address the lesions, but having tools to help in the meantime is crucial. More importantly, your loved one will most appreciate the effort you made to educate yourself about their disease, especially during the stress the holidays may bring. Give them the gift of understanding and empathy this year, and maybe something to help their pain in the meantime. 

Please note: We do not have financial affiliations with any of these products listed above.

Related Reading:

  1. Find an Endometriosis Specialist for Diagnosis, Treatment, & Surgery
  2. Endometriosis Facts & Myths: Dispelling the Misconceptions
  3. What You Need to Know About Endometriosis Excision Surgery
  4. Managing Endometriosis: What You Need to Know. 


Endometriosis and Painful Intercourse: Is it Really Just Endometriosis?

Those with endometriosis oftentimes will experience pain and discomfort with intercourse, especially pain with deep thrusting, also known as deep dyspareunia. However, many people also experience a different type of pain that extends beyond intercourse – superficial dyspareunia or pain upon entrance. Many people will have been diagnosed with ‘vaginismus’ and oftentimes given dilators, told to “just relax” or “have a glass of wine,” which is terrible advice. While some may have vaginismus, or pelvic floor dysfunction, for many the culprit could be that birth control pill that was given to you and advertised as a treatment for your endometriosis.  It is a mixed bag on how many people benefit from the use of oral contraceptive pills (OCPs), and they can be a helpful tool for many. That being said, one thing is certain: medications always have consequences – sometimes good, sometimes not good. 

In today’s blog, we will discuss a condition called vestibulodynia, and we will specifically cover hormonally associated vestibulodynia which is a prevalent health concern that results in pain in the vestibule, the tissue within the vulva at the opening of the vagina which also surrounds the urethra. It’s a subcategory of a broader term, vulvodynia, which refers to chronic pain in the vulva. This article aims to provide an in-depth understanding of vestibulodynia, its causes, symptoms, and effective treatment methods.

Vestibulodynia vs Vulvodynia vs Vaginismus?

Vestibulodynia is a general term used to describe discomfort in the vestibule, a part of the vulva that sits at the entrance of the vagina. The vestibule is the transition point between external and internal, similar to the entrance of a building. Vulvodynia is the broader category that includes vestibulodynia but can be pain anywhere in the vulva and typically is present for longer than three months and has specific causes and associated factors. Vaginismus lies within these and often is a misdiagnosis, the term refers to a chronic muscle spasm upon penetration or attempted penetration. This is one of the oldest terms used and while some may have true vaginismus, in the case of endometriosis there are much more likely causes, such as the birth control pill and other hormonal suppressive agents. 

Think about it – if you touch a hot stove, the muscles in your shoulder and arm reflexively pull you away. If a penis, speculum, finger, or tampon hit tissue that is painful and irritated, the surrounding muscles will tense reflexively because it is painful. So yes, there is a muscle spasm, but the cause of the spasm is the inflamed and painful vestibule, possibly due to consequences from the birth control pill. There are other causes of pain here, which we will cover in future blogs. 

Subtypes of Vestibulodynia

Recent research has led to the identification of a few subtypes of vestibulodynia based on the root cause of the discomfort:

·   Neuroproliferative vestibulodynia

·   Hormonally-mediated vestibulodynia

·   Inflammatory vestibulodynia

The vestibule tissue is fundamentally different from the skin around it, developing from a different part of the embryo. This biological difference is crucial to understanding the causes of pain specifically in the vestibule. In this post, we will be reviewing hormonally mediated vestibulodynia, and in upcoming posts we will discuss neuroproliferative vestibulodynia as there are some interesting new research in the connection between neuroproliferative vestibulodynia and endometriosis.

Causes of Vestibulodynia

The reason why some individuals develop vestibulodynia while others do not, is still under investigation. However, a 2014 study suggests that there may be a genetic risk factor for developing vestibulodynia when taking anti-androgen medication.

Hormonally-mediated vestibulodynia can be caused by several factors, times in life or medications that alter hormones and result in a suboptimal state. This could be during periods of amenorrhea (lack of a period) in young adults, medications including combined oral contraceptive pills, aromatase inhibitors used in breast cancer, and other hormonal suppressive medications as well as acne medications (Accutane and Spironolactone). Periods in life that result in reduced hormones including breastfeeding (lactational amenorrhea) and perimenopause through menopause which we describe as GSM (genitourinary syndrome of menopause). The vestibule tissue is particularly sensitive to a lack of hormone signals, so for those with endometriosis, while your birth control may be helping your painful periods, it maybe causing you to have painful intercourse. 

Symptoms of Vestibulodynia


Individuals with vestibulodynia typically experience discomfort at the entrance of the vagina, known as the vestibule. The pain in the vestibule can be described in many ways. People with hormonally-mediated vestibulodynia may describe their discomfort as burning, stinging, or tearing. 

Provoked vestibulodynia refers to vestibular pain that occurs with touch or pressure, while unprovoked pain occurs spontaneously. Sometimes, it can be challenging to distinguish provoked from unprovoked pain before all triggers are recognized, especially when they are seemingly simple things like sitting or wearing tight clothing.

People often feel discomfort any time there is contact or pressure on the vestibule. This includes during vaginal penetration (dyspareunia), tampon use, and speculum exams. Day-to-day activities that put pressure on the vestibule, such as wearing tight clothing, sitting for long periods, or wiping with toilet paper, can also cause discomfort. 


Because this tissue also impacts the urethra, for some, the primary symptoms are urinary in nature. Urinary urgency, frequency, or UTI-like feelings without an infection are common and some will even receive a diagnosis of interstitial cystitis/painful bladder syndrome, also very common to see in those with endometriosis. 

Pelvic Floor Tightness

It is believed that pelvic floor dysfunction may develop in people with vestibulodynia due to a subconscious guarding response against discomfort (remember the stove analogy). However, chronic tightening of the pelvic floor muscles can create more discomfort. The muscles can accumulate knots (trigger points) and become shortened and weak. The weakness is because the muscles are not functioning optimally, please do not go and do kegels! 

Additional symptoms of pelvic floor dysfunction can include feeling tension, discomfort, and burning in the hips, legs, lower back, and vulva, especially the vestibule. One can also experience urinary symptoms like frequency, urgency, and leakage, as well as bowel symptoms like constipation or discomfort with bowel movements.

Diagnosis of Vestibulodynia

The first step towards diagnosing vestibulodynia is a thorough history of your story by a knowledgeable provider. Your story holds crucial clues to your diagnosis. People with hormonally-mediated vestibulodynia may have discomfort that developed later in life after any of the associated factors discussed above, including starting a medication, surgery, breastfeeding, or menopause.

Then there should be a very specific examination of the pelvis, vulva, and vagina. In patients with hormonally-mediated vestibulodynia, the vestibule usually appears very red and irritated (erythema), but also pale (mucosal pallor). The provider should manually examine the pelvic floor muscles to determine if there is excess tension in the muscles.

A process called a Q-tip test is essential for mapping discomfort in the vulva. The provider will gently press a cotton swab to each part of the vulva while the patient reports their degree of discomfort at each spot. It is important that the provider touch each region of the vestibule, all the way around the vaginal opening. The physical exam is extremely important prior to using dilators as this may cause more irritation because the cause (or one cause) of the muscle tension is the vestibule and needs attention before dilators come into treatment. 

Some specialists will check labs including total testosterone, free testosterone, and SHBG (sex hormone binding globulin), and many with hormonally mediated vestibulodynia show altered levels; though you do not need labs to confirm this diagnosis. 

Treatment of Vestibulodynia

Fortunately, in the case of hormonally-mediated vestibulodynia, the standard treatment has a very high success rate. If vestibulodynia developed after starting a medication that is known to affect hormone levels, then patients should stop taking that medication. Stopping the medication is often not enough to help the vestibule tissue heal quickly because hormone levels might stay low for a long time after taking birth control pills.

Providers should prescribe a topical hormone gel to apply directly to the vestibule to restore the hormone signals to the tissue. The standard is 0.01-0.03% estrogen and 0.1% testosterone gel. The hormone gel is usually made by a compounding pharmacy. Custom compounded medications are especially helpful if someone is sensitive to a medication’s base, the inactive ingredients, and needs a different base.

Patients typically use the gel 1 to 2 times daily and start to notice improvement in 6 to 12 weeks. Some patients stop using the hormone gel once the offending medication has been stopped for a while, but many women choose to stay on this therapy.

Support for Vestibulodynia Patients

There are many societies with interests in female sexual dysfunctions in addition to ISSWSH. The National Vulvodynia Association (NVA) is a US-based association founded by patient advocates that focuses specifically on vulvodynia. They provide some educational materials for the public and fund research of vulvodynia. Tight Lipped is also a patient facing, grass-roots, advocacy group helping to change medical education around this condition. 

There are many online support groups and communities of patients who support each other on social media. To find fellow patients locally, ask a provider if they know of another patient seeking community or any local groups to join.


Understanding and effectively managing vestibulodynia necessitates a comprehensive understanding of its causes, symptoms, and treatments. The information in this article seeks to bridge the gap between scientific research and the general public, providing evidence-based insights into this prevalent health concern. If you are experiencing symptoms of vestibulodynia, seek advice from a healthcare professional. There is a broad range of treatment options available, and you are not alone in your journey towards healing and managing this condition.

While this article provides a comprehensive overview of vestibulodynia, it is essential to remember that each individual’s experience with the condition can vary. Therefore, it’s crucial to consult with healthcare professionals and consider personal circumstances when making decisions regarding management and treatment.

Find a specialist:

Additional reading:


  1. Rubin, R. W. C. (2022). Hormonally mediated vestibulodynia. Accessed from
  2. Burrows LJ, Goldstein AT. The treatment of vestibulodynia with topical estradiol and testosterone. Sex Med. 2013 Aug;1(1):30-3. doi: 10.1002/sm2.4. PMID: 25356284; PMCID: PMC4184715.

Pelvic Floor Physical Therapy: What you Need to Know 

In recent years, pelvic floor physical therapy (PFPT)  has increased in popularity, much like endometriosis. More people have at least heard the term, and it has caught the attention of mainstream media recently in FX’s American Horror Story: Delicate. Though I will say the depiction of what we do was a bit horrific if you’ve watched the show, PFPT is a crucial part of one’s endometriosis journey. While there has been a large (and much needed) increase  in practitioners and social media reels, there are some things you need to know to find the right physical therapist for you. 

In earlier blogs, we’ve posted about the benefits of PFPT before excision surgery as well as the benefits after excision surgery which you can find in the links listed below.

Endometriosis and the Pelvic Floor

Endometriosis is most recognized for its 5 clinical manifestations: infertility, dysmenorrhea (painful periods), dyspareunia (painful intercourse), dyschezia (painful bowel movements), and dysuria (painful urination). It is important to note that many of these manifestations may have alternative causes aside from endometriosis, many of which can stem from pelvic floor dysfunction. When it comes to endometriosis, one of the most frustrating parts is getting a diagnosis, especially because it truly requires surgical intervention for definitive confirmation. Something that we emphasize is that when it comes to endometriosis, it is important to address all of the pain generators in addition to the lesions themselves in order to have the best outcome. 

Endometriosis has a 7-10 year delay in diagnosis, providing ample opportunity for additional symptoms to develop either because of progression of the disease, ongoing chronic pain causing physical limitations, or even due to side effects of “treatments” for endometriosis such as hormonal suppression therapies like birth control and GnRH agonists/antagonists. 

One of the key aspects of endometriosis that is often underestimated is its association with pelvic floor muscle dysfunction. The pelvic floor muscles (PFMs) play a crucial role in supporting the pelvic organs, providing core stability, controlling bowel and bladder functions, and contributing to sexual arousal and orgasm.

Women with endometriosis often experience PFM dysfunction due to the chronic pain and inflammation caused by the disease. This can lead to a variety of problems, including hypertonia (excessive muscle tone), trigger points (painful knots in the muscles), and myofascial pain (pain in the muscle and its surrounding fascia). 

The Role of Pelvic Floor Physical Therapy

PFPT is a specialized form of physical therapy focusing on the pelvic floor’s muscles, ligaments, and connective tissues, addressing issues from the knees to the rib cage and beyond. Contrary to common misconceptions, PFPT goes beyond postpartum care, challenging the notion of a one-size-fits-all solution like Kegel exercises.  Those with endometriosis typically fall into the category of “hypertonic” or “high-tone” pelvic floor dysfunction versus weakness or “low-tone” pelvic floor dysfunction, and this needs a vastly different approach than kegels. 

Understanding that not all PFPTs are equal, training variations exist, with many PTs needing additional education beyond basic training. PFPTs treating pelvic pain often require a multidisciplinary approach, encompassing interventional pain management and sexual medicine, which is often not taught in the additional courses PFPTs are required to take beyond their basic education in PT school.

The bottom line here is that if your PT only has training in treating “low-tone” pelvic floor dysfunction and is recommending kegels, you may need to see what other options are available. There is also no standardization in what is considered to be adequate pelvic floor PT, though there are some key aspects those specialized in pelvic pain will utilize. 

  • Manual Therapy including myofascial release and visceral mobilization, involves the use of hands-on techniques to manipulate the body’s tissues. This can help alleviate hypertonia and trigger points in the PFMs, improve circulation, and give different inputs to the nervous system resulting in reduced symptoms.
  • Exercises which typically do not involve kegels, at least initially, will focus on exercises that reduce tension in the pelvic floor muscles and will progress to include exercises that optimize your biomechanics and when appropriate, facilitate return to your previous level of function which may include weight lifting, running, yoga, etc.
  • Modalities such as TENS unit or e-stim, ultrasound, or biofeedback. Biofeedback may be very helpful for those who are visual learners or may be the only option in your area, but ultimately, these should be adjunct therapies to complement the other techniques vs. the focus of your sessions.
  • Education is probably one of the most important pieces of what we do. As the provider that likely spends the most time with patients, we can help answer questions, provide support, and essentially act as your liaison between providers to help streamline care.
  • Differential Diagnosis. While PTs cannot make medical diagnoses, we can help in better identifying pain generators and communicating this to your team. For example, if your main complaint is painful sex (dyspareunia), we can help differentiate whether this is due to tight and painful pelvic floor muscles, vestibulodynia (a type of vulvodynia specific to the tissue surrounding the urethra and vagina) which is associated with superficial dyspareunia (or entrance pain) vs. deep dyspareunia which is more associated with endometriosis, or specific palpation techniques that point more towards endometriosis lesions. 

Additional Considerations

Finding a PT that fits your needs may be difficult as this is a specialty that needs more practitioners. However, if you are suffering from pain and are not getting the results you expect, the frequency and length of appointments may be a factor. Typically patients with pelvic pain benefit most with at least weekly, sometimes twice per week, appointments for at least 6-8 weeks to begin to see changes. Ideally each appointment is 40-60 min and involves a combination of techniques, especially manual therapy. Because PFPTs are hard to find, sometimes busy schedules do not allow for this treatment frequency, so don’t write off PT altogether if your outcome was less than optimal. Additionally, there is a wide range of techniques we utilize which vary depending on individual training. Most important, not everyone is a good fit for each person and it is really important to find a provider you feel comfortable with.

The Impact of Pelvic Floor Physical Therapy on Endometriosis

Through a combination of these techniques, pelvic floor physical therapy can have a significant impact on the management of endometriosis. Studies have shown that this form of therapy can help reduce pelvic pain, improve PFM function, and enhance overall quality of life for women with endometriosis.

Moreover, pelvic floor physical therapy can also help address some of the underlying issues associated with endometriosis, such as muscular dysfunction and chronic inflammation. By improving the function of the PFMs and reducing inflammation, this form of therapy can help alleviate some of the pain generators present in those with endometriosis, leading to more effective and long-lasting relief and better outcomes along with surgery. 

While PFPT is instrumental, it should be part of a broader treatment plan that includes medical treatments, complementary therapies, and lifestyle changes. Integrating PFPT ensures that endometriosis patients receive comprehensive and effective care for the best outcomes. 

By integrating pelvic floor physical therapy into the broader treatment plan, healthcare providers can help ensure that endometriosis patients receive the most comprehensive and effective care possible.

Check out our iCareBetter vetted physical therapists here.

Additional reading:  Managing Endometriosis: What You Need to Know. 


  1. Wojcik, M., Szczepaniak, R., & Placek, K. (2022). Physiotherapy Management in Endometriosis. Int J Environ Res Public Health, 19(23). 
  2. Fraga, M. V., Oliveira Brito, L. G., Yela, D. A., de Mira, T. A., & Benetti-Pinto, C. L. (2021). Pelvic floor muscle dysfunctions in women with deep infiltrative endometriosis: An underestimated association. Int J Clin Pract, 75(8), e14350. 

Endometriosis Guidelines: A Closer Look at a Potential Source of Confusion in Treatment (Part 2)

Understanding Endometriosis Treatment Confusion

Endometriosis affects millions of women worldwide, presenting with pain, irregular menstruation, and infertility. To shed light on the most effective treatment methods, this article is Part 2 in our series on this topic.  It summarizes and comments on the findings from a recent 2021 review which provided a detailed analysis of various endometriosis treatment global guidelines as of September 2020. 

There are often some discrepancies between guidelines for any disease.  However, for endometriosis, a prior review in 2018 revealed that only about 7% of recommendations were comparable between international guidelines.  Up to 28% of the recommendations were not supported by good research evidence at all.  This helps explain why there is such a wide variation between doctors’ recommendations in clinical practice.  

Key Guidelines reviewed in the most recent publication were:

  • American College of Obstetricians and Gynecologists (ACOG)–reviewed in our last post, which you can read HERE
  • Society of Obstetricians and Gynaecologists of Canada (SOGC)
  • European Society of Human Reproduction and Embryology (ESHRE)
  • Australian National Endometriosis Clinical and Scientific Trials (ACCESS)
  • Royal College of Obstetricians and Gynaecologists (RCOG)
  • French National College of Gynecologists and Obstetricians (CNGOF)
  • American Association of Gynecologic Laparoscopists (AAGL)
  • German Society for Gynecology and Obstetrics (DGGG)

Summary Review of Treatment Recommendations

  • Non-Hormonal Medical Pain Management
    • Nonsteroidal anti-inflammatory drugs (NSAIDs): While this is considered by all guidelines to be first-line therapy for dysmenorrhea and acyclic pelvic pain, it is not specific for endometriosis.  A diagnosis and targeted therapy is more prudent since a large review showed no difference in effectiveness between NSAIDs and placebo. 
  • Hormonal Treatment Options:
    • Progestins and Combined Oral Contraceptives (COCs): Widely recommended for initial pain management. Specific formulations and dosages vary across guidelines. Of interest, there is little mention of compounded micronized progesterone which is hard to study but may deserve a place in the conversation. The Levonorgestrel Intrauterine System (LNG-IUS) is particularly noted for its localized progestin delivery, reducing systemic side effects and effectively managing pain.
    • Megace (Megestrol Acetate): A potent progestin recommended by several guidelines but varies as a first-line vs second-line option. The additional benefit is less bone loss than that seen with GnRH agonist therapy.  
    • GnRH Agonists: Uniformly recommended in all guidelines for severe symptoms after first-line therapy; potential side effects, which can be long-lasting, include decreased bone density and menopausal-like symptoms.  Add-back low-dose estrogen therapy can reduce symptoms. Most guidelines, and the FDA, recommend durations of 6 months or less.  
    • Emerging Hormonal Therapies: GnRH antagonists are gaining attention for their rapid onset of action and fewer side effects compared to agonists. The evidence is not conclusive. 
    • Danazol and Gestrinone: Older treatments with androgenic effects, are less commonly used today due to side effects. Gestrinone is not currently available in the United States. 
    • Selective Estrogen Receptor Modulators (SERMs) and Selective Progesterone Receptor Modulators (SPRMs) are emerging options being explored for their targeted action and potential benefits.
    • Aromatase Inhibitors: Considered in some cases, especially for pain unresponsive to other treatments.  Most guidelines agree that this is a possible second-line option, but the evidence is not conclusive.  A possible niche for effective use may be in post-menopausal patients who have endo. 
  • Surgical Approaches: Navigating the Complexities
    • Laparoscopic Surgery: Endorsed for its efficacy and reduced recovery time, compared to big incision (laparotomy) surgery. However, the extent of surgery (complete vs. partial removal of lesions) varies among guidelines. Studies are likely hampered by different skill sets between participating surgeons.  
    • Robotic Surgery: AAGL and others highlight its benefits in complex cases, but its cost and accessibility limit widespread use. Specialized training is required. 
    • Ablation vs. Excision: The choice between these two methods remains a contentious topic, for some reason. Ablation is simpler and requires much less technical skill but is only applicable for treating superficial lesions.  It may not be as effective in the long term as excision, which is more comprehensive and accurate in terms of removing all of the visible disease.  Again, the skill base of surgeons is critical, and high variability in this regard may be affecting the ability to prove or disprove the effectiveness and safety of each.  
    • Endometrioma: Cystectomy or excision of endometriomas is superior to drainage in terms of lower recurrence.  Excision also provides the opportunity for pathologic confirmation, and this may be important where it is not clear whether or not there is also a tumor present.  Where fertility is a major concern, the more atraumatic the approach to surgery, the less ovarian reserve is affected, and this is another area where surgeon expertise is critical. 
    • Deep Infiltrating Endometriosis: Highly specialized excisional surgeries are recommended because ablation simply does not work with these lesions. There is an even stronger emphasis on the surgeon’s expertise and patient selection.  Intuitively, the best outcomes probably rest with selecting the best possible technology in a master surgeon’s hands.  Some strongly believe that this means robotic surgery for advanced cases with highly distorted anatomy. 
    • Hysterectomy:  This is considered a “definitive” or last resort surgery but may be helpful for complete excision of endo at any point.  It also allows the removal of any co-existing pain-producing adenomyosis, which is embedded in the wall of the uterus. 
    • LUNA (laparoscopic uterine nerve ablation) and PSN (presacral neurectomy):  Guidelines reflect multiple reviews that suggest no benefit to LUNA but a possible benefit for PSN in selected cases.  PSN is technically very challenging and treatment should be individualized.  As far as LUNA is concerned, studies include a mix of ablation and excision, which means a lack of precision in many of them and, again, surgeon skill level may be a factor.  Thus a definitive conclusion may be elusive until a better methodology to accurately study this is employed. 
  • Complementary and Alternative Therapies: Exploring Additional Avenues
    • Acupuncture and Electrotherapy (TENS): Mentioned in some guidelines as adjunct therapies, with some encouraging results.  More research is needed to fully validate their effectiveness.  However, these are low-risk options. 
    • Nutritional Supplements: Some guidelines suggest that dietary changes and supplements might play a role in symptom management.  This includes microbiome management for optimal estrogen metabolism.  There will likely never be large randomized studies for any of these variables because they would have to be huge and thus impractical to conduct.  But in today’s emerging world of personalized molecular medicine, other study methodologies are being explored to determine which of these approaches to diet and lifestyle may be more effective than others. 
  • Infertility and Endometriosis: A Delicate Balance
    • Surgical vs. Non-Surgical Approaches: The decision to opt for surgery in infertility cases is complex and depends on individual factors like age, severity of endometriosis, and previous treatments.  Reducing inflammation appears to be beneficial to effective intrauterine implantation and gestation. 
  • Emerging Treatments and Research
    • Future Directions: Ongoing research into immunotherapies, new hormonal agents, and gene/molecular therapy offer promising avenues for more personalized treatment strategies. 

Endometriosis management is a highly dynamic field with evolving guidelines and currently very discrepant recommendations due to incomplete or low-quality scientific evidence. Understanding current options is crucial for women to make informed decisions about their health. Regular consultations with endometriosis experts, staying informed about new research, and considering a multi-disciplinary holistic approach to treatment can significantly improve quality of life.

Additional Reading:


  1. Kalaitzopoulos, D. R., Samartzis, N., Kolovos, G. N., Mareti, E., Samartzis, E. P., Eberhard, M., Dinas, K., & Daniilidis, A. (2021). Treatment of endometriosis: a review with comparison of 8 guidelines. BMC Womens Health, 21(1), 397. 
  2. Hirsch M, Begum MR, Paniz É, Barker C, Davis CJ, Duffy J. Diagnosis and management of endometriosis: a systematic review of international and national guidelines. BJOG. 2018;125(5):556–64.

Preparing for the Holidays: Tips for Managing Flares

As the holiday season approaches, individuals grappling with endometriosis or other chronic illnesses are contemplating how to sidestep discomfort and flare-ups. Despite our concerted efforts to prevent or mitigate the frequency and intensity of flares associated with endometriosis, the truth remains that flare-ups are inevitable. 

The holiday season holds the promise of joy, connections, and quality time with loved ones for many, but for others, it may bring stress, indulgence, worry, temptation, or even apprehension. The prospect of navigating gatherings, grappling with uncomfortable inquiries, or being compelled to make challenging food choices after diligently avoiding certain items for an extended period can be disheartening. Although flares may be an inherent part of the journey at any given time, holidays are no exception. The good news is that there are strategies available to effectively manage or minimize flares during these festive times!

Managing endometriosis or any chronic illness during the holiday season can present unique challenges, but there are strategies to help minimize flares and make the most of the festive season. Here are some tips:

Plan and Pace Yourself:

  • Plan your activities and commitments wisely. Don’t overcommit to events or tasks.
  • Prioritize what’s most important to you and conserve your energy for those activities.

Communicate Openly:

  • Communicate with friends and family about your condition. Let them know your limitations and needs.
  • Be open about your health concerns, so they can better understand and support you during gatherings.
  • Or have a script of what you may want to say to those you do not want to share this information with such as: “Thank you for asking, though I’d prefer not to share those details right now, thank you for understanding.”

For a list of resources for yourself or others, check these out:

  1. 6 Movies & documentaries about Endometriosis you need to watch
  2. 4 Endometriosis Books You Must Read

Choose Your Events:

  • Select events that align with your energy levels and health status.
  • It’s okay to decline invitations or leave early if you’re not feeling well.

Mindful Eating:

  • Food is more than just its ingredients and nutrients, food is a major part of many of our cultures, enjoy it! 
  • Remember, stressing about trigger foods may be just as triggering as enjoying some of your favorite dishes.
  • Consider bringing a dish that aligns with your dietary restrictions to ensure there’s something you can comfortably eat.
  • Eat prior to going to events to avoid overindulging in foods that may be a trigger for your symptoms. 

Rest and Relaxation:

  • Schedule breaks for rest and relaxation. Give yourself permission to step away from activities and take time for self-care.
  • Incorporate relaxation techniques such as deep breathing or meditation to manage stress.

Create a Comfortable Space:

  • If attending gatherings, find a comfortable spot to rest if needed.
  • Consider bringing a cushion, heating pad, or any other items that provide comfort during flare-ups.

Be Kind to Yourself:

  • Understand that flares may still happen despite your best efforts. Be kind to yourself and acknowledge that it’s okay to take a step back when needed.

Stay Connected:

  • Stay connected with supportive friends or online communities. Sharing experiences and tips with others who understand what you’re going through can be comforting.

Use your toolbox!

  • For many, you have gathered your individual tools that have worked well for you in the past, don’t forget about these!
  • Connect with your providers, if you haven’t seen your providers in a while, it may be helpful to touch base with your mental health therapist, nutritionist, or physical therapist. 
  • Maybe you opt for that less intense workout to give your body a break.

Remember, everyone’s experience with endometriosis is unique, so tailor these tips to your specific needs and preferences. It’s essential to prioritize your well-being and enjoy the holiday season in a way that works best for you.

For more on this topic, check out our blog Managing Endometriosis: What You Need to Know. 


Endometriosis Guidelines: A Closer Look at a Potential Source of Confusion in Treatment Debates

Treatment strategies for endometriosis vary widely, with the primary objective being to alleviate pain and enhance fertility where necessary. However, the confusion and inconsistency in recommendations is alarming.  This article reviews and comments on some of the key current management strategies supported by the American College of Obstetrics and Gynecologists (ACOG), by way of Bulletin #114 (2010 and reaffirmed in 2022) and Bulletin #760 concerning adolescents (2018 and reaffirmed 2022). In the following posts, we will review other guidelines to give a more in-depth look at these inconsistencies and what you may face as you navigate your journey with endometriosis. 

Other internationally recognized bodies have published various guidelines seeking to help clinicians with the diagnosis and treatment of endometriosis. Unfortunately, there is significant discrepancy between some of the recommendations due to the complex nature of the disease and limitations of research to date. Many patients will look to online resources and forums after seeing providers and not seeing results. What they may be surprised to find is that information on sites dedicated to endometriosis are often inconsistent with what is proffered by different guideline resources. 


Surgery is considered a cornerstone in the management of pain and infertility associated with endometriosis. The timing of surgery and the type of surgery recommended varies between guidelines. However, it is illuminating to note that ACOG guideline Bulletin #114 states that “definitive diagnosis of endometriosis only can be made by histology of lesions removed at surgery.”

Minimally invasive surgery is highly preferred over open surgery (laparotomy) due to less pain, shorter hospital stay, quicker recovery, and better cosmetic results. However, a high level of skill and expertise is required to perform these procedures, whether it be laparoscopic or robotically assisted surgery. Despite better technology inherent in robotic surgery, outcomes research does not clearly show which modality is better overall.  However, the skill of the surgeon likely trumps the surgical tools used. Robotic surgery may be better suited for particularly difficult cases involving severely distorted anatomy due to advanced endo or scarring from repeat surgeries.  

The excision of endometriosis is widely recommended for patients with endometriosis-associated pain. However, there is ongoing debate on the preferred surgical technique (ablation versus excision) due to lack of conclusive evidence. Currently, the studies that look at excision surgery vs. ablation have significant limitations, potentially due to variation in the skill and training of the surgeons involved in these studies.  Meaning, studies to date may not have been done by true excision specialists and resulted in incomplete removal thereby skewing the research results.  This variation in surgeon expertise is a common plight affecting surgical procedure outcomes research. 

In ovarian endometriosis (endometriomas or chocolate cysts), minimally invasive excision of endometriomas is superior to drainage and ablation in terms of reducing recurrence of dysmenorrhoea, dyspareunia, cyst recurrence, and the need for further surgical interventions. 

In cases where women have completed their family planning and failed to respond to conservative treatments, hysterectomy with simultaneous excision of endometriotic lesions is considered the last resort. However, except for cases in which there is coexisting adenomyosis, hysterectomy is not necessarily required for pain relief purposes.  Each situation should be highly individualized. 

Medical Management of Endometriosis

While surgery is an effective treatment strategy and helps many patients, medical management currently plays a crucial role in managing symptoms and preserving fertility. These treatments primarily focus on pain management, hormonal suppression, and birth control.

Pain management is a critical aspect of endometriosis treatment. Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for symptomatic treatment of dysmenorrhea and acyclic pelvic pain. In fact, in their article discussing dysmenorrhea and endometriosis in adolescents, without any workup, ACOG believes that the majority of adolescents have primary dysmenorrhea which is defined as painful menstruation in the absence of pelvic pathology and recommends first line-therapies such as NSAIDs and birth control. The question is: without undergoing a definitive workup and assessment (surgery) for endometriosis and knowing that imaging is insufficient for diagnosis – how is it determined they do not have pelvic pathology? Furthermore, ACOG considers those that respond symptomatically to birth control pills and NSAIDs as a confirmation of primary dysmenorrhea, though some people with endometriosis also respond symptomatically to birth control pills and NSAIDs. 

Hormonal suppression, through the use of progestins, combined oral contraceptives, micronized progesterone, or Gonadotropin-releasing hormone (GnRH) analogues, is a common treatment strategy. This recommendation assumes that estrogen is responsible for endometriosis, but this is based on an incomplete understanding of endometriosis genesis and progression. Hormones are clearly involved but, based on increasing molecular evidence, this is not the sole factor in promoting growth of endometriosis. 

Birth control pills, specifically combined oral contraceptives, are often used as a first-line therapy for endometriosis-associated pain. This works by suppressing ovulation, which may help slow the growth of endometriotic tissue but has not been proven to induce regression or resolution. 

GnRH analogues are recommended as second-line treatment options for endometriosis-associated pain. They work by suppressing the production of estrogen, thereby theroretically reducing the growth of endometriotic tissue. Along these lines, ACOG states that “there is no data that support the use of preoperative medical suppressive therapy,” yet in clinical practice, many individuals are offered these medications inconsistently related to consideration or timing of surgery. Additionally, their level B evidence (second level) recommendations state “After an appropriate pretreatment evaluation (to exclude other causes of chronic pelvic pain) and failure of initial treatment with OCs (oral contraceptives) and NSAIDS, empiric therapy with a 3-month course of a GnRH agonist is appropriate.” It can be argued that this is extremely problematic given that there is no conclusive data to support the use of these medications prior to surgery. Finally, there is a significant  risk of short and potentially long term side effects and complications. 

Complementary Therapies

Complementary therapies such as dietary interventions, acupuncture, and electrotherapy are increasingly being recognized as potential adjunctive treatments for endometriosis. Quite a bit is evidence supported, but more research is needed to fully establish their efficacy and safety. Thus guidelines do not routinely address such options, leaving patients to their own devices and trial and error.  

In conclusion, the management of endometriosis requires a multi-faceted approach, incorporating both surgical and medical treatments which will be variable from patient to patient. In the past few years, there have been some improvements in the amount of research as well as advocacy. Finding a knowledgeable specialized surgeon and care team is of utmost importance.  The majority of OBGYNs do not focus on endo, have not undergone further specialized training and generally align with the guidelines set forth by ACOG, largely driven by perceived medico-legal concerns related to standard of practice.. Furthermore, other guidelines seem to differ in their opinions and recommendations regarding medical management and surgery, so stay tuned for more information.

Related reading:

  1. Find an Endometriosis Specialist for Diagnosis, Treatment, & Surgery
  2. Why was iCareBetter built? 
  3. What You Need to Know About Endometriosis Excision Surgery


  1. Bulletins–Gynecology, A. C. o. P. (2000). ACOG practice bulletin. Medical management of endometriosis. Number 11, December 1999 (replaces Technical Bulletin Number 184, September 1993). Clinical management guidelines for obstetrician-gynecologists. Int J Gynaecol Obstet, 71(2), 183-196. 
  2. ACOG Committee Opinion No. 760: Dysmenorrhea and Endometriosis in the Adolescent. (2018). Obstet Gynecol, 132(6), e249-e258. 

Endometriosis Affects Sexual Function: What You Need to Know

Many people know endometriosis as a “menstrual” disease or associate it with painful periods and/or infertility; however, endometriosis impacts many aspects of one’s life, including sexual function and intimacy.. This article aims to shed light on the complex interplay between endometriosis and sexual dysfunction, highlighting the critical points from recent scientific findings and providing an empathetic and informative perspective for those affected by the condition.

Impact on Sexuality

Endometriosis is notorious for causing severe pelvic pain, which is often exacerbated during menstruation. However, its effect extends beyond physical discomfort, with a significant impact on a woman’s sexual function. The correlation between endometriosis and sexual dysfunction is a compelling topic for scientific research, as it profoundly affects the quality of life of those living with this condition. One of the primary clinical manifestations of endometriosis is dyspareunia. What is important to know is that the lesions may directly cause deep dyspareunia (pain with deep thrusting), though the lesions as well as ‘treatments’ for endometriosis may also impact sexual functioning and leads to a decrease in sexual desire or arousal, resulting in a cycle of distress and avoidance of sexual intimacy.

Beyond Pain: Emotional and Psychological Effects

The effects of endometriosis on sexual function aren’t limited to physical symptoms. The condition can also trigger feelings of anxiety, distress, and guilt, affecting a woman’s self-esteem and overall mental health. Furthermore, the chronic nature of endometriosis and its association with infertility can impose additional psychological stress, further exacerbating sexual dysfunction. Over time, one may anticipate the pain, or have anxiety about what the sexual experience may be like, therefore causing reduced desire and arousal, or resulting in avoidance of sex or intimacy altogether.  

Understanding the Prevalence of Sexual Dysfunction in Endometriosis

A significant proportion of women living with endometriosis experience some form of sexual dysfunction. However, the severity and type of dysfunction can vary greatly, influenced by factors such as the type and extent of endometriosis, individual pain tolerance, and psychological well being.

Several scientific studies have delved into the intricate relationship between endometriosis and sexual dysfunction. A systematic review of nine studies conducted between 2000 and 2016 found that around two-thirds of women with endometriosis experienced some form of sexual dysfunction. These dysfunctions extended beyond deep dyspareunia, encompassing issues like hypoactive sexual desire, arousal problems, and orgasmic disorders.

The Role of Deep Infiltrating Endometriosis (DIE)

Deep Infiltrating Endometriosis (DIE), a severe form of the disease, is often associated with a higher prevalence of sexual dysfunction. Studies focusing on patients with DIE have found a significant impairment in various aspects of sexual functioning, including satisfaction, frequency of intercourse, and orgasm.

The Multidimensional Nature of Human Sexuality

Human sexuality is a complex phenomenon, influenced by a multitude of physical, psychological, and relational factors. As such, sexual dysfunction in women with endometriosis is not solely a result of physical pain but can also be shaped by the individual’s mental health and the quality of their intimate relationships.

Psychological distress, often associated with chronic pelvic pain, can significantly affect sexual functioning. Women living with endometriosis often experience anxiety and depression, which can act as powerful inhibitors of the sexual response cycle.

The quality of intimate relationships plays a crucial role in shaping sexual function. Marital satisfaction, perceived partner support, and the degree of intimacy can significantly influence the sexual experiences of women living with endometriosis.

Addressing Sexual Dysfunction in Endometriosis: A Multidisciplinary Approach

Given the multifaceted nature of sexual dysfunction in endometriosis, a comprehensive and multidisciplinary approach is crucial for effective management. Such an approach extends beyond medical treatment for painful symptoms, encompassing psychological support and psychosexual therapy.

Your general gynecologist or endometriosis specialist may not necessarily be the person to also address your sexual dysfunction. This is a major area in which many providers are not trained in. ISSWSH, which stands for the International Society for the Study of Women’s Sexual Health, is an international, multidisciplinary organization that focuses on sexual health. Often, these people are the ones you want to see in regards to your sexual dysfunction. They include urologists, gynecologists, mental health professionals, physical therapists, nurse practitioners and more.  

Psychological support is crucial in managing the mental health challenges associated with endometriosis. Therapists and psychologists can provide coping strategies for anxiety and depression, addressing feelings of guilt and distress associated with sexual dysfunction.

Empowerment Through Knowledge

Education and awareness are powerful tools in managing endometriosis and its impact on sexual function. By understanding the nature of the disease and its potential effects on their sexual health, women can seek appropriate help and take proactive steps towards improving their quality of life.

Endometriosis and its impact on sexual function is a complex issue, requiring a multifaceted, compassionate, and patient-centric approach. By acknowledging the physical, psychological, and relational aspects of sexual dysfunction, healthcare professionals can provide holistic support to those living with endometriosis, empowering them to navigate the challenges of this chronic condition and enhancing their overall quality of life.

Related reading:

  1. Endometriosis Pain after Orgasm: What You Need to Know
  2. Understanding the Relationship between Sex and Endometriosis
  3. What You Need to Know About Endometriosis and Intimacy

References:Barbara, G., Facchin, F., Buggio, L., Somigliana, E., Berlanda, N., Kustermann, A., & Vercellini, P. (2017). What Is Known and Unknown About the Association Between Endometriosis and Sexual Functioning: A Systematic Review of the Literature. Reprod Sci, 24(12), 1566-1576.


Understanding Endometriosis: Unveiling the Common Symptoms and Their Impact

A recent article from Australia on common symptoms and endometriosis was released recently that followed several thousand women that were both surgically and clinically diagnosed (evaluated separately) with endometriosis and their symptoms to look at associations. There are minimal longitudinal studies available, so this article can be very impactful in raising awareness of the variable, but common, symptoms those with endometriosis experience.  

Endometriosis, a chronic gynecologic disorder, is characterized by the presence of endometrium-like tissue outside the uterus. This condition has a profound impact on women’s (XX) lives, often leading to increased hospitalizations, diminished work productivity, and a reduced quality of life. While menstrual symptoms are the most commonly associated with endometriosis, an array of other symptoms can significantly affect the physical and mental wellbeing of women diagnosed with this condition. This article aims to provide an in-depth understanding of the common symptoms associated with endometriosis and their impact on women’s health.

The Prevalence of Endometriosis

Endometriosis is a prevalent health condition affecting approximately 1 in 9 women (11.4%) in Australia by the age of 44 years and in the US the estimation is 1 in 10, though this may be inaccurate due to the significant delay or issues with misdiagnosis. The nonspecific nature and normalization of the symptoms often lead to a significant delay in the diagnosis of endometriosis, with several studies reporting an average delay of 7 to 11 years. This delay in diagnosis results in untreated endometriosis-related symptoms, increased hospitalizations, higher healthcare resource utilization, and potentially reduced success using assisted reproductive technologies. Additionally, some of the overlapping symptoms may be due to the “treatments” offered for symptom management such as hormonal supressive therapies.

Endometriosis and Menstrual Symptoms

Women diagnosed with endometriosis frequently report an array of menstrual symptoms. These may include severe period pain (dysmenorrhea), heavy menstrual bleeding, irregular periods, and premenstrual tension. The association between endometriosis and these symptoms is strong, with the odds ratio for severe period pain being as high as 3.61.

Endometriosis and Mental Health Problems

Apart from physical discomfort, endometriosis can significantly affect a woman’s mental health. Studies reveal a higher incidence of mental health problems, including depression, anxiety, and other mental health disorders, in women with endometriosis. The adjusted odds ratios for depression and anxiety are 1.67 and 1.59, respectively.

Endometriosis and Bowel Symptoms

Bowel symptoms are another common complaint among women with endometriosis. These may include constipation, hemorrhoids or piles, indigestion, or heartburn, bloating, diarrhea, or a combination of these. Additionally, one of the clinical manifestations is dyschezia, or discomfort/pain associated with bowel movements. The adjusted odds ratio for constipation is 1.67, indicating a significant association between endometriosis and bowel symptoms. Additional studies have demonstrated that approximately 90% of those with endometriosis have IBS-like symptoms. 

Endometriosis and Urinary Symptoms

Urinary symptoms, such as burning with urination (dysuria) and vaginal discharge or irritation, are also more prevalent in women with endometriosis. The increased odds of urinary symptoms suggest a possible alteration in the pelvic innervation caused by endometriotic lesions.

Endometriosis and Pain Symptoms

Endometriosis is often associated with other forms of pain, including back pain, headaches or migraines, and stiff or painful joints. The adjusted odds ratios for these pain symptoms range from 1.50 to 1.76, further emphasizing the multifaceted impact of endometriosis on women’s health.

Endometriosis and Nonspecific Symptoms

In addition to the symptoms described above, endometriosis is also linked to various nonspecific symptoms. These may include severe tiredness, difficulty sleeping, palpitations, and allergies or hay fever or sinusitis. The association between endometriosis and these symptoms underlines the complex nature of this condition and its wide-ranging effects on women’s health.We need more understanding whether these symptoms are a direct result of the endometriosis, the side effects of treatments, or another related issue. 

The Importance of Early Diagnosis

Given the wide array of symptoms associated with endometriosis and their significant impact on a woman’s quality of life, the importance of early diagnosis and treatment cannot be overstated. Early intervention can not only alleviate the physical discomfort associated with the disease but also significantly improve mental health outcomes. Furthermore, it can potentially prevent the development of chronic pain conditions and other long-term health complications.


Endometriosis is a complex condition that affects multiple aspects of a woman’s health. It is associated with a wide range of symptoms, extending beyond menstrual problems to include mental health issues, bowel and urinary symptoms, pain, and other nonspecific symptoms. Understanding these symptoms and their impact on women’s lives is crucial for providing comprehensive care to those diagnosed with this condition. While further research is needed to elucidate the specific mechanisms underlying these associations, the current evidence underscores the importance of early diagnosis and intervention in improving health outcomes for women with endometriosis.

Related reading:

  1. Understanding fatigue and endometriosis: A Practical No-Nonsense Guide
  2. Interstitial Cystitis and Endometriosis: Unraveling the “Evil Twins” Syndrome of Chronic Pelvic Pain
  3. Endometriosis Signs and Symptoms: Everything You Need to Know


  1. Gete DG, Doust J, Mortlock S, et al. Associations between endometriosis and common symptoms: findings from the Australian Longitudinal Study on Women’s Health. Am J Obstet Gynecol 2023;229:536.e1-20.

Choosing Your Battle Against Endometriosis: Understanding Excision, Ablation, and Robotic Techniques

The gold standard for diagnosis of endometriosis, a chronic, debilitating condition impacting millions of women (XX), is minimally invasive surgery with histological confirmation. Due to advancements and understanding of the disease, we now recommend that surgical treatment of the lesions be performed at the same time as a diagnostic surgery. It is well understood and agreed upon that in order to obtain a biopsy, the tissue must be removed and excised for analysis but the type of surgical approach to address the lesions is not consistent among all practitioners. 

If you were to ask someone well versed in endometriosis such as an endometriosis excision surgeon or even a patient advocate who is well up to date on their understanding and research, you’d likely hear that excision surgery is the gold standard for treatment and the preferred approach is minimally invasive. However, there are still those who would provide a counterargument stating that there is a place for ablation, especially, according to some guidelines, in the pediatric and adolescent age group. Those who proffer minimally invasive excision surgery differ in opinion about the adequacy of older technology laparoscopy vs. the technical benefits of robotically assisted enhancements.  

This article aims to provide some insight as to the understanding and nuances behind these arguments, and the limitations in the current research, as well as provide a comprehensive guide on the different treatment approaches for endometriosis, including excision surgery, robotic surgery, and the role of ablation.

Understanding Endometriosis

Endometriosis is a heterogeneous, inflammatory condition where endometrial-like tissue is found throughout the body, typically in the abdominopelvic cavity. While some patients with endometriosis can remain asymptomatic, an estimated 35-50% experience severe pelvic pain, infertility, and other symptoms related to the location of the endometriosis lesions or implants.  Endo is intensely inflammatory and fibrogenic, which often creates huge anatomic distortion, causing infertility and pain.  Tackling endo surgically requires advanced skills for these reasons. 

Current and Future Treatment Approaches for Endometriosis

Today’s treatment options are largely limited to hormonal manipulation and surgery. According to various medical advisory organizations, medical therapies should be offered as first-line therapies to alleviate endometriosis symptoms and potentially treat the endo, and then surgical intervention becomes an option. Sometimes surgery is only offered when pain is not alleviated, potentially allowing the endometriosis and resulting fibrosis to grow.  

There is a strong counterargument to starting with medical/hormonal therapy, which is often initiated based on clinical symptoms and findings that suggest endometriosis may be present.  Leading with medical treatment, which can have significant and lasting side effects, means potentially injurious and ineffective treatment can be prescribed when in fact there is no endometriosis present. In addition, due to relative progesterone resistance, symptoms may be ameliorated but the aberrant endometriotic tissue is not usually eradicated.  Meanwhile, fibrosis from your body’s healing efforts continues to accumulate. Therefore, excision may be considered a cornerstone initial step to remove the macroscopically evident bulk of disease followed by potential preventive strategies to suppress any residual microscopic disease after the diagnosis is pathologically established.  

Excising all visible lesions, associated adhesions, and scarring or fibrosis, is thought to reduce disease recurrence, relieve pain, and enhance fertility rates. However, while this can provide long-term relief, it is not usually curative.   In complex endometriosis cases (stage III or IV according to the revised American Society for Reproductive Medicine classification), achieving the goal of safe and complete excision of visible lesions, especially using conventional laparoscopy can be technically challenging, and requires specialized training. 

While this article is not focused on other treatment options, keep in mind that holistic, nutritional, Eastern and natural approaches have a role in alleviating symptoms and, to a degree, can influence the course of endo as well.   

Future treatments on the horizon will go far beyond surgery and hormonal manipulation.  We already know that there are other molecular pathways that drive endo growth and these will eventually be effectively harnessed for diagnostics, monitoring, and treatment.  Some of these pathways can already be influenced by nutritional and other holistic methods. 

Excision Surgery for Endometriosis

Excision surgery, most often performed via laparoscopy or robotics, has largely replaced ablation and big incision surgery. There is general agreement that minimally invasive surgery is superior to big incision (laparotomy) type of surgery.  However, ablation is still commonly performed, partly because it is simply easier and requires far less skill.   

During excisional surgery, visible endometriosis lesions are removed, which studies have shown significantly reduces the rate of disease recurrence and associated pelvic pain.  However, not all studies clearly support excision over ablation.  Additional research is required to settle this question and this is very difficult to do because of the extremely wide variance of surgeon skill. Suffice it to say that publications by experts in excisional surgery seem to clearly support this technique over ablation. 

The technical aspects of laparoscopy and robotics, as well as the surgeon’s expertise, dexterity, surgical precision, coordination, and visualization limitations, can cause complications during surgical dissection to vary widely, particularly in severe endometriosis cases. For this reason, it is prudent that a surgeon trained in specialized excision techniques perform these surgeries to minimize complications as well as to ensure adequate removal of all visible lesions. 

Robotic Surgery for Endometriosis

Over the past fifteen years, robotically enhanced surgery has emerged as an additional tool that can help circumvent the technical challenges of conventional laparoscopy. It offers several advanced features, including 3-D and magnified visualization, wristed instruments, motion scaling, and ergonomic positioning for the surgeon. But what does this mean in terms of benefits to you as the patient? 

First, 3-D technology and magnified view mean that the surgeon can see every little detail which conventional 2-dimensional laparoscopy may not allow the surgeon to discriminate, even using so-called “near contact laparoscopy.”  This is because magnified 3-D allows depth perception so that even sub-millimeter irregularities on the peritoneal surface can be identified. Also, in a difficult case with distorted anatomy, it allows the surgeon to better avoid damaging adjacent organs, like the bowel and ureters.  

Second, the instruments at the tips are “wristed”, meaning they behave like tiny human hands.  Conventional laparoscopic instruments are straight sticks with scissors or graspers at the end, which can limit options in tight spaces to cut, push, pull and tear. Robotic wristed instruments can result in more precise motions to excise endo in difficult places and avoid bleeding and other complications.  

Third, the fulcrum of activity during conventional laparoscopy is the abdominal wall.  When the surgeon moves the instruments, because of their straight nature, the abdominal wall is constantly being tweaked and traumatized. In contradistinction, since the surgical activity fulcrum is at the instrument tips during robotic surgery, there is less ongoing trauma to the abdominal wall.  This results in less abdominal wall pain over the first hours and days after surgery. 

Fourth, the risk of needing to convert to a big incision because the surgery is not going well using minimally invasive surgery is higher for laparoscopy compared to robotics.  So, you have twice the risk of waking up with a much bigger incision during a planned conventional laparoscopy.  Big incisions are prone to hernia and infection, not to mention more painful during recovery.  Generally, the more difficult the surgery the higher the conversion risk. Unfortunately, it is not possible with endometriosis (due to its intensely inflammatory and scarring nature) to accurately predict what is going to be an easy vs difficult surgery. This is truly a case of an ounce of prevention (optimal preparedness) being worth a pound of cure (getting caught with inadequate instruments for the job and then trying to scramble and fix it).  

Research Comparing Robotic Surgery with Conventional Laparoscopy

Several studies have been conducted to compare the efficacy of robotic surgery and conventional laparoscopy in treating endometriosis. A meta-analysis by Chen et al. evaluated the safety and efficacy of robotic surgery for treating advanced-stage endometriosis. The study concluded that while robotic surgery was safe and efficient, it was also time-consuming and incurred higher costs compared to conventional laparoscopy.  Studies like this are hard to interpret because it is not possible to know the real skill base of the surgeons involved, which means conclusions about costs and efficiencies are suspect. Also, it’s important to keep in mind that from the patient’s perspective, this cost is irrelevant. The costs are almost all absorbed by the hospital or surgery center and not directly passed on to the patient. 

The bottom line is that an experienced laparoscopic excision surgeon will likely be able to get the right surgery done safely in straightforward and moderately complicated cases.  A robotic surgeon should be vested enough in the newer technology (i.e., does a lot of robotic surgery, if not all robotics) to realize a difference.  In other words, in most cases, the surgeon is the most important part.  However, due to the superior technology, a highly skilled robotic surgeon will likely complete a complicated case safely (e.g., Stage III or IV with multiple prior surgeries), without conversion to a big incision, more often than a highly skilled laparoscopic surgeon, due to the limitations of inferior technology.  

From a practical perspective, you can experience/simulate the difference yourself between 2-D and 3-D vision or between straight stick laparoscopic surgery vs wristed robotics technology.  Wear a patch or tape one eye closed and immobilize your elbows and wrists with splints and tape, leaving only two fingers to grasp things with, and go about your daily business (NOTE: please don’t do this without someone assisting you because you will find that you misjudge distances and are unable to carry out tasks safely).  Can you adjust to this handicap over time?  Of course, as can a surgeon.  However, it is certainly not optimal to avoid using your wrists and both eyes if you have a choice. 

Robotic Surgery for Deep Infiltrating Endometriosis (DIE) and Extragential Endometriosis

DIE is a severe form of endometriosis characterized by endometrial tissue growth more than 5mm deep into the peritoneum. Approximately 40% of patients with endometriosis suffer from DIE. DIE can cause dense adhesions and fibrosis, distorting pelvic structures, including genital organs, the bowel, and the urinary tract, causing severe pelvic pain. There is also an overlap of molecular abnormality markers (primarily ARID1A mutations) between DIE and clear cell cancer arising from endometriosis.  This has led researchers to suggest that the DIE  type of endo is pre-malignant.  Removing DIE requires an even higher skill base, and robotics can facilitate far safer and complete surgery for the reasons noted above.  

Ablation for Endometriosis

Let’s consider the technique of ablation, as opposed to excision, in a little more detail.  This procedure involves destroying endometrial lesions using heat or laser energy rather than removing them. This method was introduced in the 70’s but has significant limitations. The issue with ablation is that while it may be adequate for very superficial disease, it does not remove the lesion, and more importantly, you cannot determine how deep the lesion goes by burning the surface and not carefully excising the lesion. Ultimately this can leave behind endometriosis which can continue to wreak havoc on the body.  In addition, the more trauma to your body (ablation via thermal damage is more traumatic than precise excision), the more your body resorts to scarring and fibrosis for healing.  This fibrosis can continue to cause pain and lead to complications like urinary system obstruction.  Finally, the ureters ( tubes that connect your kidneys to your bladder) and bowel are often right underneath endo lesions.  These are thin, delicate structures that are in danger of damage by thermal spread.  If they leak due to damage this can lead to emergency surgery, colostomy (wearing a bag for stool on your belly), urinary reconstruction and even death.  Therefore, it should only be done in circumstances where the risk is low, such as the eradication of tiny endo superficial ovarian lesions when all else (including endometriomas) has been excised.   


Regardless of the approach to excision – robotic or conventional laparoscopy, the need for better research utilizing highly skilled surgeons performing wide-excision is needed to definitively demonstrate the superior overall benefits compared to ablation surgeries. As of now, research is relatively sparse due to flaws in the research process discussed in this article and many more statistical reasons. Again, we are burdened by a lack of superlative surgeons and this is not a surgery for less skilled surgeons to dabble in, whether it be in research study participation or patient care.  As a result, the lack of absolute positive outcome superiority currently impacts the availability and insurance reimbursement for those seeking a safe and effective excision surgery.   At this time, since everyone’s situation is different, the best course of action is to get an expert opinion from the best endometriosis specialist you can find.  

Looking for a specialist? Check out our related blogs:

N.B. The above is based on a combination of published data and the author-surgeon’s personal experience, spanning over three decades, using both laparoscopy and robotic surgery for advanced excisional surgery, inclusive of advanced endometriosis and radical cancer excision. 


  1. Pundir, J., Omanwa, K., Kovoor, E., Pundir, V., Lancaster, G., & Barton-Smith, P. (2017). Laparoscopic Excision Versus Ablation for Endometriosis-associated Pain: An Updated Systematic Review and Meta-analysis. J Minim Invasive Gynecol, 24(5), 747-756. 
  2. Kang, J.-H., & Kim, T.-J. (2020). The role of robotic surgery for endometriosis. Gynecologic Robotic Surgery, 1(2), 36-49. 

Dr. David Redwine Obituary : A Modern Hero in Endometriosis Research and Excision Surgery

The recent death of David Redwine has undoubtedly left many with sadness and devastation. Our thoughts are with his friends, family, colleagues, and the endometriosis community as a whole. The world of gynecology has been significantly influenced and transformed by the groundbreaking work of Dr. David Redwine, a significant contributor to those suffering from this disease. A modern hero in this community in his contributions to endometriosis research, excision surgery, and fighting alongside patients and advocating for better answers and better care. His innovative approaches and relentless pursuit of knowledge have positioned him as a leading advocate for patients with endometriosis, a debilitating condition that affects millions of women worldwide. 

Who is David Redwine?

A formidable figure in the medical community, Dr. David Redwine has devoted his career to understanding and treating endometriosis. His profound commitment to research and patient care has made him a renowned authority in the field.

Redwine’s Contribution to the Understanding of Endometriosis

Endometriosis is a complex and often misunderstood condition. Dr. Redwine’s research has been instrumental in challenging established theories and introducing new perspectives on the origins and treatment of the disease.

Challenging Sampson’s Theory

One of the most significant contributions of Dr. Redwine has been his challenge to the widely accepted Sampson’s Theory of endometriosis. The theory, proposed by Dr. John Sampson in the 1920s, suggests that endometriosis is caused by retrograde menstruation, where menstrual blood containing endometrial cells flows back through the fallopian tubes and into the pelvic cavity. Redwine questioned the validity of this theory, arguing that if retrograde menstruation were indeed the cause of endometriosis, there should be ample microscopic evidence of refluxed endometrial cells attaching to the pelvic lining and subsequently proliferating. Yet, such evidence is conspicuously lacking. While modern day understanding by experts support alternative theories and are moving toward more plausible explanations, Dr. Redwine is largely to thank for this movement. 

Proposing an Embryonic Origin

In place of Sampson’s Theory, Redwine proposed that endometriosis originates from an embryonic source. He argued that endometriosis is derived from mesoderm, the middle layer of the three embryonic layers, and is a result of abnormal differentiation and migration of cells during embryonic formation of the female reproductive tract. This theory suggests that endometriosis is a congenital condition that can manifest later in life under the influence of hormones and other factors. 

The Concept of Mulleriosis

To further elucidate the embryonic origin of endometriosis, Redwine introduced the concept of ‘Mulleriosis.’ This term embraces a wider perspective, encompassing all pathologies associated with abnormal development of the Mullerian ducts, the precursor structures to the female reproductive organs.

Redwine’s Innovations in Endometriosis Surgery

Dr. Redwine has not only helped reshape our understanding of endometriosis but also revolutionized its treatment. He is a staunch advocate for excision surgery, a procedure that aims to completely remove endometriosis lesions. While early surgeries also focused on excision surgery, though lacking the precision and advanced technology we have today, the introduction of ablation surgery in the 70’s has complicated research findings, surgical outcomes, and the overall role of surgery in the treatment of this disease resulting in a further push towards hormonal suppression and the fight against Big Pharma. 

The Importance of Excision Surgery

Whereas traditional first-line therapies often rely on hormonal therapy or less thorough surgical methods, Redwine emphasizes the importance of excision surgery in effectively treating endometriosis. Through extensive research and practice, he has demonstrated that excision surgery can significantly alleviate symptoms and improve the quality of life for patients with endometriosis.

The Concept of Cure

Contrary to the prevalent belief that endometriosis is incurable, Redwine insists that the disease can be effectively treated through excision surgery. He defines ‘cure’ as the complete absence of the disease, as proven by follow-up laparoscopy. While this topic may be nuanced to a degree and there are cases of regrowth, those of who have undergone a true excision surgery, and those that perform skilled excision surgery understand the difference of persistent pain vs. incomplete technique. 

Redwine’s Advocacy for Patients with Endometriosis

In addition to his clinical and research work, Dr. David Redwine is a passionate advocate for patients with endometriosis. He strongly believes in empowering patients with knowledge about their condition and available treatment options. 

Redwine is committed to educating both the medical community and the public about endometriosis. He regularly delivers lectures and presentations, sharing his insights and the latest research findings. His dedication to education aims to foster a more informed and empathetic understanding of endometriosis.

As a fervent advocate for patient-centered care, Redwine emphasizes the need to listen to patients’ experiences and concerns. He argues that an effective treatment approach should consider not only the physical manifestations of the disease but also its impact on a patient’s mental and emotional well-being.

You Will Be Missed!

Dr. David Redwine’s pioneering work in endometriosis research, excision surgery, and patient advocacy has had a profound impact on the understanding and treatment of the disease. His unwavering dedication to advancing knowledge and improving patient care serves as an inspiration for both medical professionals and patients alike. Dr. Redwine’s contributions will undoubtedly continue to shape the future of endometriosis care and research, despite his recent passing. His name will always be known in this community for the significant contributions he has made and the patients whom he has helped whether directly, or indirectly. 

Rest in peace Dr. Redwine, you will be missed. 


Complementary Endometriosis Therapy Related to Pelvic Pain

Endometriosis, a medical condition that affects nearly one in ten women worldwide, is characterized by persistent pelvic pain that can significantly hamper their quality of life. While we await more research in diagnosing endometriosis and effective non-hormonal treatments, not to mention better research regarding excision surgery and improved access to care, it is crucial that patients have access to effective pain management strategies. Complementary therapies offer promising avenues for managing pelvic pain resulting from endometriosis, providing patients with a sense of control and agency in their own treatment. This article will delve into these natural therapies, offering a comprehensive guide to several popular and easily accessible options.These natural therapies include Transcutaneous Electrical Nerve Stimulation (TENS) units, dietary changes, Cannabidiol (CBD), turmeric, meditation, yoga, and acupuncture. While these therapies show promise, more research is needed to fully understand their efficacy and mechanisms of action.

The Pain Experience in Endometriosis

Understanding the pain associated with endometriosis is complex. It’s believed to be multifaceted, involving nociceptive, inflammatory, and neuropathic components. Endometriosis lesions can cause mechanical pain through compression and infiltration of nerves, and the chronic inflammatory state associated with the condition can lead to elevated levels of inflammatory cytokines and markers. Neuropathic pain can result from damage to neurons, as well as from central sensitization of pain in the central nervous system.

Pain from endometriosis can wax and wane, presenting in “flares” of variable duration that can significantly impact patients’ lives, often requiring increased pain medication. Those with endo may have cyclical or non-cyclical pain, and many people suffer from ovulation pain, which you can read more about here.

Self-management, involving active participation in managing one’s chronic condition, has been associated with improved knowledge and self-efficacy, and can be particularly important during times of isolation and distancing, such as during a pandemic. 

Transcutaneous Electrical Nerve Stimulator (TENS)

TENS units are handheld devices that deliver small electrical pulses to the body, providing a form of pain relief. These units work by the Gate Control theory, inhibiting the transmission of pain through smaller nerve fibers. They offer a patient-controlled, non-pharmacological option for pain management that is readily accessible and inexpensive.

Research has shown TENS units to be well-tolerated, with minimal side effects, and effective in reducing pain. Patients have reported significant decreases in pain scores and reduced need for pain medication with TENS unit use. While most studies have focused on the effectiveness of TENS for primary dysmenorrhea, there is a need for more research to understand its applicability to patients with endometriosis. If you are interested in learning more about TENS therapy, and the Apollo TENS, check out our recent blog here.

Dietary Modifications

Diet can play an essential role in managing endometriosis symptoms and is an important aspect when it comes to gastrointestinal symptoms. Certain nutritional deficiencies can contribute to metabolic changes that increase oxidative stress and epigenetic abnormalities, potentially exacerbating the condition. A balanced diet rich in specific nutrients such as folic acid, methionine, zinc, vitamins B12, B6, A, C, and E can help prevent these negative impacts.

Conversely, certain foods, such as red meat and processed foods, have been associated with increased inflammation and the development of endometriosis. Consuming foods rich in omega-3 fatty acids, such as fish oil, and foods containing polyphenols, like citrus fruits, apples, green tea, olive oil, and chocolate, may help prevent and improve inflammatory markers and in turn, modulate disease progression. It is important to note that there is currently no specific guidance on the optimal diet for endometriosis, and more research is needed to establish evidence-based dietary recommendations. Of course, we understand that there may be overlapping conditions that impact the tolerance of these foods in people with endometriosis and it is important to work with a trained provider for individualized recommendations. 

Cannabidiol (CBD)

CBD, a cannabinoid derived from the cannabis plant, has been gaining attention for its potential health benefits and its role in pain management. The endocannabinoid system, which CBD impacts, has direct effects on various physiological functions, including pain perception and inflammation. CBD is generally well-tolerated, with side effects including decreased appetite, fatigue, sleep disturbances, gastrointestinal upset, and hypersensitivity reactions. While there are no published randomized control trials of CBD use in endometriosis, surveys show a positive impact on endometriosis pain, and anecdotal evidence suggests it may be a useful adjunctive treatment. 


Turmeric, a spice derived from the curcuma longa plant, has been used for centuries for its medicinal properties. Its active ingredient, curcumin, has anti-inflammatory properties and has been shown in animal studies to have potential therapeutic effects against endometriosis.

While the benefits of turmeric for endometriosis are not well-studied, no harmful side effects have been reported with supplementation. More research is needed to determine the optimal dosage for managing endometriosis symptoms.


Meditation, specifically mindfulness meditation, has been associated with improved outcomes in chronic pain syndromes. It involves focusing on the present and cultivating an attitude of acceptance and non-judgment, which can help manage the stress and psychological comorbidities often associated with chronic pain conditions like endometriosis.

Research has shown that meditation can significantly improve pain catastrophizing scores, suggesting a beneficial effect on pain perceptions. However, more studies are needed to confirm its effectiveness and to understand how best to integrate it into treatment plans for endometriosis.


Yoga, a mind-body intervention, has been reported to improve pain and quality of life in patients with endometriosis. While research on the efficacy of yoga for endometriosis management is limited, preliminary studies suggest it may provide beneficial effects. However, more research is needed to understand the specific mechanisms by which yoga may alleviate endometriosis-related pain and to determine the optimal type and duration of yoga practice for maximum benefit. 


Acupuncture, a component of Traditional Chinese Medicine, involves the insertion of thin needles into specific points on the body. It has been used as a complementary therapy in endometriosis management, with studies showing a small but overall positive effect on endometriosis symptoms. To read more about the impact of acupuncture on endometriosis, read our blog here: Acupuncture: An Underexplored Solution for Endometriosis Pain.


Complementary therapies offer promising options for managing endometriosis-related pelvic pain. While more research is needed to validate and understand their effectiveness fully, they provide patients with accessible, patient-controlled strategies for managing their pain. By incorporating these therapies into their treatment plans, patients can take an active role in managing their condition, improving their quality of life, and gaining a sense of control over their health. You can read more about integrative therapies for endometriosis here


  1. Li, Linda ; Lou, Kristie ; Chu, Amanda et al. / Complementary therapy for endometriosis related pelvic pain. In: Journal of Endometriosis and Pelvic Pain Disorders. 2023 ; Vol. 15, No. 1. pp. 34-43.

TENS Therapy: A Non-invasive Pain Relief Option for Dysmenorrhea

Dysmenorrhea and endometriosis are two common health issues that many women face. These conditions often cause severe pelvic pain, disrupting everyday life. Pain relief for these conditions traditionally involves medication whether it be oral contraceptive pills or other hormonal suppressive medications or non-steroidal anti-inflammatory medications, which can sometimes lead to unwanted side effects. In many cases, those with endometriosis need additional support as these are not always effective. While excision surgery should be discussed, even those who have had successful surgeries continue to have persistent pain. Conditions such as dysmenorrhea, adenomyosis, and endometriosis can all contribute to persistent pain. Our blog titled Endometriosis and Adenomyosis: Decoding Their Contribution To Pelvic Pain helps explain these connections.

Modalities do exist that can be helpful for some, with a low side-effect profile. One particular modality of interest has been various Transcutaneous Electrical Nerve Stimulation (TENS) devices, and there have been improvements in these devices especially for those with dysmenorrhea also known as painful periods. One device that we are fond of is the Apollo from My Obi.

What is TENS Therapy?

TENS therapy is a pain management technique that uses low-voltage electrical currents to alleviate pain. It’s a non-invasive treatment that doesn’t involve medication, making it an attractive option for those who experience side effects from traditional pain relief methods.

How Does TENS Therapy Work?

TENS therapy functions by sending electrical currents through the skin to stimulate the nerves. These currents trigger the production of endorphins, the body’s natural painkillers, and block the pain signals from reaching the brain. The intensity and duration of the current can be adjusted to suit individual needs and pain tolerance.

Operation of TENS Devices

TENS devices, such as the Apollo belt and the OVA device, are designed to be user-friendly. They are lightweight and can be clipped onto clothing, allowing users to continue with their daily activities while receiving treatment. The devices come with preset programmes, which the user can select and adjust according to their comfort level.

Benefits of TENS Therapy

TENS therapy offers numerous benefits, especially for women suffering from dysmenorrhea and endometriosis. They are often readily available and affordable, some devices offer a heating option as well! 

Non-pharmacological Treatment Option

One of the main advantages of TENS therapy is that it’s a non-pharmacological treatment. It doesn’t involve medication, reducing the risk of side effects or interactions with other drugs.

Increased Blood Flow

TENS therapy can also increase blood flow to the abdomen. This improved circulation helps to reduce inflammation and swelling, further relieving pelvic pain.


TENS therapy is controlled by the user. This means the intensity and duration of treatment can be adjusted to suit individual needs and pain levels.

Effectiveness of TENS Therapy for Period Pain and Endometriosis

Several studies support the use of TENS therapy for period pain and endometriosis. A review of these studies found TENS therapy to be effective in reducing pain in women with primary and secondary dysmenorrhea. In terms of endometriosis, TENS therapy may offer a viable treatment option, although more research is needed in this area.

Side Effects and Contraindications

TENS therapy is generally safe with few side effects. However, it may not be suitable for everyone. For instance, people with heart conditions or those with a pacemaker should avoid TENS therapy. It’s always best to consult with a healthcare professional before starting any new treatment.


TENS therapy provides a non-invasive, user-controlled, and effective pain relief solution for dysmenorrhea and endometriosis. It increases blood flow and stimulates the production of endorphins. Moreover, it’s a non-pharmacological treatment, making it an attractive option for those who experience side effects from traditional pain relief methods. However, it’s always best to consult with a healthcare professional before starting any new treatment.

The potential of TENS therapy is promising, and further research could unlock more benefits for women suffering from pelvic pain. By exploring alternative treatments like TENS therapy, we can continue to improve the quality of life for those affected by conditions like dysmenorrhea and endometriosis. If you suffer from pelvic pain or dysmenorrhea you may want to seek help from a specialist, not sure? Read about the signs and symptoms that warrant help here!


Schiotz, H. A., Jettestad, M., & Al-Heeti, D. (2007). Treatment of dysmenorrhoea with a new TENS device (OVA). J Obstet Gynaecol, 27(7), 726-728. 


Endometriosis and the Microbiome: Insights and Emerging Research

Endometriosis is a multifaceted, heterogenous, inflammatory condition that impacts 10%-15% of women (XX) in their reproductive years, most commonly associated with chronic pelvic pain and infertility. 

Over the years, numerous theories have been proposed to explain its pathogenesis, but none have conclusively clarified its origins. Recently, however, researchers have begun investigating the complex interplay between endometriosis and the human microbiome. This article aims to provide an in-depth exploration of the current research into the relationship between endometriosis and the microbiome, with a particular focus on gut health, inflammation, and pathogenesis. 

Understanding Endometriosis

Endometriosis is marked by the growth of endometrial-like tissue found outside of the uterine cavity. This tissue is commonly found implanted over visceral and peritoneal surfaces within the abdominopelvic cavity, but can extend to the connective tissue and organs throughout the body. The condition can lead to severe dysmenorrhea, pelvic pain, and subfertility among a number of other symptoms and manifestations, significantly impairing a person’s quality of life.4

Read more: What causes endometriosis?

The Human Microbiome and Its Role in Health and Disease

The human microbiome comprises microorganisms that colonize our bodies and play crucial roles in nutrient metabolism and various physiological functions. The composition and balance of these microbial communities can significantly influence our health. For instance, the gut microbiota synthesizes vitamins B12 and K, maintains intestinal mucosal integrity, promotes angiogenesis and epithelial repair, and modulates immune functions.5 

Disruptions in gut microbiota composition, a state known as dysbiosis, can contribute to the development and progression of numerous diseases, including inflammatory bowel diseases, arthritis, psoriasis, neuropsychiatric diseases, and even malignancies.4 Given that endometriosis is a chronic inflammatory disease potentially triggered by altered immune functions and increased angiogenesis, there is a growing interest in investigating the role of microbiota dysbiosis in the pathogenesis and pathophysiology of endometriosis.1,4

The Microbiome-Endometriosis Connection: An Emerging Field of Research

Recent studies have commenced exploring whether microbiome composition is altered in women with endometriosis. For instance, one study identified significant differences in the microbial community structure between those with and without endometriosis.1,5 This study found that the abundance of Acinetobacter, Pseudomonas, Streptococcus, and Enhydrobacter significantly increased, while the abundance of Propionibacterium, Actinomyces, and Rothia significantly decreased in the endometriosis group.5

Another study focused on the microbiota of extracellular vesicles in the peritoneal fluid.4,5 These vesicles, small structures made of bilayered lipid membranes released by cells, carry proteins, nucleic acids, and lipids, and play a key role in immune function, inflammatory reactions, and disease development. Like other cells, bacteria can release extracellular vesicles that modulate host-cell immune responses and other health conditions. The study found significant differences in the microbial community of these vesicles between women with and without endometriosis.5

Highlighting the complex relationship between the microbiome and endometriosis, several studies have shown an increased bacterial colonization of menstrual blood and endometrial tissue in women with endometriosis compared to control subjects.5 A study on rhesus monkeys demonstrated that altered composition of the intestinal microflora and intestinal inflammation are associated with endometriosis. While we know animal comparison is not exactly like humans, the reproductive tract of rhesus monkeys closely resembles humans in both the form and function.7

Read more: Endo-Fighting Microbiome Optimization: Research-based Tips

Microbiome and the Inflammatory Response in Endometriosis

Endometriosis is known to trigger an inflammatory response within the body, characterized by increased production of pro-inflammatory cytokines, autoantibodies, growth factors, oxidative stress, and alterations in T-cell and natural killer cell reactivity.1 This dysregulated immune response potentially creates an immunosuppressive environment that enables the growth of these endometriosis lesions.1

Recent studies suggest that gut microbiome-derived extracellular vesicles could play a critical role in this process.5 These vesicles, ranging from 20 to 400 nm in diameter, can traverse the intestinal barrier, enter the systemic circulation, and potentially influence the peritoneal environment. They may carry a cargo of proteins, nucleic acids, and lipids that can influence immune function, inflammatory responses, and the development of diseases like endometriosis.

One study demonstrated that extracellular vesicles from women with endometriosis carry unique cargo that can influence inflammation, angiogenesis, and proliferation.5 Another study identified specific proteins in the exosomes of peritoneal fluid samples from patients with endometriosis, suggesting a role of exosomes in the diagnosis and treatment of endometriosis.5

The Gut Microbiome and Estrogen Levels

The gut microbiome is a significant regulator of estrogen levels, influencing estrogen metabolism and hence potentially affecting estrogen-dependent diseases like endometriosis.3 In postmenopausal women, fecal microbiota richness and levels of fecal Clostridia taxa have been associated with systemic estrogen levels. Therefore, gut dysbiosis leading to abnormal circulating levels of estrogen could potentially play a role in the development of endometriosis or the associated symptoms.3

The Microbiome as a Diagnostic and Therapeutic Target

The alterations in microbiota composition associated with endometriosis may provide valuable diagnostic markers for the disease. For instance, one study has proposed a microbiota-based model that can distinguish infertile patients with and without endometriosis.1 Another study has found that specific bacterial species are enriched in the endometrium and peritoneal fluid of patients with endometriosis.2

On the therapeutic front, the modulation of gut microbiota through dietary interventions, prebiotics, probiotics, or fecal microbiota transplantation could potentially represent a novel treatment approach for endometriosis.4 However, more research is needed to explore the potential of these strategies and to understand the precise mechanisms through which the microbiota influences endometriosis development and progression.

Read More: Integrative Therapies for Endometriosis


The complex relationship between the microbiome and endometriosis is still in its early stages of investigation. Recent studies indicate that alterations in microbiota composition may be associated with endometriosis. These insights not only enhance our understanding of endometriosis pathogenesis but also open up new possibilities for the diagnosis and treatment of this prevalent condition.

As our understanding of the microbiome continues to grow, so does the potential for novel, integrative health strategies that target this complex ecosystem. Further research is required to confirm the observed associations and to elucidate the mechanisms underlying the microbiome-endometriosis connection. Such research holds the promise of ushering in a new era in our approach to endometriosis, one that acknowledges the intricate interplay between our bodies and the microbes that inhabit them.

While there are limitations in the current usefulness of this research, we do know that the immune system is involved with regulating the disease. An important question remains: are the microbiota changes seen in those with endo the chicken or the egg?


  1. Leonardi, M., Hicks, C., El-Assaad, F., El-Omar, E., & Condous, G. (2020). Endometriosis and the microbiome: a systematic review. BJOG, 127(2), 239-249. 
  2. Oishi, S., Mekaru, K., Tanaka, S. E., Arai, W., Ashikawa, K., Sakuraba, Y., Nishioka, M., Nakamura, R., Miyagi, M., Akamine, K., & Aoki, Y. (2022). Microbiome analysis in women with endometriosis: Does a microbiome exist in peritoneal fluid and ovarian cystic fluid? Reprod Med Biol, 21(1), e12441. 
  3. Svensson, A., Brunkwall, L., Roth, B., Orho-Melander, M., & Ohlsson, B. (2021). Associations Between Endometriosis and Gut Microbiota. Reprod Sci, 28(8), 2367-2377. 
  4. Jiang, I., Yong, P. J., Allaire, C., & Bedaiwy, M. A. (2021). Intricate Connections between the Microbiota and Endometriosis. Int J Mol Sci, 22(11). 
  5. Lee, S. R., Lee, J. C., Kim, S. H., Oh, Y. S., Chae, H. D., Seo, H., Kang, C. S., & Shin, T. S. (2021). Altered Composition of Microbiota in Women with Ovarian Endometrioma: Microbiome Analyses of Extracellular Vesicles in the Peritoneal Fluid. Int J Mol Sci, 22(9). 
  6. Wei, W., Zhang, X., Tang, H., Zeng, L., & Wu, R. (2020). Microbiota composition and distribution along the female reproductive tract of women with endometriosis. Ann Clin Microbiol Antimicrob, 19(1), 15. 
  7. Burns, K. A., Pearson, A. M., Slack, J. L., Por, E. D., Scribner, A. N., Eti, N. A., & Burney, R. O. (2021). Endometriosis in the Mouse: Challenges and Progress Toward a ‘Best Fit’ Murine Model. Front Physiol, 12, 806574. 

History of Endometriosis: Unraveling the Theories and Advances

Endometriosis is a complex condition that affects a significant number of women (XX) and on average takes 7-10 years for a diagnosis. The majority of people date their symptoms back to adolescence though go years seeking answers. Throughout their journey, many people  receive either a wrong diagnosis or were simply dismissed altogether.  In recent years, there has been a marked improvement in the recognition of the word ‘endometriosis’ but why does this disease remain such an enigma to so many healthcare professionals? Furthermore, endometriosis has been a subject of medical investigation for over a century with debates about how to approach treatment, understanding of the pathogenesis, clinical manifestations, and treatment methods.

Research in this field has evolved over time, but are we really that much further along than we were a century ago? One of the most frustrating concepts for those of us who truly understand endo, is the regurgitation of the theory of retrograde menstruation postulated in the 1920’s by Dr. John A. Sampson. The theory that endometriosis is derived from retrograde menstruation is an incomplete understanding of this original theory, that has perpetuated misinformation and our current recommended treatments – hormonal suppression and hysterectomies. Sampon’s original theory was more involved, but future research into alternative theories seems much more promising. Even so, our current “validated or trusted treatments” are still rooted in early understanding. This article delves into the intricate history of endometriosis, tracing its theories and advances, or lack thereof, to provide a comprehensive overview of this complex condition.

The Early Recognition of Endometriosis

Initial Observations and Descriptions

The first description of a disease resembling endometriosis can be attributed to Thomas Cullen in the early 20th century.1 Cullen identified endometriosis and adenomyosis as a single disease, characterized by the presence of endometrium-like tissue outside the uterine cavity.2 This breakthrough laid the foundation for future research and understanding of endometriosis.

Sampson’s Theory of Retrograde Menstruation

The term “endometriosis” was coined by John A. Sampson in the late 1920s.3 Sampson proposed the theory of retrograde menstruation as the primary cause of endometriosis, due to the observation during surgery of the similarity in endometriosis lesions and the endometrium, suggesting that endometrial cells are transported to ectopic locations via menstrual flow. This theory gained widespread acceptance and significantly influenced the direction of endometriosis research. Though he did note early on that there were additional factors to allow the growth of these lesions to transform, similar to more current theories and the immune system involvement.

Advances in Diagnosing Endometriosis

The Advent of Laparoscopy

The introduction of laparoscopy in the 1960s revolutionized the diagnosis of endometriosis.4 This minimally invasive surgical procedure allowed physicians to visually identify and classify endometriosis lesions, leading to a significant increase in the diagnosis of the disease.

Differentiating Clinical Presentations

With the advent of laparoscopy, three distinct clinical presentations of endometriosis were identified: peritoneal, deep adenomyotic, and cystic ovarian.5 These classifications, along with advances in imaging techniques such as ultrasound and magnetic resonance imaging (MRI), have improved the precision of endometriosis diagnosis.

Development of Medical Therapies for Endometriosis

Early Interventions

The first attempts at treating endometriosis with synthetic steroids began in the 1940s.6 Initially, androgenic substances were used, but their side effects led to a search for more effective and tolerable treatments. Fun fact: testosterone was actually the first hormone used in attempts to “treat” the disease. 

The Pseudo-pregnancy Regimen

The 1950s saw the advent of the “pseudo-pregnancy” regimen, where hormones were used to mimic the hormonal environment of pregnancy, thereby suppressing ovulation and endometrial growth.7 During this time, there were limited options and this suggestions came from the observation that symptoms were improved when pregnancy occurred. This approach utilized a combination of estrogen and progestin medications and marked a significant advance in the medical management of endometriosis. At this time, birth control was becoming more widespread and more options were being developed. The myth that is still perpetuated today by uninformed practitioners and society of “just get pregnant, it will cure your endo” or “just have a baby” stems from this belief. In 1953 a physician legitimized the limited options and made recommendations suggesting that frequent and often pregnancy was one of the only options and “subsidize your children” was the solution for the increased financial burden. There are so many infuriating suggestions at this recommendation, but the 50’s were a different time, with limited research and options. 

Gonadotropin-Releasing Hormone (GnRH) Agonists

Gonadotropin-releasing hormone (GnRH) agonists emerged as a primary medical therapy for endometriosis in the late 20th century.8 These drugs work by reducing the production of estrogen, thereby limiting the growth of endometriotic tissue, at least in theory. However, the side effects of hypoestrogenism led to the development of ‘add-back’ therapies to mitigate these effects.Not to mention poor regulation and research practices present in the 1990’s including falsified data on the true impact of these drugs. 

Evolution of Surgical Treatments

Conservative Surgery & Advancements in Endoscopic Surgery

The development of laparoscopy also transformed the surgical management of endometriosis. Conservative surgical techniques, including the excision of visible endometriosis lesions and adhesion lysis, became feasible.9 These procedures aimed to preserve fertility while effectively managing the disease. The late 20th century saw further advancements (again, in theory) in laparoscopic surgery for endometriosis. Techniques such as CO2 laser vaporization and the use of circular staplers for bowel resection improved the effectiveness and safety of surgery.10

Unraveling the Pathogenesis of Endometriosis

The Role of the Peritoneal Environment

Research in the 1980s began to focus on the peritoneal environment’s role in endometriosis. Studies found evidence of a local peritoneal inflammatory process, including increased activation of peritoneal macrophages and elevated cytokine and growth factor concentrations.11

Endometrial Dysfunctions

Investigations also revealed biochemical differences between eutopic and ectopic endometrium in women with endometriosis. These differences suggested that endometriosis might be associated with endometrial dysfunction, contributing to both the pathogenesis and sequelae of the disorder.12 While research exists that shows differences in BOTH the endometriosis lesions and the endometrial environment, this is correlational research, and does not imply causation. 

Immunological Factors

The involvement of the immune system in the pathogenesis of endometriosis was another significant discovery. Altered immune responses, including decreased T-cell and natural killer cell cytotoxicities, were observed in those with endometriosis.13

The Connection Between Endometriosis and Adenomyosis

In the late 20th century, researchers revisited the connection between endometriosis and adenomyosis, suggesting that the two conditions might represent different phenotypes of the same disorder.14 This theory proposed that both endometriosis and adenomyosis are primarily diseases of the junctional zone myometrium.

Modern Approaches to Endometriosis Treatment

Use of Gonadotropin-Releasing Hormone Agonist and Levonorgestrel-Releasing Intrauterine System

In more recent years, GnRHa therapy, often combined with ‘add-back’ therapy, has become a popular “treatment” for endometriosis.15 The levonorgestrel-releasing intrauterine system (LNG-IUS), which releases a progestin hormone into the uterus, has also shown promise in the management of endometriosis-associated chronic pelvic pain.16 In reality, this may be more true for adenomyosis and further research is needed. Research with less bias seems to oppose these claims stating that “GnRH drugs show marginal improvement over no active treatment” when compared with other hormonal suppression medications. Thanks to marketing, this is not well known among consumers. 19 Not to mention the significant side effects that further contribute to the various chronic overlapping pain syndromes associated with endometriosis. 

The Future of Endometriosis Research and Treatment

The evolution of endometriosis theories and advances underscores the complexity of this condition. As we continue to unravel the mysteries of endometriosis, there is an ongoing need for research into its pathogenesis, diagnosis, and treatment. The future of endometriosis research and treatment lies in a deeper exploration of its genetic-epigenetic aspects, the role of oxidative stress, and the impact of the peritoneal and upper genital tract microbiomes.18


The history of endometriosis is marked by a continual evolution of theories, advancements in diagnostic and therapeutic approaches, and an expanding understanding of the disease’s complex pathogenesis. From the initial descriptions by Thomas Cullen to the modern laparoscopic techniques and hormonal therapies, the journey of understanding and treating endometriosis has indeed been a frustrating one.

One of the most frustrating aspects is that when we really understand the first observations of endometriosis in the 1800’s into the early 1900’s, it is not far from where we are today. This demonstrates the serious need for more research, better research, and more in depth understanding of the pathogenesis and treatment approaches for endometriosis. While this has improved in the last five years, it is not enough. We need to do more, and we need to do better. Healthcare policy change is an extremely slow process and in my personal observation, decided among individuals who show less understanding than those with the disease. 

10. References

Disclaimer: This article is intended to provide general information on the topic and should not be used as a substitute for professional medical advice. Always consult with your healthcare provider for personal medical advice.

  1. Cullen, T. (1920). Adenomyoma of the Uterus. WB Saunders.
  2. Sampson, J.A. (1927). Metastatic or Embolic Endometriosis, due to the Menstrual Dissemination of Endometrial Tissue into the Venous Circulation. American Journal of Pathology, 3(2), 93–110.
  3. Sampson, J.A. (1927). Peritoneal endometriosis due to menstrual dissemination of endometrial tissue into the peritoneal cavity. American Journal of Obstetrics & Gynecology, 14, 422–469.
  4. Brosens, I., & Benagiano, G. (2011). Endometriosis, a modern syndrome. Indian Journal of Medical Research, 133(6), 581–593.
  5. Amro, B., et al. (2022). New Understanding of Diagnosis, Treatment and Prevention of Endometriosis. International Journal of Environmental Research and Public Health, 19(11), 6725.
  6. Miller, E.J. (1944). The use of testosterone propionate in the treatment of endometriosis. American Journal of Obstetrics & Gynecology, 48(2), 181–184.
  7. Kistner, R.W. (1958). The use of newer progestins in the treatment of endometriosis. American Journal of Obstetrics & Gynecology, 75(2), 264–278.
  8. Hughes, E., et al. (2007). Ovulation suppression for endometriosis for women with subfertility. Cochrane Database of Systematic Reviews, (3), CD000155.
  9. Brosens, I., et al. (2022). New Understanding of Diagnosis, Treatment and Prevention of Endometriosis. International Journal of Environmental Research and Public Health, 19(11), 6725.
  10. Keckstein, J., & Becker, C.M. (2020). Endometriosis and adenomyosis: Clinical implications and challenges. Best Practice & Research Clinical Obstetrics & Gynaecology, 69, 92–104.
  11. Dmowski, W.P., & Braun, D.P. (1997). Immunology of endometriosis. Best Practice & Research Clinical Obstetrics & Gynaecology, 11(3), 365–378.
  12. Lebovic, D.I., et al. (2001). Eutopic endometrium in women with endometriosis: ground zero for the study of implantation defects. Seminars in Reproductive Medicine, 19(2), 105–112.
  13. Dmowski, W.P., & Braun, D.P. (1997). Immunology of endometriosis. Best Practice & Research Clinical Obstetrics & Gynaecology, 11(3), 365–378.
  14. Leyendecker, G., et al. (2009). Endometriosis results from the dislocation of basal endometrium. Human Reproduction, 24(9), 2130–2137.
  15. Surrey, E.S., & Soliman, A.M. (2019). Endometriosis and fertility: A review of the evidence and an approach to management. Journal of the Society of Laparoendoscopic Surgeons, 23(2), e2018.00087.
  16. Vercellini, P., et al. (2003). Endometriosis and pelvic pain: relation to disease stage and localization. Fertility and Sterility, 79(2), 156–160.
  17. Sutton, C.J., et al. (1994). Laser laparoscopy in the treatment of endometriosis: a 5 year study. British Journal of Obstetrics and Gynaecology, 101(3), 216–220.
  18. Brosens, I., & Benagiano, G. (2011). Endometriosis, a modern syndrome. Indian Journal of Medical Research, 133(6), 581–593.
  19. Johnson, N. P., Hummelshoj, L., & World Endometriosis Society Montpellier, C. (2013). Consensus on current management of endometriosis. Hum Reprod, 28(6), 1552-1568. 


Navigating the Path to Your Best Endometriosis Specialist

The journey towards resolving endometriosis involves an important decision – selecting the best endometriosis specialist. Leveraging expert resources like Nancy’s Nook and iCareBetter can be instrumental in this process.

Determining Your Needs in a Surgeon

Being aware of your specific requirements can help you make an informed choice. Here are a few considerations you should keep in mind:

Training and Experience

A surgeon’s training, notably in Minimally Invasive Gynecologic Surgery (MIGS) or Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS) is crucial. Such surgeons have spent more time in operation theaters, honing their skills through extensive practice.

Ensure your surgeon is board-certified and inquire about their experience, including the number of surgeries they’ve performed, complications they’ve encountered, and outcomes.

Surgical Support Team

The surgeon’s team is equally important. Ask about their procedure in case of bowel, bladder, ureter, or diaphragmatic involvement. Inquire if everything can be done during a single procedure.

Approach to Excision

Surgeons may have different opinions on excision versus ablation. Find out their thoughts on the subject and where and when they excise or ablate.

Post-Surgery Care

Ask if the surgeon routinely prescribes suppressive medications pre and post-surgery. Understand their reasons if they do.


Don’t hesitate to inquire about costs, insurance acceptance, payment policies, and any hidden charges.

Comfort Level

Ensure you feel comfortable conversing with your surgeon and that your queries are answered satisfactorily.

Factors That May Not Influence Your Decision

Certain aspects may not influence the quality of surgical care:

  • Gender: The surgeon’s gender does not impact their surgical ability.
  • Preferred Tools: The surgical tool used is less important than the surgeon’s skill.
  • Bowel Prep: Surgeons may have different preferences for bowel prep before surgery, but it doesn’t seem to influence the outcome.

Factors That Might Influence Your Decision

Some factors might play a role in your decision-making process:

  • Reputation: Be cautious while considering a surgeon’s reputation. Some may get media coverage or have excellent bedside manners, but that doesn’t necessarily make them a skilled surgeon.
  • Office Management: A well-managed front office can make your experience smoother.
  • Location: Depending on your comfort and ability to travel, location might influence your decision.
  • Timing: The availability of the surgeon and your urgency might also play a role.

The Most Important Factor

Patients often report being most satisfied with surgeons who actively listen to them. Your surgeon should respect your knowledge and experiences without objection to being recorded or having someone with you during consultations.

Leading Endometriosis Specialists

iCareBetter has a list of endometriosis specialists and surgeons vetted for their surgical skills. Nancy’s Nook on Facebook also provides a list of providers.

Managing Your Relationship with Your Current Doctor

Dealing with a current doctor who might not be capable of handling your endometriosis can be challenging. Here are some tips:

  • Think long-term, maintain a cordial relationship, and educate your doctor about your condition without alienating them.
  • Be respectful and considerate of your doctor’s opinions.
  • Try to keep your doctor on your side by asking for their support.
  • Remain calm and collected during discussions.
  • If you choose to seek surgery elsewhere and decide not to return to your current physician, send a copy of the operative and pathology reports with a note of gratitude.
  • If your doctor dismisses you as a patient, consider it as a sign that it wasn’t a good fit.
  • Routine care can be handled by a GP or Family Doctor, a Nurse Practitioner, or a Physician’s Assistant.

Remember, in addition to iCareBetter, which has a peer-reviewed video vetted group of endometriosis surgeons, Nancy’s Nook also provides a list of providers to help you navigate this journey.


Choosing an endometriosis specialist is a significant step on your health journey. Leveraging resources like Nancy’s Nook and iCareBetter can provide valuable insights to guide your decision. Always remember, your comfort and trust in your healthcare provider are paramount.


Acupuncture: An Underexplored Solution for Endometriosis Pain

Endometriosis is a complex, multifaceted health condition that predominantly affects women of reproductive age. Characterized by the growth of endometrial-like tissue outside the uterus, this condition can lead to chronic pelvic pain, dysmenorrhea, and infertility, significantly impacting the quality of life. Today’s treatment is limited to expert surgical excision and hormonal manipulation, with variable success.   In recent years, acupuncture has gained attention as a potential complementary treatment for endometriosis-related pain. This ancient Chinese technique may hold promise for providing effective pain relief and enhancing overall well-being.

Understanding Endometriosis

Endometriosis is an estrogen-dependent, inflammatory gynecological disorder that can lead to chronic visceral pelvic pain and infertility. This condition is believed to affect approximately 10% to 15% of women during their reproductive years, causing symptoms such as chronic pelvic pain, deep dyspareunia, dysmenorrhea, dyschezia, dysuria, and more. It is theorized that endometriosis-related changes might be a result of alterations in the peripheral and central nervous systems, predisposing affected individuals to other long-lasting pain conditions.

Despite the availability of hormonal, pharmacological and surgical treatments, many of these interventions fail to sufficiently address the perceived pain. Moreover, they often come with significant side effects, presenting an additional burden of symptoms and potential for harm. 

Read more: 20 Signs and Symptoms of Endometriosis.

Read more: What causes endometriosis?

The Science of Acupuncture:

Acupuncture is a traditional Chinese medicine technique that involves inserting thin needles into specific points on the body to balance the flow of energy or “Qi”. It has been used for centuries to treat various conditions, including pain and inflammation. The modern science corollary is that acupuncture may work by stimulating nerves, muscles, and connective tissues, which increases blood flow and activates the body’s natural painkillers. While this modern evidence supports the use of acupuncture it is important to keep in mind that energy medicine is quite poorly understood.  Acupuncture is an ancient form of energy medicine. A lot more research is mandated to understand how this truly works and how it might be improved or adjusted on an individual basis. 

Acupuncture and Endometriosis:

Pain Relief:

For endometriosis sufferers, the most significant benefit of acupuncture is pain relief. A study by Wayne et al. (2008) revealed that acupuncture significantly reduces pelvic pain, dysmenorrhea, and discomfort associated with endometriosis, enhancing the quality of life. The modern medicine mechanisms underlying this pain relief are thought to be related to the release of endorphins, the body’s natural painkillers, and the reduction of inflammatory markers. 

Hormonal Balance:

Endometriosis is often associated with hormonal imbalances, particularly an excess of estrogen. Acupuncture is believed to modulate hormonal levels by impacting the hypothalamus-pituitary-ovarian (HPO) axis, which plays a crucial role in regulating reproductive hormones. A harmonious hormonal balance can help in managing endometriosis symptoms and reducing the progression of endometrial lesions. However, most studies show that acupuncture increases estrogen levels.  So, this is a bit contradictory other than to say that other acupuncture-induced mechanisms influencing hormonal balance and homeostasis may be in play.  

Improved Blood Flow:

Acupuncture is known to enhance blood circulation to the pelvic area, which can be beneficial for endometriosis patients. Improved blood flow can help reduce inflammation and promote the healing of endometrial lesions. This enhanced circulation can also alleviate the ischemia and hypoxia conditions commonly found in endometriotic tissues, potentially reducing the development of new lesions.

Reduced Stress and Anxiety:

Living with chronic pain and other symptoms of endometriosis can lead to increased stress and anxiety. Acupuncture is reputed to mitigate stress and anxiety by modulating the activity of the amygdala and other brain regions associated with emotion regulation, promoting relaxation and mental well-being.

Empirical Evidence:

Several studies and clinical trials have substantiated the efficacy of acupuncture in managing endometriosis symptoms. A systematic review by Zhu et al. (2011) concluded that acupuncture could be considered an effective and safe alternative for relieving endometriosis-related pain. Another study by Rubi-Klein et al. (2010) demonstrated that acupuncture reduces the severity and duration of pain during menstruation in women with endometriosis.

Integration with Conventional Treatment:

While acupuncture demonstrates the potential to alleviate endometriosis symptoms, it is crucial to view it as a complementary therapy.  It is not a standalone treatment option for endo.  Integrating acupuncture with conventional medical treatments, such as hormonal therapy, non-narcotic pharmaceuticals, and excisional surgery, can offer a holistic approach to managing endometriosis. This integrative approach can address both the physiological symptoms and the psychological stress associated with the condition, improving the overall quality of life for patients.

Read more: Integrative Therapies for Endometriosis

Limitations and Considerations:

While acupuncture offers promising benefits for endometriosis, limitations exist, including the variability in acupuncture techniques and the lack of standardized treatment protocols. Moreover, the effectiveness of acupuncture may be influenced by individual differences, necessitating personalized treatment plans. It is essential for patients to consult with experts in this field to determine the appropriateness of acupuncture based on their medical history and specific circumstances.


Acupuncture emerges as a valuable complementary therapy for endometriosis, offering relief from pain, hormonal balance, improved blood flow, and reduced stress and anxiety. Empirical evidence substantiates its efficacy, and integrating it with conventional treatments can provide a comprehensive approach to managing endometriosis. However, individual variability and the lack of standardized protocols necessitate personalized treatment plans and consultation with experts in acupuncture as well as endo specialists. As research continues to unravel the mechanisms underlying acupuncture’s therapeutic effects, it holds the promise of enhancing the quality of life for individuals grappling with endometriosis.


Wayne, P.M., et al. (2008). Acupuncture for pelvic and back pain in pregnancy: a systematic review. American Journal of Obstetrics & Gynecology, 198(3), 254-259.

Zhu, X., et al. (2011). Acupuncture for pain in endometriosis. Cochrane Database of Systematic Reviews, (9), CD007864.

Rubi-Klein, K., et al. (2010). Is acupuncture in addition to conventional medicine effective as pain treatment for endometriosis? A randomised controlled cross-over trial. European Journal of Obstetrics & Gynecology and Reproductive Biology, 153(1), 90-93.

Lund I, Lundeberg T (2016).  Is acupuncture effective in the treatment of pain in endometriosis? J Pain Res; 9: 157–165.


Endometriosis and Its Implications on Early Menopause: A Comprehensive Insight

Endometriosis, a chronic inflammatory condition, has been studied for its severe impact on women’s reproductive health in some aspects more than others. One area that has been relatively understudied is the connection between endometriosis and early menopause. This article will delve into the intricate relationship between endometriosis and early menopause, exploring the latest research studies, the associated risk factors, and the potential implications for women’s health.

I. Understanding Endometriosis

Endometriosis is an often painful condition in which tissue similar to the one lining the inside of the uterus — the endometrium — grows outside the uterus, typically on the ovaries, Fallopian tubes, and the tissue lining the pelvis. In some cases, it can spread beyond the pelvic area. Endo mostly affects women during their childbearing years and may also lead to fertility problems.

Read more: What causes endometriosis?

II. The Enigma of Early Menopause

Early menopause, also known as premature menopause or early natural menopause (ENM), is defined as the cessation of menstrual periods before the age of 45. This condition can have a profound impact on a woman’s life, affecting her fertility, cardiovascular health, cognitive function, and overall mortality rate.  The main driver is premature ovarian failure (POF) or insufficiency (POI).  Without proper levels of estrogen and progesterone, among other hormones, and highly coordinated hormonal fluctuations, menses cease.  Menses can also cease due to direct damage to the uterine endometrial lining, but that is far less common.  In this latter situation, in contrast to ovarian insufficiency, there are no symptoms of hot flashes or mood swings and the like.  

Read more: Endometriosis And Menopause: Everything You Need To Know

III. The Intersection of Endometriosis and Early Menopause

The potential implications of endometriosis on early menopause have not been extensively researched. There is a need for more comprehensive studies to understand the intricate associations and mechanisms linking these two conditions.

IV. Recent Studies on Endometriosis and Early Menopause

Recent investigations have shed light on the possible association between endometriosis and early menopause. These studies suggest that women with endometriosis may be at a higher risk of experiencing early menopause, even after adjusting for various demographic, behavioral, and reproductive factors.

V. Key Findings From the Studies

The studies indicate a statistically significant association between endometriosis and early menopause. Women with endometriosis, particularly those who never used oral contraceptives and are nulliparous, may have a heightened risk of experiencing a shortened reproductive lifespan. 

Studies focusing on premature ovarian failure (POF) or insufficiency (POI) suggest that this, in and of itself, is highly heterogeneous and related to mutations in more than 75 genes.  Some of these mutations overlap with those associated with endometriosis, particularly in the range of inflammatory autoimmune disorders.  

VI. Factors Influencing the Association

Multiple shared clinical factors may influence the association between endometriosis and early menopause, including body mass index (BMI), cigarette smoking, oral contraceptive use, parity, and history of infertility attributed to ovulatory disorder.

Given the genetic overlap of autoimmune and other disorders that influence POI and POF, it is quite probable that this is the root cause of the association between endometriosis and early menopause.  However, this remains to be scientifically validated. 

In those patients with advanced endo, where ovaries are partially removed or badly, as in the case of large endometriomas, there may be a direct anatomic cause for POI and POF.   

VII. Implications of the Findings

The findings of these studies have important implications for women’s health. They suggest that women with endometriosis may need to consider the potential risk of early menopause in their reproductive planning. Additionally, healthcare providers may need to consider these findings when developing individualized treatment plans for women with endometriosis.  A full evaluation should include screening for autoimmune disorders and possible genetic analysis for associated conditions.   

VIII. Limitations and Future Research

While these findings are significant, they are also limited by certain factors, including the reliance on self-reported data and the lack of racial and ethnic diversity in the study populations. Future research should aim to address these limitations and further explore the clinical and genetic or molecular association between endometriosis and early menopause.

IX. Coping With Endometriosis and Early Menopause

Living with endometriosis and dealing with early menopause can be challenging. However, understanding the connection between these conditions and seeking timely medical advice can help women manage their symptoms and maintain their quality of life. The first step is evaluation and management by providers who have specific and focused expertise in managing endometriosis. 

Read more: Navigating HRT for Menopause in Women with Endometriosis

X. Conclusion

The association between endometriosis and early menopause is a significant area of women’s health that mandates further exploration. While recent studies suggest a potential link, more comprehensive research is needed to fully understand the implications of this association. In the meantime, it is crucial for women with endometriosis to be aware of the potential risk of early menopause and to seek expert consultation with endometriosis specialists. 



Postmenopausal Malignant Transformation of Endometriosis

Endometriosis is a pain and infertility producing condition which predominantly affects premenopausal women.  Estimates suggest that up to 10% of women worldwide suffer from the condition during their reproductive years. While the incidence of postmenopausal endometriosis is considerably lower, studies have suggested that this may still be in the neighborhood of 2.5%.  So it is a misconception that endo is exclusively a disease of younger women. 

Further, although endometriosis is a benign disorder, there lies a risk of malignant transformation, at all ages. This article delves into the potential for malignant transformation of postmenopausal endometriosis.

Understanding Endometriosis and Menopause

Postmenopausal endometriosis refers to the occurrence or continuation of endometriosis symptoms after menopause, which typically occurs around age 50. This is defined as the cessation of menstrual cycles for twelve consecutive months. After this point, the ovaries produce minimal estrogen, a hormone which is generally considered essential for endo growth. So, without this hormone, or lowered levels, most cases of endometriosis naturally diminish. Yet, for some postmenopausal women, endometriosis can persist or even manifest anew. 

The cause or causes of endometriosis in younger women are controversial and incompletely defined.  Through uncertain but likely multifactorial mechanisms, endometriosis is characterized by the presence and growth of ectopic endometrial-like tissue outside the uterus. While one might assume that a hypoestrogenic state associated with menopause would alleviate endometriosis, this isn’t always the case. 

In postmenopausal women, the causes of endometriosis are less clear. Some contributing factors include:

  • Residual Disease: Endometriosis that began before menopause may continue after menopause due to residual disease and growth stimulated by factors other than estrogen or high sensitivity to low estrogen levels.
  • Exogenous Estrogen: Hormone replacement therapy (HRT) can potentially stimulate the growth of endometrial cells. This may be particularly relevant for postmenopausal women who take estrogen-only HRT, which can reactivate endometrial implants or even initiate new growths. 
  • Endogenous Estrogen Conversion: Adipose (fat) tissue can produce estrogen by converting it from other hormones. Postmenopausal women with higher amounts of adipose tissue might produce enough estrogen to promote the growth of endo. Fat can also store xeno-estrogens from certain toxins and then slowly release them into circulation.  The tissue microenvironment around endometriosis lesions also contributes to local estrogen production. 

Malignant Transformation: A Rare but Possible Event

While endometriosis is overwhelmingly benign, studies have indicated that women with endometriosis have an increased risk of developing certain types of ovarian cancers, specifically clear cell and endometrioid carcinomas.

Some factors that might increase the risk include:

  • Duration of Endometriosis: Prolonged presence of endometriosis lesions might increase the risk of malignant transformation. In general, cancer risk increases with age and  it is well known that chronic inflammation contributes to formation of cancer.  Endo is inflammatory in nature. Thus, if endo is still growing after menopause this means more time in an inflammatory state, hypothetically contributing to the risk. 
  • HRT Use: As mentioned, exogenous estrogen can stimulate endometriosis growth, potentially increasing the risk of malignant changes in existing lesions. This is not proven but may be a contributory factor which is very complicated due to individual variations in receptor activity and levels of estrogen.
  • Genetic Factors: Some genetic mutations might predispose women to both deeply invasive endometriosis and ovarian cancer, and there is overlap.  Epigenetic factors regulate which genes turn on an off during life and are influenced by environmental factors.  There is also a potential cumulative effect in the number of active mutated genes over the years. Some of the key genetic factors include:
  • PTEN: PTEN is a tumor suppressor gene. Its mutations have been identified in both endometriosis and endometrioid and clear cell ovarian cancers. Loss of PTEN function can lead to uncontrolled cell growth and might play a role in the malignant transformation of endometriosis.
  • ARID1A: ARID1A mutations are frequently seen in endometriosis-associated ovarian cancers. This gene is involved in chromatin remodeling, and its mutation can lead to disruptions in DNA repair and subsequent malignant transformation.
  • KRAS and BRAF: Mutations in these genes are known to play roles in the pathogenesis of various cancers. They’ve been identified in benign endometriotic lesions and might contribute to the early stages of malignant transformation.
  • Inherited Genetic Mutations: Women with inherited mutations in BRCA1 and BRCA2 genes, known for their association with breast and ovarian cancers, might also have an increased risk of developing endometriosis and its subsequent malignant transformation.


Postmenopausal endometriosis, although less common than its premenopausal counterpart, cannot be overlooked. The absolute risk of malignant transformation, albeit very low, emphasizes the importance of regular monitoring and endo specialist consultations for postmenopausal women with endometriosis or its symptoms.  When postmenopausal endometriosis is suspected or diagnosed, especially if it is invasive and there are unusual symptoms or pelvic masses, a consultation with a gynecologic oncologist is also prudent.  


Bulun SE. Endometriosis. N Engl J Med. 2009;360(3):268-279. 

Pearce CL, Templeman C, Rossing MA, et al. Association between endometriosis and risk of histological subtypes of ovarian cancer: a pooled analysis of case-control studies. Lancet Oncol. 2012;13(4):385-394. 

Luca Giannella, Chiara Marconi, Jacopo Di Giuseppe, et al. Malignant Transformation of Postmenopausal Endometriosis: A Systematic Review of the Literature. Cancers (Basel) 2021 Aug 10;13(16):4026.

Luca Giannella, Chiara Marconi, Jacopo Di Giuseppe, et al.  The association between endometriosis and gynecological cancers and breast cancer: a review of epidemiological data. Gynecol Oncol. 2011;123(1):157-163. 

Sato N, Tsunoda H, Nishida M, et al. Loss of heterozygosity on 10q23.3 and mutation of the tumor suppressor gene PTEN in benign endometrial cyst of the ovary: possible sequence progression from benign endometrial cyst to endometrioid carcinoma and clear cell carcinoma of the ovary. Cancer Res. 2000;60(24):7052-7056. 

Wiegand KC, Shah SP, Al-Agha OM, et al. ARID1A mutations in endometriosis-associated ovarian carcinomas. N Engl J Med. 2010;363(16):1532-1543. 

Dinulescu DM, Ince TA, Quade BJ, Shafer SA, Crowley D, Jacks T. Role of K-ras and Pten in the development of mouse models of endometriosis and endometrioid ovarian cancer. Nat Med. 2005;11(1):63-70. 

Saha R, Pettersson H, Svedberg P, et al. Endometriosis and the risk of ovarian and endometrial adenocarcinomas: a meta-analysis. BMJ Open. 2020;10(4):e034760.


Can Endometriosis Become Malignant After Menopause?

Endometriosis, a condition commonly affecting women of reproductive age, doesn’t just vanish in menopause. In fact, an estimated 2-4% of postmenopausal women suffer from symptomatic endometriosis. Although endometriosis is generally benign, there lies a risk of malignant transformation. This article delves into the malignant transformation of postmenopausal endometriosis, presenting a comprehensive analysis of the topic.

Understanding Endometriosis and Menopause

Endometriosis is a complex clinical syndrome characterized by the presence of ectopic endometrial-like tissue. This pathological condition primarily affects women of reproductive age, often causing infertility and chronic pelvic pain leading to severe functional limitations.

While one might assume that the cessation of menstruation and the hypoestrogenic state associated with menopause would alleviate endometriosis, this isn’t always the case. Postmenopausal endometriosis can affect up to 4% of women. Recurrences or malignant transformations, although rare, are possible events.

Malignant Transformation: A Rare but Possible Event

While endometriosis is a benign condition, it carries a risk of malignant transformation. Approximately 1% of ovarian endometriosis can turn into cancer. However, a prospective study found a standardized incidence ratio of malignant transformation of 8.95, indicating that malignant transformation, while rare, is a serious concern.

In the case of postmenopausal endometriosis, malignant transformation is even rarer. There are no definitive percentages about its prevalence, with data derived from studies, including case reports and case series. This scarcity of data highlights the need for further research into this topic.

Recurring Clinical Conditions

In the malignant transformation of postmenopausal endometriosis, some clinical conditions tend to recur:

  • History of endometriosis
  • Definitive gynecological surgery before menopause
  • Estrogen-only hormone replacement therapy (HRT) for a relatively long time

These conditions, however, have shown a significant decrease in recent years. This decrease could be due to changes in the attitudes and management of gynecologists, influenced by up-to-date scientific evidence about the use of major surgery in gynecological pathologies.

The Role of Hormone Replacement Therapy (HRT)

HRT plays a significant role in postmenopausal endometriosis. Among the women who used HRT, estrogen-only therapy was taken by approximately 75% of women. The duration of treatment had a median of 11 years, with the course of treatment exceeding five years in most women.

Current recommendations on HRT include continuous combination formulations or Tibolone for women with previous endometriosis. However, these recommendations are based on limited data, emphasizing the need for more extensive studies on this topic.

Cancer Lesion Characteristics and Treatment

The malignant transformation of endometriosis can present with varying characteristics and may require different treatment approaches. Approximately 70% of cases had histology of endometrioid adenocarcinoma or clear cell carcinoma. The most frequent localization of the lesions was at the level of the pelvis, ovary, and vagina.

Most women underwent surgical treatment, with procedures including excision of the mass, hysterectomy with bilateral salpingo-oophorectomy, and surgical debulking. Adjuvant medical treatment was performed in about 60% of cases.

Patient Outcomes and Follow-up

The outcomes for patients with malignant transformation of postmenopausal endometriosis are generally favorable. The survival rate is approximately 80% in 12 months, with a recurrence rate of 9.8% and a death rate of 11.5%.

The duration of follow-up had a median of 12 months. However, follow-up data is still too incomplete to provide adequate information on the prognosis, highlighting the need for further research in this area.


The malignant transformation of postmenopausal endometriosis presents a clinical challenge that requires further exploration. As gynecologists’ attitudes and management strategies evolve, it’s crucial to continue research into this area, to provide accurate and individualized evaluation and information for patients.

While endometriosis is generally a benign condition, the risk of malignant transformation, particularly in postmenopausal women, should not be overlooked. Comprehensive understanding and timely management of this condition are crucial to improving patient outcomes.



The Hidden Connection Between Systemic Lupus and Endometriosis

Based on possible shared characteristics and pathogenesis the interconnectedness of various ailments becomes a focal point of research. Such is the relationship between endometriosis and lupus, two seemingly unrelated conditions that share intriguing parallels. This article aims to shed light on the increased risk of being diagnosed with endometriosis in patients suffering from Systemic Lupus Erythematosus or SLE.  The purpose of unraveling connections is that this may lead to treatment discoveries. 

Understanding Endometriosis

Endometriosis is a multifaceted disease that primarily affects women in their reproductive years. It is characterized by the abnormal growth of endometrial-like tissue outside the uterus, leading to chronic pelvic pain, and potential infertility.

The pathophysiology of endometriosis involves a systemic inflammatory response, influenced by female sex hormones that may subtly affect the maintenance of immunity or the development of autoimmune diseases.

Getting to Know Systemic Lupus Erythematosus (SLE)

SLE is a chronic, autoimmune disease that can affect various parts of the body, including the skin, joints, kidneys, heart, and lungs. It involves the immune system attacking the body’s own tissues, leading to inflammation and damage. Women, especially of childbearing age, are more frequently diagnosed with SLE than men. Other factors such as ethnicity, age of onset, and socioeconomic class significantly influence SLE incidence, with notable geographic differences observed. 

Endometriosis and SLE: The Intriguing Association

Epidemiological studies suggest a solid link between endometriosis and female-dominant autoimmune diseases. However, not all studies support a significant association between endometriosis and SLE. The potential for spurious associations due to small study sizes and suboptimal control selection is high.

Unraveling the Connection: A Comprehensive Study

Given these inconsistencies, and accepting that the findings may not be applicable to all geo-ethnic populations, a large nationwide retrospective cohort study was conducted to assess the risk of endometriosis in women diagnosed with SLE. The study analyzed data from the Taiwan Longitudinal Health Insurance Research Database 2000 (n = 958,349) over a 13-year follow-up period (2000–2013).

Study Design and Population

The study adopted a retrospective cohort design with primary data sourced from the Taiwan National Health Insurance Research Database (NHIRD). The study cohort included women diagnosed with SLE between 1997 and 2013, and the index date was defined as the first diagnosis of SLE.

Assessed Outcome

The primary outcome was defined as the diagnosis of endometriosis. Given the lack of non-invasive diagnostic tools for endometriosis, the disease’s diagnosis was derived from clinical evidence or surgical intervention. Every effort was made to optimize parameters of non-surgical diagnosis of endo but surgical validation was lacking in a large number of subjects, representing a significant study weakness. 

Results and Implications

The study, within stated limitations,  found a statistically significant association between SLE and endometriosis, after controlling for age.

Conclusion: A Call for Further Research

The risk of endometriosis was found to be significantly higher in SLE patients compared to the general population in this study. This adds substantially to the overall body of evidence supporting an association.  However, more research is needed to fully understand this association and to determine if it can be generalized across different geo-ethnic populations.  Clearly, more basic science research is also critically needed to support epidemiologic associations. 



Can endometriosis cause miscarriage? Understanding Endometriosis and Its Impact on Miscarriage

Endometriosis is a prevalent health condition, affecting approximately 10% of women worldwide. It is often associated with chronic pain and infertility, but its potential connection to miscarriage is not as widely recognized. This article aims to shed light on the link between endometriosis and miscarriage, drawing on recent scientific research and expert insights.

What is Endometriosis?

Endometriosis is a chronic condition where tissue similar to the lining of the uterus, known as endometrium, grows outside the uterus. This tissue can grow on the ovaries, fallopian tubes, or the lining of the pelvic cavity. Just as the inner lining of the uterus thickens, breaks down, and bleeds with each menstrual cycle, so too does the endometrial-like tissue outside the uterus. However, this displaced tissue has no way to exit the body, leading to various problems.

Read More: What causes endometriosis?

Pathogenesis of Endometriosis

Endometriosis develops in stages, with severity ranging from minimal to severe. The American Society for Reproductive Medicine groups endometriosis into four stages: minimal (Stage I), mild (Stage II), moderate (Stage III), and severe (Stage IV). The stages reflect the extent, location, and depth of endometrial-like tissue growth, as well as the presence and severity of adhesions and the presence and size of ovarian endometriomas.

Symptoms of Endometriosis

While some women with endometriosis may have no symptoms, others may experience:

  • Painful periods
  • Pain during intercourse
  • Pain with bowel movements or urination
  • Excessive bleeding
  • Infertility
  • Other signs and symptoms such as fatigue, diarrhea, constipation, bloating, or nausea

Read more: 20 Signs and Symptoms of Endometriosis

Endometriosis and Pregnancy Complications

Endometriosis has long been associated with infertility, with studies indicating that up to 50% of women with infertility have the condition. However, less is known about its impact on women who do conceive. Emerging research suggests that endometriosis may increase the risk of several pregnancy complications, including preterm birth, cesarean delivery, and miscarriage.

Read More: How Does Endometriosis Cause Infertility? 

Endometriosis and Miscarriage: Understanding the Connection

Recent research has begun to explore the potential link between endometriosis and miscarriage. Miscarriage, also known as spontaneous abortion, is defined as the loss of a pregnancy before 20 weeks of gestation. It is estimated that about 10-20% of known pregnancies end in miscarriage. The actual number is likely higher, as many miscarriages happen so early in pregnancy that a woman might not even know she’s pregnant.

The Role of Inflammation

One theory proposes that the inflammation associated with endometriosis could interfere with the early stages of pregnancy. Endometriosis is characterized by chronic pelvic inflammation, which could potentially disrupt the implantation of the embryo or the development of the placenta.

The Impact of Surgical Treatment

Another factor to consider is the potential impact of surgical treatment for endometriosis. There have only been a few clinical trials and they do not indicate that surgical excision reduces the risk of miscarriage.  However, there are two very large databases from Sweden and Scotland that suggest a benefit to removing known endometriosis to lower pregnancy loss risk.  More research is required. 

Hormonal Factors

Endometriosis can alter the hormonal environment of the uterus, which could potentially impact early pregnancy. More research is needed to fully understand how these hormonal changes might contribute to miscarriage risk.

Research Insights: Endometriosis and Miscarriage Risk

Several studies have investigated the link between endometriosis and miscarriage. A meta-analysis published in 2020 in the journal BioMed Research International found that women with endometriosis had a significantly higher risk of miscarriage compared to women without the condition. This risk was particularly pronounced in women who conceived naturally, rather than those with tubal infertility who conceived through assisted reproductive technology (ART).

Coping with Endometriosis and Miscarriage

The potential link between endometriosis and miscarriage can come as distressing news. However, it’s important to remember that many women with endometriosis have successful pregnancies.  So, counseling and intervention really depend on the individual situation. With repeat losses, there are many potential reasons but it appears that endo can be one of them.  

Read more: Find an Endometriosis Specialist for Diagnosis, Treatment, & Surgery.


Endometriosis is a complex condition that can impact various aspects of a woman’s health, including her fertility and pregnancy outcomes. While research suggests a potential link between endometriosis and miscarriage, many women with the condition have successful pregnancies. If you have endometriosis or suspect you have endo, and having difficulty conceiving or experiencing pregnancy losses,  it’s crucial to seek consultation with an endometriosis specialist.   



Epigenetics and Endometriosis Hereditary: Unraveling the Complex Web of Hereditary Implications

Endometriosis, a medical condition afflicting numerous women worldwide, continues to puzzle medical researchers due to its complex nature and the myriad of genetic and environmental factors contributing to its development. This article aims to dissect the convoluted genetic aspect of endometriosis, providing a comprehensive understanding of its hereditary implications.

1. Introduction to Endometriosis

Endometriosis is a condition characterized by the growth of endometrium-like tissue outside the uterus. This disease exhibits significant diversity in its manifestation, with the tissue appearing in various forms and locations. It has a significant impact on the quality of life of the affected individual, often causing pain, infertility, and other related complications.

2. The Puzzle of Endometriosis Hereditary

2.1 Hereditary Factors in Endometriosis

Endometriosis has been confirmed as a hereditary disease, with the risk of developing the condition significantly higher in first-degree relatives of affected women. Twin studies further corroborate this, showing a similar prevalence and age of onset in twins. Despite this, the exact genetic mechanisms contributing to endometriosis remain elusive and likely presents with an inheritance pattern that is multifactorial. 

2.2 Genetic and Epigenetic Incidents in Endometriosis

Genetic and epigenetic incidents, both inherited and acquired, significantly contribute to the development of endometriosis. These incidents, which can cause changes in gene expression, are often triggered by environmental factors such as oxidative stress and inflammation. Familial clustering of endometriosis has been shown in an array of studies with similar findings. First-degree relatives are 5 to 7 times more likely to have surgically confirmed disease. 

Familial endometriosis may be more severe than sporadic cases. This also supports the multifactorial inheritance of endometriosis and a genetic propensity as it may spread more severely to offspring or siblings. These women with familial inheritance may also have earlier age of onset and symptoms. 

3. Theories on the Pathogenesis of Endometriosis

3.1 The Implantation Theory

The implantation theory, popularized by Sampson in 1927, suggests that endometriosis is caused by the implantation of endometrial cells in locations outside the uterus. This theory, while reasonable, fails to explain certain observations, such as the occurrence of endometriosis in men and women without endometrium.

3.2 The Metaplasia Theory

The metaplasia theory postulates that endometriosis is a result of metaplastic changes, a process where one type of cell changes into another type due to environmental stress. This theory, while accounting for some observations, is limited by the varying definitions of “metaplasia” and the disregard for genetic or epigenetic changes.

3.3 The Genetic/Epigenetic Theory

The genetic/epigenetic theory proposes that endometriosis results from a series of genetic and epigenetic incidents, both hereditary and acquired. This theory is compatible with all known observations of endometriosis, providing a comprehensive understanding of the disease’s pathogenesis.

4. The Genetic/Epigenetic Theory: A Closer Look

4.1 Genetic and Epigenetic Incidents: The Triggers of Endometriosis

According to the genetic/epigenetic theory, endometriosis is triggered by a series of genetic and epigenetic incidents. These incidents can be hereditary, transmitted at birth, or acquired later in life due to environmental factors such as oxidative stress and inflammation.

4.2 The Role of Redundancy in the Development of Endometriosis

Redundancy, where a task can be accomplished by multiple pathways, plays a significant role in the development of endometriosis. This redundancy can mask the effects of minor genetic and epigenetic changes, causing them to become visible only when a higher capacity is needed.

4.3 The Genetic/Epigenetic Theory and Endometriosis Lesions

Endometriosis lesions are clonal, meaning they originate from a single cell that has undergone genetic or epigenetic changes. The genetic/epigenetic theory proposes that these lesions can remain dormant for extended periods, similar to uterine myomas, and may only be reactivated by certain triggers such as trauma.

5. Clinical Implications of the Genetic/Epigenetic Theory

5.1 Understanding the Nature of Endometriosis Lesions

According to the genetic/epigenetic theory, most subtle or microscopic lesions are normal endometrium-like cells that would likely resolve without intervention. In contrast, typical, cystic, and deep lesions are benign tumors that do not recur after complete excision but may progress slowly or remain dormant for an extended period.

5.2 The Role of Factors in Endometriosis Hereditary

The genetic/epigenetic theory suggests that genetic and epigenetic defects inherited at birth may play a significant role in the development of endometriosis. These hereditary factors may not only contribute to the disease’s onset but also to associated conditions such as subfertility and pregnancy complications.

5.3 Variability in Endometriosis Lesions

The genetic/epigenetic theory explains that endometriosis lesions can vary significantly in their reaction to hormones and other environmental factors. This variability is due to the specific set of genetic and epigenetic changes present in each lesion.

6. Prevention and Treatment of Endometriosis: A Genetic/Epigenetic Perspective

6.1 Prevention of Genetic/Epigenetic Incidents

Preventing the genetic/epigenetic incidents that trigger endometriosis can be a complex task. However, reducing repetitive stress may be useful in this regard.

6.2 Treatment of Endometriosis

The genetic/epigenetic theory suggests that the treatment of endometriosis should focus on the complete excision of the lesions to prevent recurrence. However, it also proposes that less radical surgery may be sufficient in some cases where the surrounding fibrosis and outer cell layers are composed of normal cells with reversible changes.

7. Conclusion

While the genetic/epigenetic theory provides a comprehensive understanding of the pathogenesis of endometriosis, it remains a theory until disproven by new observations. Further research is needed to fully elucidate the genetic and epigenetic mechanisms contributing to endometriosis, paving the way for more effective prevention and treatment strategies. Despite the complexity and challenges, the pursuit of knowledge in this field continues, offering hope for a future where endometriosis can be effectively managed and potentially prevented.


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Unraveling the Connection Between Endometriosis and Autoimmune Diseases

Endometriosis causes pain, multiple bowel symptoms and infertility, among many other debilitating symptoms, in about 10% of women, mostly in the reproductive age range. Developing research has shown that there is a link to various autoimmune conditions. 

Understanding Endometriosis

Endometriosis is a chronic gynecological disorder characterized by the presence of endometrial-like tissue growing outside the uterus. This means the cells look like those which line the inner part of the uterus but differ markedly in multiple ways at the molecular level.  The more we find out the less it is clear what the origins are.  However, they are likely partly genetic and partly based on other multiple influences of the environment on your body and genes. 

The Immune System’s Role

Research suggests that abnormalities in the immune system may play a key role in the development of endometriosis. These abnormalities could prevent the immune system from effectively clearing ectopic endometrial cells, regardless of how they get there, allowing them to implant and grow outside the uterus. This hypothesis suggests that endometriosis might be, at least in part, an immunity-associated disorder.

Furthermore, endometriosis is often associated with a chronic inflammatory response, triggered by the presence of ectopic endometrial-like cells. This inflammation, coupled with the immune system’s inability to effectively remove ectopic cells, could partly explain the chronic pain often associated with endometriosis.

Is Endometriosis an Autoimmune Disease?

Autoimmune diseases occur when the immune system mistakenly attacks the body’s own cells, viewing them as foreign invaders. The link between endometriosis and autoimmune diseases is still being explored, but multiple studies suggest that women with endometriosis may have a higher risk for certain autoimmune diseases.  It is not clear if endo carries a risk of developing autoimmune diseases or if the reverse is true or if they simply share common molecular mechanisms which results in both potentially occurring in any given individual.  At this point it is important to stress that an “association” does not mean “cause”. 

This review aims to delve into the current state of research on the association if endometriosis is an autoimmune disease. It presents key findings from population-based studies, discusses the potential implications, and highlights areas for future research.

Systemic Lupus Erythematosus (SLE) and Endometriosis

Systemic Lupus Erythematosus (SLE) is an autoimmune disease characterized by inflammation and damage to various body tissues, including the skin, joints, kidneys, and heart. Some studies have suggested a positive association between endometriosis and SLE.

One study suggested a seven-fold increase in the odds of having SLE among women with endometriosis. However, the study relied on self-reported diagnoses, which may introduce bias. A more recent cohort study found a more modest but still significant elevation in SLE risk among women with endometriosis.

Sjögren’s Syndrome (SS) and Endometriosis

Sjögren’s Syndrome (SS) is an autoimmune disorder characterized by dry eyes and mouth, often accompanied by other systemic symptoms. Several studies have investigated the potential link between SS and endometriosis.

A meta-analysis of three case-control studies found a 76% higher odds of SS in women with endometriosis. However, these studies had small sample sizes and wide confidence intervals, indicating a need for further research. Confidence intervals describe the range of results around a measurement which indicate how accurate the conclusion might be.  The tighter it is among measurements the better. 

Rheumatoid Arthritis (RA) and Endometriosis

Rheumatoid Arthritis (RA) is a chronic inflammatory disorder affecting many joints, including those in the hands and feet. Some studies have suggested a link between endometriosis and an increased risk of developing RA.

One meta-analysis, for example, found a 50% increased risk of RA among women with endometriosis. Again, the studies included in the analysis had limitations, including small sample sizes and wide confidence intervals.

Autoimmune Thyroid Disorders (ATD) and Endometriosis

Autoimmune thyroid disorders (ATDs), including Graves’ disease and Hashimoto’s thyroiditis, occur when the immune system attacks the thyroid gland, leading to either overactivity (hyperthyroidism) or underactivity (hypothyroidism) of the gland.

A meta-analysis of three case-control studies suggested a non-significant increase in the odds of ATD in women with endometriosis. However, the studies had high heterogeneity and low-quality scores, suggesting that further research is needed.

Coeliac Disease (CLD) and Endometriosis

Coeliac disease (CLD) is an autoimmune disorder where ingestion of gluten leads to damage in the small intestine. Some studies have suggested a possible link between endometriosis and CLD.

A meta-analysis of two case-control studies found a four-fold increase in the odds of CLD among women with endometriosis. Again, these studies had small sample sizes and wide confidence intervals, indicating a need for further research.

Multiple Sclerosis (MS) and Endometriosis

Multiple Sclerosis (MS) is a chronic disease that attacks the central nervous system. Current research on the association between MS and endometriosis is limited and inconclusive, with some studies suggesting a possible link while others finding no significant association.

Inflammatory Bowel Disease (IBD) and Endometriosis

Inflammatory bowel disease (IBD), including Crohn’s disease and ulcerative colitis, is characterized by chronic inflammation of the gastrointestinal tract. Some studies indicate a possible association between IBD and endometriosis.

One study found a 50% increase in the risk of IBD among women with endometriosis. However, the study had a small sample size and the confidence interval was wide, indicating a need for further research.

The Bigger Picture

While the evidence for an association between endometriosis and certain autoimmune diseases is compelling, it’s important to emphasize that correlation or association does not imply causation. Further research is needed to determine whether endometriosis actually increases the risk of developing autoimmune diseases or vice versa, or whether the two share common risk factors or underlying mechanisms.

The potential link between endometriosis and autoimmune diseases highlights the importance of a comprehensive approach to women’s health. For women with endometriosis, being aware of the potential increased risk of autoimmune diseases can inform their healthcare decisions and monitoring.

The Path Ahead

The intersection of endometriosis and autoimmune diseases is a complex and evolving field of research. Better understanding the relationship between these conditions could help improve diagnosis, treatment, and ultimately, the quality of life for patients with endometriosis.

By continuing to explore this connection, we are gaining new insights into the pathophysiology of endometriosis and autoimmune diseases, potentially leading to novel treatments and preventive strategies. 



Navigating HRT for Endometriosis and Menopause in Women

Endometriosis, a chronic condition, is often associated with the fertile years of a woman’s life. But what happens when these women reach menopause? Can the symptoms of endometriosis persist, or even worsen, during this transition? This article aims to shed light on these questions and provide guidance for women with a history of endometriosis approaching menopause.

Understanding HRT and Endometriosis: A Quick Overview

Endometriosis is a medical condition characterized by the growth of endometrial-like tissue (the tissue that lines the uterus) outside the uterus. This condition, affecting approximately at least 10% of women in their reproductive years, can lead to debilitating pain, infertility, and other complications. However, the diagnosis of endometriosis often gets delayed due to the non-specific nature of its symptoms and the lack of reliable diagnostic tools.

The exact cause of endometriosis remains unclear, but estrogen dependence, progesterone resistance, inflammation, environmental factors and genetic predisposition are some of the known contributing factors. The primary treatment and support options for endometriosis include hormonal therapy, pain management, pelvic floor physical therapy and excisional surgery.

Endometriosis and Menopause: The Connection

Menopause, the cessation of menstruation, is a natural phase in a woman’s life. It is commonly believed that endometriosis, an estrogen-dependent condition, resolves after menopause due to the decline in estrogen levels. However, this belief is being challenged as more cases of postmenopausal endometriosis are reported.

The persistence or recurrence of endometriosis after menopause can be attributed to multiple factors. One factor may be persistent higher levels of estrogen in some women.  One common estrogen source is Hormone Replacement Therapy (HRT) to manage menopausal symptoms. HRT, which usually includes estrogen, may reactivate endometriosis in some cases. However, it is a complex interplay of estrogen, progesterone or progestins if they are included, receptor sensitivity and number and other molecular signaling factors, including the presence or absence of genomic alterations.  It’s also important to keep in mind that endometriosis cells and their surrounding support cells can locally produce estrogen.  Estrogen can also be generated by the interconversion of other hormones in your fat cells.  So, taking hormonal replacement is not the only potential source of estrogen after menopause.  

Numerous case reports and series have documented the recurrence of endometriosis or malignant transformation of endometriotic foci in postmenopausal women. In these reports, the majority of women had undergone surgical menopause (ovaries were removed) due to severe premenopausal endometriosis.

Recurrence of Endometriosis

In several case studies, postmenopausal women reported symptoms similar to those experienced during their premenopausal years. These symptoms included abnormal bleeding if the uterus was still intact and pain, often in the genitourinary system. Notably, all women who experienced recurrence were on some form of Hormone Replacement Therapy (HRT), particularly unopposed estrogen therapy.

Malignant Transformation of Endometriotic Foci

Case studies have also reported instances of malignant transformation of endometriotic foci in postmenopausal women on HRT. These cases highlight the potential risk of exogenous estrogen in stimulating malignant transformation in women with a history of endometriosis.  It’s critical to point out that this is rare and that is why these are case reports rather than large studies.  When these steps towards malignant transformation  have been found they are usually associated with genetic alterations like PTEN, TP53 and ARID1A.  These alterations are more often found in deep infiltrating and endometrioma types of endometriosis, which are less common than the superficial variant. 

Should HRT be Given to Women with Previous Endometriosis?

The decision to prescribe HRT to women with a history of endometriosis is complex and should be individualized on a holistic basis, looking at the risk and benefit overall. This includes risk and benefit for other symptoms and conditions like hot flashes, osteoporosis, heart disease, skin and vaginal changes, and more.  While HRT is the most effective treatment for these menopausal symptoms, it may increase the risk of recurrence or, more rarely,  malignant transformation of the endometriosis. 

Several observational studies and clinical trials have sought to assess the risks of HRT in women with a history of endometriosis. Although these studies suggested a small association between HRT and endometriosis recurrence, the differences between treatment and control groups were not statistically significant.  This means that for the vast majority, it is likely safe to take hormone replacement therapy, especially when considering the far more common benefits of such therapy.  

Whether or not the uterus has been removed or not is another  factor.  HRT for those with an intact uterus usually includes estrogen and a progestational agent, most often a synthetic progestin.  This is to protect against developing uterine endometrial cancer.  If the uterus is surgically absent, then only estrogen is usually administered.  There is a big reason for this.  The large Women’s Health Initiative (WHI) study performed over twenty years ago revealed that the risk of breast cancer mainly increases with hormone therapy that contains a progestin (synthetic progestational agent).  Estrogen alone does not increase this risk.  This is because progestins act as growth factors (mitogens) in breast tissue.  While natural progesterone was not evaluated in the WHI study, we know that it is not a mitogen from other studies.  So, if your uterus has not been removed, from a breast risk perspective, it may be reasonable to inquire about natural progesterone rather than a synthetic progestin as part of hormonal replacement therapy.  

It is also important to recognize that ectopic endometriosis cells are not as sensitive to progestational hormones as is eutopic endometrium, located in the uterine lining.   So, the real benefit of adding progestin or progesterone may not be as significant as it is in theory.  This requires more study, looking at the very complex molecular interplay of these hormones with their receptors located on and in endometriosis cells.  

Should HRT be Given Immediately Following Surgical Menopause?

Another question that arises is whether HRT should be initiated immediately after surgical menopause. Delaying the start of HRT could potentially allow any residual endometriotic tissue to regress before introducing exogenous estrogen. However, current research is inconclusive, with studies showing mixed results.

What Menopausal Treatments are Most Appropriate for Women with Previous Endometriosis?

If a woman with a history of endometriosis decides to opt for HRT, choosing the most suitable preparation is crucial. Current research suggests that combined HRT, which includes both estrogen and progestin (or progesterone), may be a safer option for women with residual endometriosis.  Keep in mind the caveat about breast tissue and synthetic vs natural progesterone. However, more research is needed to confirm these findings.

Conclusions and Guidance

Navigating the transition to menopause can be challenging for women with a history of endometriosis. While HRT can be effective in managing menopausal symptoms, it may also increase the risk of endometriosis recurrence or malignant transformation.

Women with a history of endometriosis should have a thorough discussion with their healthcare providers about the overall potential risks and benefits of HRT.  It is also important to explore the risk and benefit of synthetic vs natural progestational agents. Not all practitioners are well versed in this innuendo.  

It’s also important to remember that each woman’s experience with endometriosis and menopause is unique. Therefore, individualized care that takes into account the symptoms, medical history, and personal preferences is crucial.  

Ultimately, more high-quality research is needed to better understand the molecular relationship between endometriosis and menopause, and to guide the management of menopausal symptoms in women with a history of endometriosis.



What Cause of Endometriosis?

Actionable Insights into the Cause of Endometriosis and Evidence-Based Treatments on the Horizon

Most of what you read online and in books or articles says something like “The cause of endometriosis is unknown, but we have a number of theories, some of which are more likely than others.” But what does this practically mean for you as an individual?   As someone who is looking for answers for pain relief or infertility solutions or a diagnosis or why your endo recurred, you probably want practical answers not abstract theories. Actionable answers seem remarkably elusive.  To add to your frustration, you may also find yourself stumbling upon a storm of “controversies” regarding the best treatment options, further muddying the water in your personal quest for answers.

Basically, endometriosis is a chronic and often painful condition that affects at least 10% of women (XX) of reproductive age and significantly, but not entirely, fueled by sex hormones, mainly estrogen.  It is exceedingly rare in men (XY) but has been reported with high doses of prolonged estrogen therapy for prostate cancer and similar conditions.  Thus, the scope of how many people with endometriosis may be changing. Endo may have increasing implications for trans women who might be prescribed prolonged estrogen therapy. 

This article is an introductory overview of the most current research on the etiology, pathobiology, and potential therapeutic strategies for this extremely complex and prevalent condition.  In other words, it attempts to connect what we know with some practical insights for you to base decisions on, including factoring in what may be coming as options down the road. This may or may not alter your decision-making today as well.  

At the end of this article, we will introduce some practical tips and strategies for getting you to where you want to go. But you must understand the basis for these first, or it won’t make sense.   

What is Endometriosis?

Endometriosis is a medical condition characterized by the growth of endometrial-like tissue, similar to the internal lining of the uterus, outside the uterus. You see this mentioned a lot, but what does it mean exactly?  It means that the cells look quite similar under the microscope, but molecularly they are very different.   

Gene expression : Endometriotic cells often express genes associated with survival, inflammation, angiogenesis (blood vessel formation to have access to nutrients), and invasion more highly than typical endometrial cells. Major examples include genes coding for COX-2, VEGF, MMPs, and various cytokines, which are often upregulated. These all encode for aggressive epigenetics (something you will read about below): Epigenetic differences, including DNA methylation and histone modification differences, have been observed between endometriotic and endometrial cells. These changes can alter gene expression without changing the DNA sequence itself.

Hormonal responses: Endometriotic cells often show altered responses to hormones, including estrogen and progesterone. For example, they usually contain higher levels of aromatase, an enzyme that produces estrogen.  In addition, they may be less responsive to progesterone compared to normal intra-uterine endometrial tissue due to changes in progesterone receptor expression.

Immune response: Endometriotic lesions often contain immune cells, such as macrophages and T cells, and produce pro-inflammatory cytokines. This suggests an ongoing inflammatory response, which may contribute to the symptoms of endometriosis and the survival of endometriotic cells outside the uterus.

The presence of these aberrant endometrial-like tissues in ectopic or unusual locations often results in chronic pelvic pain, intestinal symptoms like bloating, fertility problems, and a lot of other symptoms that can significantly impact the quality of life. 

The Prevalence and Impact of Endometriosis

Beyond affecting at least 10% of XX women and potentially an increasing number of XY trans-women, the condition is detected in up to 50% of women seeking treatment for fertility issues. Moreover, epidemiological studies suggest that women with endometriosis may be at a higher risk of developing other health conditions including, but not limited to, asthma, rheumatoid arthritis, intestinal dysbiosis, other immune dysfunction, cardiovascular disease and even cancers like ovarian, breast and melanoma. So, while endo cannot explain all symptoms, these symptoms and signs may still be very related and due to a common root cause of endometriosis. Too often, an endo diagnosis is extremely delayed, up to a decade, because medical evaluation and testing do not explore these connections.  In other words, for example, intestinal complaints are looked at in isolation, and connections to painful periods, pain during sex, or infertility are overlooked.   

Symptoms and Diagnosis of Endometriosis

While debate concerning possible causes of endometriosis may continue for some time and the etiologies may overlap or differ between individuals, the first step is to get a correct diagnosis. That leads to the best personalized and informed treatment plan. 

The symptoms of endometriosis  can vary greatly based on where it is located in your body, the inflammation it is causing and all of the related conditions. But, the most common symptoms include bloating, chronic pelvic pain (both cyclical and non-cyclical), painful menstrual cycles, painful intercourse, and pain during bowel movements and urination. In addition to physical discomfort, endometriosis is often associated with fatigue and depression, further compounding the impact of the condition.

Diagnosing endometriosis is challenging due to the overlap of its symptoms with more common conditions. This can result in up to a decade of visiting emergency rooms and various specialists, who look at the symptoms through their specialty’s diagnostic lens with somewhat of a tunnel-vision result.  So, a gastro will focus on the gut, a general gynecologist will focus on the uterus and ovaries, a neurologist will focus on nerves, a urologist will focus on the bladder, and so on, all looking for common diagnoses within their specialties. These more common diagnoses are usually not endometriosis.  Further, there are no specific blood tests yet and imaging is not very accurate. However, inflammatory markers and other tests can help an endo specialist hone in on the diagnosis.  Similarly, imaging via ultrasound or MRI may be helpful in finding obvious signs of endometriomas (ovarian cysts filled with old blood and endometriosis tissue) or deep infiltrating type of endometriosis.  This simply helps preparation for surgery in the event of findings like disease near the sciatic nerve or growing into the bladder or rectum. However, if negative, the surgeon and/or team must still expect and be ready to handle the unexpected.

Today, a definitive diagnosis of endometriosis can only be achieved by biopsy, usually during a diagnostic minimally invasive surgery.  Ideally, the surgeon who is operating should be capable of removing any endo that is found by excising it, at that time and not at a subsequent surgery.  This is where the diagnosis overlaps with an effective known treatment, excision surgery. The skill base for this is usually beyond most general gynecologists unless they have devoted extra time and training to acquire more advanced surgical skills.  If possible, this diagnosis and possibly therapeutic surgery should be done correctly the first time to minimize misdiagnosis, complications and repeat surgeries. 

Based on some of what you are about to read, diagnostics will likely soon be enhanced, and accurate blood tests will become available for diagnosis and monitoring.  These tests will be based on proteomics and miRNA signatures, which means that endometriosis is associated with various measurable proteins and ribonucleic acids (RNA) of a specific kind, circulating in the blood.    A lot of research has already been done on this, but it is a matter of finding a combination of these that is accurate.  

Unraveling the Cause or Causes of Endometriosis

It is highly unlikely that there will be a discovery of “THE’ unifying cause of endometriosis any time soon, if ever. However, this is still possible on a gene level and is a focus of ongoing research. But when you are looking for actionable, practical answers, this uncertainty should be framed a little better.  Far more likely than not, the causes (plural) of endometriosis are polygenic (multiple gene aberrations), multifactorial, and most likely differ between individuals. The same situation exists in other diseases we treat.  There is no single cause of cancer, blood pressure problems, different types of diabetes, and so on.  Yet, treatment options are increasing because we are now searching for causative factors and targeted therapies at a molecular, genetic, epigenetic and genomic level.  That is a mouthful, but these subcellular molecular factors control everything in your body, normal and abnormal. More on this below. 


One of the most widely accepted theories for the origin of endometriosis is the very old concept of “retrograde menstruation”, proposed by Sampson. It has been both overly glorified and vilified and certainly misunderstood often. This theory suggests that endometrial tissue fragments and cells escape from the uterus during menstruation, being forced backward through the Fallopian tubes, and implant in the pelvic cavity, directly forming endometriosis lesions.  But since retrograde menstruation is very common (at least 70-90% of all women based on laparoscopy observational studies), why do most or all women with a uterus not have endo?  Also, from a molecular point of view, eutopic endometrium and ectopic endometriosis cells differ in many respects. The answer to these disconnects is that perhaps this theory is indeed totally wrong and outdated.  Or perhaps there are factors in most women that can bio-molecularly or immunologically repel the growth of spilled endometrial cells, while some can’t. Or perhaps, since we know somatic stem cells exist in the endometrium, only a fraction of a certain type of stem cell may grow and differentiate if dropped into the peritoneal cavity and not all endometrial cells.  So, before completely retiring this theory, more sophisticated studies are required with today’s scientific tools. We have come a long way since the limited science that was available more than 100 years ago, when this was initially proposed.   

One thing is for certain, for endo to grow and cause problems it must get there somehow and take root first.  Other than retrograde menstruation, how else might that happen? 

Other theories as to how endo originates include: 

1/ Müllerianosis, which means an organoid structure called a “choristoma” composed of Müllerian rests which are islands of tissue of endometrial, endocervical and endosalpingeal that are deposited in unusual areas during the growth of an embryo. This was also suggested by Sampson.   

2/ Coelomic metaplasia: this theory suggests that peritoneal mesothelium (lining) could transform into endometrial-like tissue (also proposed about 100 years ago) 

3/ Endometrial somatic stem/progenitor cells may play a role in the formation of endometriosis lesions, getting to the peritoneum either by retrograde menstruation (a variation of the original theory) or via lymph or tiny vascular transport channels 

4/ Benign metastasis, meaning that endometrial cells are transported by the lymphatic system beyond the uterus 

5/ Bone marrow pluripotent stem cells (i.e. can turn into any cell imaginable), which we know circulate in the blood, can reach the pelvis or other areas directly, implant due to a favorable local growth environment and grow.  

There are others, and variations or mixtures of the above have also been proposed. 

The truth, as almost always, is likely in between all these theories and likely differs between individuals to some extent. Today, we have molecular evidence that supports most of the above in varying degrees and tends to overlap.  

Endometriosis Growth and Progression 

Finding out how endometriosis develops will eventually lead to prevention strategies, which may be highly individualized.  But for now, the more actionable question is, once the initial cells are there, what causes them to grow and regrow, and at different rates?  It is the growth that gets you into trouble with symptoms by triggering inflammation, fibrosis (scar tissue) and pain.   Keep in mind that there are three general types of endo: 1/ superficial 2/ deep infiltrating and 3/ endometrioma.  These can overlap, or not. So, most likely, there will never be a one-size-fits-all solution. 

However, what happens with progression, when it happens and why it happens is where the rubber meets the road. In answering these questions, insights and actionable strategies can be developed.  The following are avenues or pathways by which endometriosis cells can be fueled to grow.  Therefore, they present actionable intervention possibilities, now and into the future as we identify more targets.  

So, the following is where we are going with all this.  What is medically/surgically actionable now and what you can do proactively today that may influence your personal situation?  The latter is in the realm of lifestyle and diet but grounded in science.  There is a lot of woo-woo “alternative” stuff out there but also quite a bit of holistic natural options that is evidence-informed and can be helpful.  

Genetics and Genomics

From epidemiologic, twin, single gene, and genome-wide association studies (GWAS) there is little doubt that risk factors for developing endo is largely grounded in multiple genes (polygenic) and their polymorphisms (alterations of various magnitudes).  In addition, genes can interact with each other, either amplifying or reducing disease.  But inheriting less desirable gene polymorphisms or mutations is not the be-all end-all because how these genes are activated or suppressed is dependent upon other multifactorial influences (e.g. your environment, including nutrition, toxins and lifestyle choices).  In other words, you may inherit good cards or bad cards, but how they play out can be influenced.  These influences are based on  genomics and epigenetics  and related sciences like proteomics,  metabolomics, nutrigenomics, and so on. Basically, these sciences all study how genes are suppressed or expressed.


Epigenetics studies how genes are controlled or expressed without changing the inherited DNA sequence.  “Epi-” means on top of the genes.  These are modifications that attach to the DNA, like methyl groups (from diet and supplement sources), which can suppress or help activate genes. Environmental factors such as diet, hormones, stress, drugs, chemical toxin exposure alter methylation.  Directly related to endo, alterations in DNA methylation patterns in endometriotic lesions have been described.  The epigenome harbors other ways that this gene to environment interaction occurs.  This includes histone modification, which is regulatory mechanism that controls unraveling of DNA so it can be read or transcribed.  This is also subject to lifestyle and dietary influence today and is a major potential therapeutic target for the future.

Hormonal imbalances

Endometriosis is often described as a “steroid-dependent” disorder, reflecting the significant role of steroid hormones, mainly estrogen, in its pathogenesis. 

This is a VERY complex influence and defies logic in some cases.  It is not as simple as therapeutically adding or taking away estrogen or progesterone.  Rather, it depends on tissue levels of estrogen and progesterone as well as the number and sensitivity of estrogen and progesterone receptors. The hormones and their receptors work like a lock (receptor) and key (hormone).  And that is just the beginning, because there are different components of receptors and additional molecular pathway influences, before and after estrogen binds to its receptor. 

For example, there is more estrogen circulating when someone is significantly overweight, because there is production from the ovaries AND estrogen from fat cell interconversion AND from environmental xenoestrogen endocrine disruptors that are stored in fat. So that would mean the people who are overweight are more likely to have endo, right?  Wrong.  Endo is more common in women with a healthy BMI. In fact, problematic deep infiltrating endo and endometrioma types, is more prevalent in those who are very thin (BMI less than 18.5).  Why?  This is unknown, but various homeostatic mechanisms like estrogen receptor upregulation can hypothetically lead to higher estrogen sensitivity. Also, hormonal signals are not the only molecular influence on endo.

As another example, after  menopause , estrogen levels drop and endometriosis does tend to regress, but not in everyone. That is partly because endometriosis lesions can produce their own estrogen and there are likely other molecular growth factors in play.  There are also more ERβ receptors on endometriosis cells, and this causes higher prostaglandin production (which contributes to pain at any point in life).

In general, lowering “estrogen-dominance” to some degree suppresses endometriosis, but ideally not using synthetic progestins to “balance” hormones.   Progesterone (natural) and progestins (synthetic) do downregulate and limit the mitogenic (growth) influence of estrogen but progestins can also be a mitogenic in some tissues (e.g. breast).  In addition, overall progesterone or progestins exert less of an effect on endometriosis than on eutopic endometrial tissue normally found inside the uterus.  Likewise, dropping estrogen levels radically via GnRH agents for a relatively short period of time does not achieve the desired result and causes side effects and harm.  The risk vs benefit is particularly precarious here. Potentially, chronic gentle suppression might be more effective, and at least safer.  This can be achieved by using progesterone.  Synthetic progestins like norethindrone acetate can be used but with the caveats above. Alternatively, you can also help “balance hormones” by consuming seaweed, regular exercising and other lifestyle choices, like active xenoestrogen toxin avoidance.


Endometriosis may be partially a product of inflammation and is also characterized by generating an inflammatory response itself.  So, it can snowball and contribute to the development and persistence of symptoms. Immune cells, such as macrophages, NK and T cells, are found in abundance in endometriosis lesions, and their interactions with endometriosis cells can promote the formation and growth of these lesions. Additionally, the peritoneal fluid of women with endometriosis often exhibits an altered composition, with increased levels of pro-inflammatory cytokines and growth factors.  

Inflammation can be from various sources, including infection which may be clinical (in other words you feel sick) or chronic subclinical.  For example, it is well established that chronic endometritis (infection inside the uterine lining) is present in endometriosis patients more often than those without endo. This is an association, and the cause-effect is not well worked out, but more recently various bacteria have been implicated.  At least in animal models, antibiotic treatment targeting those bacteria have produced regression of endometriosis lesions. Bacteria from the uterus or cervix can easily travel, either directly through the Fallopian tubes or via the bloodstream, to cause inflammation in the peritoneal cavity.  This inflammatory response is postulated to lead to progression of endo. 

Leaky gut, which may be related to an unhealthy low microbiome diversity, can lead to bacterial fragments, called lipopolysaccharides (LPS), seeding the peritoneal cavity as well.  This in turn causes inflammation and the same potential effect on endo growth.   

Inflammation is not all due to infection.  It can be due to a myriad of other non-infectious factors including stress, autoimmune disorders, obesity, systemic diseases like diabetes or pre-diabetes, mast cell activation, toxin exposure and so on.  

Most of these inflammatory conditions are molecularly actionable and are the target of research. For now, general anti-inflammatory strategies can be effective, both pharmacologic and integrative.   


Dysbiosis of the gut has a direct negative effect on the gut-endocrine axis and can impact endometriosis growth.  There are three significant ways this happens. 

Estrobolome: This term refers to the fraction of gut microbiota capable of metabolizing estrogens. In healthy individuals, the estrobolome helps maintain a balance of estrogen levels by contributing to the enterohepatic circulation of estrogens, thereby affecting the overall circulating and excreted amounts of these hormones. Dysbiosis, however, can disrupt the functioning of the estrobolome, leading to alterations in the metabolism of estrogens. In the context of endometriosis, this dysbiosis may lead to excess circulating estrogen, which stimulates the growth and survival of endometrial cells outside the uterus, contributing to endometriosis. 

Gut-Endocrine Axis: The gut microbiota also influences the gut-endocrine axis, which refers to the complex interplay between the gut microbiota, gut cells, and endocrine organs. Dysbiosis can result in changes in gut permeability (also known as “leaky gut” introduced above), leading to increased inflammation and immune dysregulation. This can, in turn, disrupt normal hormone regulation, potentially exacerbating conditions like endometriosis.

Gut-Brain Axis: Dysbiosis can also influence the gut-brain axis, a bi-directional communication system that links the central nervous system with the enteric nervous system. Changes in the gut microbiota can affect this axis and lead to altered pain perception and increased stress responses, both of which can affect the experience and progression of endometriosis.

Cancer molecular shared growth drivers

It’s important to note that a very small fraction of women with endometriosis might develop an  endo-associated cancer  (<1%), and gene mutations probably drive that.  Having said that there is overlap of these genes with more aggressive variants of endo, like deep infiltrating and endometrioma.  Meaning, they may not lead to cancer but may still fuel a more aggressive form of endometriosis.  This has led some researchers to propose that endometriosis is a pre-cancerous condition in a small percentage of those with endo.  The most studied gene in this regard is ARID1A, but the following have also been associated: KRAS, PTEN, HOXA10, VEGF, ESR1 and ESR2, and FN1.  Since there is a lot of research on these in the cancer world, there may be targeted therapies for more aggressive variants of endometriosis arising from this research.

Current Treatment Strategies for Endometriosis

Current effective treatment for most endo patients is built upon a personalized evaluation, correct diagnosis, and expert excision surgery to reduce the amount of inflammation and triggering of pain and other symptoms.  This is followed by some degree of medical suppression in many patients, usually on a hormonal basis.  Personalized guidance is key, which does not go overboard by either over or under-treating. 

Excisional surgery is today’s cornerstone because it yields an accurate diagnosis and removes all visible disease if possible.  But surgery should not be performed indiscriminately.  It should be done by an expert if the index of suspicion for endo justifies the surgical risks.  It seems prudent to reserve consideration of medical suppressive treatments for use after an accurate diagnosis is made vs. use of potentially very dangerous hormonal therapies based on a suspicion of endo only.   

Before and after surgery there are quite a few optimization strategies, including pelvic floor physical therapy (PFPT) and a pain management plan which consider what the pain triggers are.   These can differ between people. Both supportive therapies are complex but integral to treatment in most cases. This helps you get ready for surgery and go through surgery more smoothly and then transition to a life without endo.  

In addition, evaluation of the related conditions covered in this article, like dysbiosis and possible small bacterial overgrowth (SIBO) and leaky gut is mandatory.  The symptoms can easily cross over from these conditions and endo, so it helps to sort out other related causes of pain and bloating. Finally, evaluation should also consider mast cell activation, chronic inflammatory response syndrome (CIRS), autoimmune hypothyroidism, fibromyalgia, irritable bowel syndrome (IBS) or disorders of gut-brain interactions, and interstitial cystitis (IS).  There are also conditions not directly related to endo but often associated, like Lyme disease and mold.  The latter two can accentuate inflammatory response and waterlogged damp buildings often have black mold.  The CDC is also warning that tick-borne disease like Lyme and Babesiosis is on the rise.    

Also, as you are now aware from reading this article, there are many other steps you can take to influence and limit the course of endo recurrence and progression .  None of this is magic and none of it is a quick fix but when guided by an expert it is also generally pro-health, not dangerous and not expensive by and large.  Again, best results are obtained with expert guidance. 

Emerging Therapeutic Approaches

Although we have some options today, there is a pressing need for novel, effective therapies for endometriosis beyond surgery and variations of hormonal therapy. For instance, immunotherapies that target specific cytokines or immune cells involved in endometriosis are currently under investigation. Other promising areas of research include therapies targeting the altered metabolic environment of endometriosis lesions and neuromodulator treatments aimed at disrupting pain pathways associated with the condition. This article is not intended to cover these future options in depth, but based on all the potential causes and influencing factors it becomes easier to see what is coming sooner than later.   

Some recent example animal studies and concepts which should get to human trials include: Targeted anti-inflammatory therapy,  antibiotic therapy targeting specific bacteria like Fusobacterium, antibody (AMY109) that binds IL-8, small interfering RNA for VEGF (siVEGF), epigenetic and histone modification targeting endo-related gene transcription including estogen and progesterone receptors, epigenetic modification of T-cell immune response in endo, ARID1A and related “cancer gene” targeting, and more. So, while we do not have these available in clinical practice yet, the research wheels are turning.  Certainly, that can be accelerated with more funding, but it is ongoing. 

Holistic Proactive Principles

While we await mainstream targeted molecular therapies you should know that the same molecular pathway targets are also influenced by natural  integrative approaches .  They may not be laser targeted on a specific molecular pathway but that can be a good thing.  Abnormal cells like endo know or learn how to work around blockades from therapy and the treatment can stop working. We know that from other diseases where molecular therapies are already quite common.   Mother nature has considered that problem, so to speak, and a lot of nutrients can have a synergistic favorable effect on multiple molecular pathways at the same time.  

Further, your microbiome, estrobolome, inflammation, oxidation, nutrition, stress, lack of exercise, and so much more, impacts your body on the basis of epigenetics that was introduced above.  More specifially, a significant part is related to nutrigenomic epigenetics.  This can be through food or well selected supplements and botanicals. 

It’s critical to note that this does not mean loading up on the weirdest supplements you never heard of that cost an arm and a leg.  The 80/20 rule, which says that you get 80% of your result from 20% of an action, suggests that you can get far with a personalized antioxidant anti-inflammatory diet.  This is often simply done via a whole food plant-based diet.  Combine this with an exercise plan and stress management and you are 80% of the way there. 


Endometriosis is a complex, multifaceted, polygenic and multifactorial disorder, and much remains to be understood about its causes and progression. As our understanding of endometriosis deepens, so too does our ability to develop accurate diagnostics and targeted, effective therapies. But for now, in expert hands and with your own proactive commitment to nutritional and lifestyle options, outcomes can be good to great. There is no disease or condition where everyone gets the benefit of a great outcome, but certainly in the case of endo it can be optimized by seeking out an endometriosis expert.  In addition, expert consultants, especially those with integrative or functional medicine training, can take it one step further.  


  1. Endometriosis: Etiology, pathobiology, and therapeutic prospects
  2. The Main Theories on the Pathogenesis of Endometriosis
  3. Nutrition in the prevention and treatment of endometriosis: A review
  4. Cancer-Associated Mutations in Endometriosis without Cancer

Updated Post: July 16, 2024


Genetics of Endometriosis: Understanding the Genetic Links in Endometriosis.

Endometriosis is a significant cause of discomfort and can greatly reduce the quality of life.  Although the disease’s origin remains somewhat elusive, research indicates a potential familial pattern. This article delves into the possible genetic basis of endometriosis, exploring its genetic and genomic aspects and their implications for improved diagnosis and treatment.

The Enigma of Endometriosis

Endometriosis is a condition where tissue similar to the endometrium – the internal lining of the uterus – grows outside the uterus. This can occur on the ovaries, fallopian tubes,the tissue lining the pelvis, and beyond. In some cases it grows superficially, in others it can invade deeply into other tissues or affect the ovaries. Despite extensive research, the exact cause of endometriosis and the reason for these variants remains an enigma. However, an interesting pattern has emerged over time – the disease appears to cluster in families, suggesting a potential genetic link.

Is Endometriosis Genetic?

Familial  predisposition suggests that endometriosis could be inherited in a polygenic or multifactorial manner. Polygenic or multifactorial inheritance refers to a condition that is affected by multiple genes (polygenic) and influenced by environmental factors (multifactorial).  Since everyone is different, this may also help explain why some people get one variant of the disease and others do not.  

Several factors make it difficult to understand the genetic link in endometriosis. The foremost is the diagnostic method. Endometriosis can only be definitively diagnosed through invasive procedures like laparoscopy or laparotomy. This can often lead to under-reporting of the disease with many people walking around undiagnosed for years. Another factor is the disease’s heterogeneous nature mentioned above, as it can manifest in different variants and locations within the body, suggesting potentially diverse disease processes.  Once these genetic links, which likely overlap, are unraveled and mapped then we will be able to diagnose endometriosis through blood tests rather than surgery.  Each genetic link eventually leads to molecular signals which can be used for diagnosis, treatment and follow-up monitoring.  

Familial Clustering and Evidence

Epidemiologic research has shown a familial clustering of endometriosis, meaning it appears more frequently within families. However, it does not seem to follow a simple Mendelian inheritance pattern. This observation supports multiple genetic factors contributing to the disease, consistent with polygenic/multifactorial inheritance and environmental impact.  

Genetic Mapping and Endometriosis

Gene mapping is a technique used to investigate potential gene mutations or polymorphisms associated with diseases like endometriosis. This method involves looking at the genome for excess sharing of informative polymorphic microsatellite markers in affected siblings. Studies using this method have highlighted areas in chromosomes 10 and 20 that may be linked to endometriosis. Despite the identification of these risk loci, the exact mechanism by which these genes influence the development of endometriosis is not yet fully understood.  So this association means someone may be at higher risk but does not guarantee that endometriosis will actually develop in any given individual. 

Genome-Wide Association Studies

Genome-Wide Association Studies (GWAS) represent a very promising method used to identify differences in the genetic makeup of individuals that could be responsible for variations in disease susceptibility. Basically, they compare the genomes of people with a certain disease (like endometriosis) to healthy individuals to look for genetic differences.

GWAS scans the genome of individuals for small variations, called single nucleotide polymorphisms (SNPs), that occur more frequently in people with a particular disease than in people without the disease. Each study can look at hundreds or thousands of SNPs at the same time. Then statistical methods can help identify which SNPs are associated with the disease.

First, genetic markers identified through GWAS could potentially be used to develop a genetic test for endometriosis. This could enable earlier and more accurate diagnosis of the disease, which is often difficult to diagnose due to its nonspecific symptoms and the need for invasive procedures to confirm diagnosis.

Second, as an example of treatment potential,  if a GWAS identifies a SNP in a gene involved in inflammation that is associated with endometriosis, researchers could develop a drug that targets this gene to reduce inflammation and treat endometriosis.  There are many other potential molecular pathways that influence endo development and progression that can and will be targeted.  

Genomics of Endometriosis

While genetics refers to the inheritance of a trait, genomics focuses on how genes are expressed, meaning how they are turned into structural proteins and signals and so forth. Genomics studies have identified significant alterations in gene expression in endometriosis, providing major insights into underlying biology. Genomic studies will likely lead to new noninvasive diagnostic strategies and possible new therapies. 

So, deeper understanding of endometriosis genomics can provide insights into the biological pathways and processes involved in the disease.  This can, in turn, inform diagnosis, treatment, and monitoring strategies.


When we better understand the genomics of endometriosis, we will be able to develop non-invasive non-surgical diagnostic tests. For example, if certain genetic variants are found to be associated with endometriosis, a simple blood test could be developed to look for these variants.

In addition to these genetic tests, understanding the molecular signaling pathways involved in endometriosis could potentially lead to the development of biomarker-based tests. Biomarkers are substances, such as proteins, that are indicative of certain biological conditions, like inflammation or fibrosis formation. If certain molecules are found to be elevated or decreased in women with endometriosis, these could be used as biomarkers for the disease.


Current treatments for endometriosis are basically limited to hormonal-based therapy, pain management, and surgery. However, these approaches do not work for everyone and can have significant short and long-term side effects. Short of a complete excision surgery, which is the cornerstone of today’s therapy, these are not curative therapies. Despite world-class excision surgery microscopic invisible post-surgical residual remains a concern and we need better options to eliminate anything that might be left in order to minimize or eliminate risk of recurrence.   

By understanding the genes and molecular pathways involved in endometriosis, we can identify new targets for biological drug development. For example, if a certain gene is found to be overactive in endometriosis, an agent could be developed to inhibit this gene. Similarly, some protein-based molecular pathways can be selectively inhibited. This is reality today in many diseases and there is no reason that endometriosis should not be amenable to similar options. 


Lastly, understanding the genomics of endometriosis could also improve disease monitoring. For example, if certain genetic variants or molecular signals are associated with disease progression, these could potentially be used to monitor disease progression or response to treatment. This could lead to more personalized treatment strategies and improve patient outcomes.  To the point of microscopic residual after excision surgery, if none is likely present and no signals point to that, then no additional therapy would be required.  On the other hand, if there is molecular evidence to support possible micro-residual then treatment might be initiated right away, or at least at the time of first molecular evidence of recurrence or progression. 

The caveat here is that the translation of genomic and molecular research into clinical practice is a complex process that requires extensive further research and validation. It’s also worth noting that endometriosis is a complex disease likely influenced by a combination of genetic, environmental, and hormonal factors, and understanding these will be crucial for developing better diagnostic and treatment strategies. 

Concluding Thoughts

The notion of endometriosis being genetic is supported by a growing body of research, highlighting the disease’s intricate and multifaceted nature. While our understanding of the genetics and genomics of endometriosis is still evolving, it holds the promise of improved diagnosis and treatment methods in the future. By continuing to explore the genetic foundations of this disease, we move closer to empowering those affected by endometriosis with knowledge and more effective treatment options.

In the end, unlocking the genetic and genomic secrets of endometriosis will pave the way for a future where this enigmatic condition is better understood, diagnosed, and treated.  While a lot of the above is in research or upcoming, some is available now.  Seek out an endometriosis expert who can discuss these with you and individualize a treatment plan.


Diana Maria Chiorean et al. New Insights into Genetics of Endometriosis—A Comprehensive Literature Review: Diagnostics (Basel). 2023 Jul; 13(13): 2265.


How Does Endometriosis Cause Infertility? 

Endometriosis, a complex and often misunderstood condition, can significantly impact a woman’s fertility. Understanding the intricacies of this condition, its causes, and its effects on fertility can be vital in paving the way for effective treatment strategies.

An Introduction to Endometriosis

Endometriosis is a benign, estrogen-dependent disorder primarily affecting approximately one in ten cisgender women in their reproductive years. It may also have an impact on transgender men, where the condition may be present in a higher percentage. While it has been reported in cisgender men, it is exceedingly rare. Thus the fertility impact discussed here is that which specifically affects the uterus, Fallopian tubes and ovaries.  

Endometriosis is characterized by the abnormal presence of endometrial-like tissue outside the uterus. This abnormally growing tissue is often found in the pelvic region, such as on the ovaries, fallopian tubes, and the outer surface of the uterus. Still, in some cases, it can extend beyond the pelvic area.

While endometriosis affects approximately 10-15% of cisgender women in their reproductive years, the condition is more prevalent in those struggling with infertility, affecting up to 25%-50% of this demographic. The exact cause of endometriosis remains a subject of research and debate, and its impact on fertility is multi-faceted and complex.

Understanding The Pathogenesis of Endometriosis

While the precise cause of endometriosis is still under debate, several theories have emerged over the years, trying to explain the pathogenesis of this condition.

Retrograde Menstruation

The oldest theory is retrograde menstruation, which suggests that during menstruation, some of the endometrial tissue flows backward, through the fallopian tubes, into the pelvic cavity instead of leaving the body. These endometrial cells then attach to the peritoneal surfaces, proliferate, and form endometriosis implants.

Coelomic Metaplasia and Metastatic Spread

Other theories suggest that cells in the peritoneum can transform into endometrial cells, a process known as coelomic metaplasia. Alternatively, endometrial tissue may spread through the bloodstream or lymphatic system to other parts of the body, a process known as metastatic spread. Both these theories could explain how endometriosis implants can be found in areas outside the pelvic region.

Altered Immunity

Another theory proposes that women with endometriosis have a compromised immune system, which fails to eliminate the endometrial cells that have migrated to the peritoneal cavity. This immune dysfunction may also contribute to the progression of the disease, as the immune system’s reactions may inadvertently promote the growth and proliferation of endometrial implants.

Stem Cells and Genetics

Recent research also suggests that stem cells and genetic factors may play a role in the development of endometriosis. Bone marrow-derived stem cells may differentiate into endometriosis cells, contributing to the formation of ectopic endometrial-like tissue.

Additionally, genetic predisposition may play a significant role in the development of endometriosis. People with a first-degree relative affected by the disease have a seven times higher risk of developing endometriosis.

Learn More: Current Knowledge on Endometriosis Etiology: A Systematic Review

How Does Endometriosis Cause Infertility?

Endometriosis can affect fertility through various mechanisms:

Effect on Gametes and Embryo

Endometriosis can impact the production and quality of oocytes (eggs), as well as sperm function and embryo health. The presence of endometriomas (cysts caused by endometriosis) and the inflammatory environment they create can negatively affect both oocyte production and ovulation.

Effect on Fallopian Tubes and Embryo Transport

Endometriosis can disrupt the fallopian tubes’ normal functioning and impact the embryo’s transport. The inflammation caused by endometriosis can impair tubal motility and cause abnormal uterine contractions, which can hinder the transportation of gametes (eggs and sperm) and embryos.

Effect on the Endometrium

Endometriosis can also impact the uterine lining or endometrium, which can lead to implantation failure. Research suggests that endometriosis can alter the gene expression in the endometrium, affecting its receptivity to implantation.

Read More: Learn More About the Connections Between Endometriosis and Infertility

Current Treatment Options for Endometriosis-Associated Infertility

The treatment of endometriosis-associated infertility is multi-faceted and can include expectant management, medical treatment, surgical treatment, and assisted reproductive technologies.

Expectant Management

While endometriosis significantly lowers fertility rates, some women with mild to moderate endometriosis can still conceive without any medical or surgical intervention. However, this approach may be more suitable for younger women with mild endometriosis and no other fertility issues.

Surgical Treatment

Surgery can be both diagnostic and therapeutic in the context of endometriosis. The goal of surgical treatment is to remove or reduce endometriosis implants and restore normal pelvic anatomy and reduce the inflammatory impact. This could potentially improve fertility, particularly in women with severe endometriosis.

Assisted Reproductive Technology

In vitro fertilization (IVF) is currently the most effective treatment for endometriosis-associated infertility. IVF can be particularly beneficial for women with severe endometriosis or those for whom other treatments have failed.

Medical Treatment

Medical treatment for endometriosis primarily targets reducing the severity of the disease and relieving symptoms. Hormonal medications such as combined oral contraceptives, progestins, danazol, and gonadotropin-releasing hormone agonists or antagonists (GnRH analogs) are commonly used. However, these medications have not shown any significant benefit in treating endometriosis-associated infertility.

Read More: Natural, Medical & Surgical Treatment of Endometriosis Infertility

Looking Towards The Future: Potential Treatments

As our understanding of endometriosis deepens, new potential treatment options are emerging, such as therapies targeting the abnormal gene expression and inflammation caused by endometriosis. Furthermore, stem cell therapies and genetic interventions hold promise for treating endometriosis-associated infertility in the future. As research continues, the hope is that these advancements will lead to more effective strategies for managing this complex condition and improving fertility outcomes in those with endometriosis.

Read More: How Do Endo Fertility Issues Impact the Mental Health of a Person?

Reference: Macer ML, Taylor HS, Obstet Gynecol Clin North Am. 2012 Dec;39(4):535-49.


Interstitial Cystitis and Endometriosis: Unraveling the Evil Twins Syndrome of Chronic Pelvic Pain


Chronic pelvic pain (CPP) is a health condition that burdens millions of women worldwide. The complexity of diagnosing and treating CPP is often overwhelming due to the multitude of potential underlying causes and associated conditions. Two such conditions, often called the “Evil Twins” syndrome, are Interstitial Cystitis (IC) and Endometriosis, both commonly found in patients suffering from CPP. This article will explore these conditions’ prevalence, diagnosis, and treatment in patients with CPP.

Understanding Chronic Pelvic Pain

Chronic Pelvic Pain (CPP) is a prevalent health condition affecting an estimated 9 million women in the United States alone. It accounts for up to 40% of laparoscopies and 10% to 12% of all hysterectomies, indicating its significant impact on women’s health. The annual expenditure on diagnosing and treating CPP is nearly $3 billion.

The “Evil Twins”: Interstitial Cystitis and Endometriosis

Two conditions frequently associated with CPP are Interstitial Cystitis (IC) and Endometriosis. These conditions can present similar symptoms and coexist in patients, making the diagnosis and management of CPP even more challenging.

Interstitial Cystitis (IC)

Interstitial Cystitis, or bladder-originated pelvic pain, is a significant disorder related to CPP. The etiology of IC is multifactorial and progressive, involving bladder epithelial dysfunction, mast cell activation, and bladder sensory nerve upregulation. The exact prevalence of IC in the United States varies, with estimates ranging from 10 to 510 per 100,000 normal population. However, current research suggests that IC might be more prevalent than previously estimated.


Endometriosis is another common condition among women with CPP, affecting more than half of the patients diagnosed with CPP. Symptoms include pain during sexual intercourse (dyspareunia), cyclical perimenstrual lower abdominal pelvic pain, symptom flares after sexual intimacy, and irritative voiding in case of urinary tract involvement. A definitive diagnosis of endometriosis requires visual confirmation of the lesion during laparoscopy and histologic confirmation of the presence of both ectopic endometrial glands and stroma.

The Overlap Between Interstitial Cystitis and Endometriosis

Research has demonstrated a high rate of overlap between IC and endometriosis in patients with CPP. This overlap poses challenges in diagnosis and treatment, as the presence of one condition does not preclude the existence of the other. Therefore, it is crucial to consider both conditions in the evaluation of patients with CPP.

Diagnosis of Interstitial Cystitis

The diagnosis of IC and endometriosis involves various tests and procedures, including the Potassium Sensitivity Test (PST), cystoscopy with hydrodistention, and laparoscopy.


Laparoscopy for direct visualization of endometriosis lesions and taking a biopsy is the gold standard for endometriosis diagnosis.

Read more: The Different Tests Used to Diagnose Endometriosis 

Potassium Sensitivity Test (PST)

The PST is a diagnostic test developed to detect abnormal permeability of the bladder epithelium, a key factor in the pathophysiology of IC. Previous studies have validated the use of the PST in diagnosing IC, particularly at the early stages of the disease.

Cystoscopy with Hydrodistention

Cystoscopy with hydrodistention is a diagnostic procedure often used to confirm the presence of IC. The bladder is filled with sterile water under passive hydrostatic pressure, then slowly drained. The presence of submucosal petechial hemorrhages, or glomerulations, confirms the diagnosis of IC.


During cystoscopy under anesthesia, your provider may remove a sample of tissue (biopsy) from the bladder and the urethra for examination under a microscope. This is to check for bladder cancer and other rare causes of bladder pain.

Urine cytology

Your provider collects a urine sample and examines the cells to help rule out cancer.


This article highlights the complex interplay between IC and endometriosis in the context of CPP. It underscores the need for careful evaluation and simultaneous consideration of these conditions in patients with CPP. A multidisciplinary approach, including the use of PST and concurrent cystoscopy and laparoscopy, is crucial for accurate diagnosis and effective treatment of concurrent interstitial cystitis and endometriosis.


Endo-Fighting Microbiome Optimization: Research-based Tips

Endometriosis is partly caused by, and causes, inflammation. The origin or genesis of this
inflammation is probably multifactorial but recent research suggests that the microbiome, the
community of microorganisms living in or on the human body, plays an important role through
inflammatory pathways. Dysbiosis, which means an imbalance or impairment of the microbiota,
is observed in endometriosis, and is thought to both contribute to and result from endo.

Studies have focused on the gut, peritoneal fluid, and female reproductive tract microbiota to
identify specific microbiome signatures associated with endometriosis. The gut microbiome, in
particular, has been extensively studied. Changes in bacterial composition, such as increased
levels of Proteobacteria and decreased levels of Lactobacilli, have been observed in the gut of
endometriosis patients. Other body sites, including the peritoneal fluid and female reproductive
tract, also show altered microbiota in endometriosis.

The dysbiosis observed in endometriosis is believed to contribute to the disease through
various mechanisms. One theory suggests that bacterial contamination, particularly with
Escherichia coli, in the menstrual blood may lead to inflammation and immune activation in the
peritoneal cavity, contributing to endometriosis development. Dysbiosis can also affect
estrogen metabolism, through dysfunction of the so called “estrobolome”. This can lead to
increased levels of circulating estrogen and a hyper-estrogenic state, which promotes
endometriosis. Additionally, dysbiosis-induced epigenetic changes and immune modulation
may play a role in direct endometriosis pathogenesis.

Research on the microbiome in endometriosis is still in its early stages, but it holds promise for
potential diagnostic and therapeutic approaches. Microbiome testing could potentially be used
as a non-invasive tool for detecting endometriosis, complementing current imaging modalities.
The technology for doing this is already here and you can get it ordered. However, the meaning
of the results is still not well understood in any given individual. So, it’s complicated.

Beyond testing, manipulating the microbiome through interventions like probiotics, antibiotics,
or dietary modifications may offer new treatment options for endometriosis. To the extent that
you can diversify your microbiome and get it to a healthier state, this is something that can be
done with little risk or cost today. Options available to you are covered below, most of which
are focused on the bacterial part of your microbiome.

Future studies will explore the role of different types of microorganisms, beyond bacteria, such
as viruses and fungi, and utilize advanced analytical methods like shotgun metagenomics and
metabolomics to gain a more comprehensive understanding of the microbiome in
endometriosis. Newer technologies like this are significantly accelerating gains in knowledge.

Meanwhile, emerging understanding of the bidirectional relationship between endometriosis
and the microbiome has implications for potential treatment strategies available today.


Antibiotics could be used to target specific bacteria associated with dysbiosis in
endometriosis, especially if you are diagnosed with small intestinal bacterial overgrowth (SIBO).
Animal studies have shown that treatment with antibiotics can reduce the size of endometriotic
lesions and associated inflammation. In humans, we know that chronic endometritis (infection
of the uterine cavity) seems to play a role in development of endo. However, this requires
expert guidance. It’s critical to exercise caution with antibiotic use to avoid disrupting healthy
commensal (good bacteria) microbiota and contributing to antimicrobial resistance. You don’t
want to grow a bug that might be resistant to multiple antibiotics down the line.


Probiotics are live bacteria that can have beneficial effects on your microbiome
health and diversity when consumed. Studies in animal models have demonstrated that certain
probiotic strains, such as Lactobacillus gasseri, can suppress the development and growth of
endometriotic lesions. Probiotics may modulate the immune response and restore a healthier
microbiota composition, potentially mitigating the inflammatory processes associated with
endometriosis. However, again, this requires expert guidance because, for example, it could
lead to ineffectiveness against or exacerbation of SIBO. This is partly because there are at least
three different general types of SIBO, based on what type of gas is produced by the


Prebiotics are basically food substances that selectively promote the growth of
beneficial bacteria in the gut. By providing a favorable environment for beneficial bacteria,
prebiotics can help restore a healthy microbiota balance. An example of a prebiotic shown to
be beneficial in SIBO treatment is partially hydrolyzed guar gum (PHGG). Further research is
needed to investigate the potential roles of prebiotics in endometriosis treatment, but it could
be a gamechanger for simple treatment of various intestinal disorders, leaky gut and so on.

Dietary modifications:

Diet can hugely influence the composition and activity of the
microbiome. Consuming a diet rich in fiber and plant-based foods, which are known to support
a diverse and healthy microbiota, may have beneficial effects on endometriosis. Low FODMAPs
diets, which restrict fermentable carbs, can help. Omega-3 polyunsaturated fatty acids (PUFAs),
found in fatty fish, flaxseeds, and chia seeds, have shown anti-inflammatory properties and
have been associated with a lower incidence of endometriosis. Incorporating these dietary
changes, among many others, may help modulate the microbiome and reduce inflammation.


The microbiome has profound effects on the immune system, and
targeting the immune response could be a potential avenue for endometriosis treatment.
Modulating the immune system through therapies such as immune-suppressing medications or
immune-modulating agents may help regulate the inflammatory processes associated with
endometriosis. The idea here is to keep it as natural as possible, but sometimes prescription
medications may turn out to be necessary.

Please keep in mind that these treatment implications are based on current research, primarily
in the lab and animal models, and further studies are needed to validate their effectiveness and
safety in humans. Additionally, personalized approaches considering an individual’s specific
microbiota composition and disease characteristics may be necessary for optimal treatment
outcomes. It is exciting research in development and will be part of upcoming revolutionary
advances which take us far beyond hormonal manipulation for endo management. Since these
approaches are exploring the root cause of endo, treatments will likely be therapeutic as
opposed to simply something that reduces symptoms, which is the case with today’s hormonal

The best part is that with proper expert guidance, much of the above can be used today
because, in most cases, the risk and cost are relatively low.


Uzuner, C., Mak, J., El-Assaad, F., & Condous, G. (2023). The bidirectional relationship between
endometriosis and microbiome. Frontiers in Endocrinology, 14, 1110824. doi:

Moreno, I., Franasiak, J. M., & Endometrial Microbiome Consortium. (2020). Endometrial
microbiota—new player in town. Fertility and Sterility, 113(2), 303-304. doi:


Understanding Fatigue and Endometriosis: A Practical No-Nonsense Guide

Fatigue is a common symptom these days, but for those living with endometriosis, it can be
particularly challenging. While it’s not one of the primary symptoms of endometriosis, fatigue is
often reported by women who have endo. What’s the relationship? What are some potential
causes and what can you do to regain some lasting energy, without hocus pocus “cures”, more
coffee, or energy drinks?

If you’re not sure if you have endometriosis, please remember that not all symptoms are
directly related to or caused by endo. While many can be related, something else can be
wrong. For example, you can have anemia from various causes, adrenal or thyroid disease and
many other conditions, some of which can be serious. Chronic fatigue is a very challenging
condition to treat but before treatment you first must get to the root cause or causes. This
requires either a mainstream internal medicine or family medicine doctor that is going to
carefully explore every angle with you. Most will just get basis tests and not spend much time
with you, because their time is limited by today’s healthcare mess. Alternatively, seek out an
integrative and/or functional medicine physician who is trained to approach all disease by
tracing it down to the root cause. This is critical and not just a matter of getting a few blood
tests. If you’re “lucky” something obvious might pop up on basic testing. But most of the time
it’s not that straightforward. Do it right!

If you already know you have endo and are experiencing fatigue along with other symptoms of
endometriosis, make sure your endo specialist is aware of this. They can help evaluate how root
causes may be in play that are directly related to endo or adenomyosis, provide an accurate
diagnosis or diagnoses, and develop a personalized treatment plan. Everyone is not the same.

Understanding Fatigue and Endometriosis:

The Impact of Chronic Pain:

Endometriosis, in most, is characterized by chronic pelvic pain, which can significantly impact
quality of life. Living with constant pain can be exhausting both physically and mentally, leading
to fatigue. Additionally, the stress and emotional burden associated with chronic pain can
further contribute to fatigue.

Hormonal Imbalances:

Hormonal imbalances play a role in the development and progression of endometriosis.
Estrogen, in particular, is thought to promote the growth of endometrial tissue outside the

uterus. Fluctuations in estrogen levels throughout the menstrual cycle can result in fatigue and
tiredness. Furthermore, if you are in a hormone balancing program of some kind, excess
progesterone can definitely cause fatigue. “Balancing hormones” requires an expert hand
because it is like conducting a symphony orchestra, as opposed to throwing in a few hormones
to see what happens. Beyond that, it is not just a matter of balancing estrogen and
progesterone. For example, people with endometriosis are six times more likely to have an
underactive thyroid. So, again, it’s a symphony orchestra, not a small band that needs
conducting for best results.

Sleep Disturbances:

Endometriosis often leads to sleep disturbances due to pain, discomfort, and hormonal
imbalances. Insufficient or poor-quality sleep can easily leave one feeling fatigued during the
day. It is essential to prioritize sleep hygiene and seek strategies to improve sleep, such as
creating a relaxing bedtime routine and ensuring a comfortable sleep environment.


Endometriosis and adenomyosis can lead to heavy or prolonged menstrual and inter-menstrual
bleeding, which can result in iron deficiency anemia. Iron is vital for carrying oxygen to the
body’s tissues, and when its levels are low, fatigue and weakness can occur. Bringing iron levels
up may mean taking iron supplements for a while or it can as simple as adjusting your diet to
include iron-rich foods, like leafy veggies.

Inflammation and Immune Dysfunction:

Endometriosis is associated with chronic inflammation and immune system dysfunction. The
inflammatory response and immune activation can definitely contribute to fatigue. Strategies
that reduce inflammation, such as a healthy diet rich in anti-inflammatory foods, regular
exercise, and stress management techniques, may help alleviate fatigue symptoms.

Management Strategies for Fatigue:

Pain Management:

Effective pain management is essential for reducing fatigue associated with endometriosis. Your
doctor may recommend over-the-counter pain relievers, such as nonsteroidal anti-
inflammatory drugs (NSAIDs), to help alleviate pain and inflammation. Hormonal treatments,
such as birth control pills or hormonal intrauterine devices (IUDs), can also be prescribed to
regulate hormone levels and reduce pain. Of course, narcotics are an option but that can lead
to feeling loopy and fatigued, defeating the purpose. Gabapentin and similar drugs can help
with central sensitization and might be used just for transition while you reduce pelvic floor
inflammation triggers using multi-modality therapies. Pelvic floor physical therapy is critical.
Integrative modalities like acupuncture and acupressure can help as well. Endo excision surgery
is always part of the conversation and requires an expert to minimize the risk of multiple repeat

Lifestyle Modifications:

a. Regular Exercise: Engaging in regular exercise can improve energy levels and reduce fatigue.
It might be counter-intuitive to go out and exercise if you are already feeling beat, it works.
Even low-impact activities like walking, swimming, or practicing yoga can have a positive
impact. Start with light exercises and gradually increase intensity based on your comfort level.
Consult with a trainer or a physical therapist to determine the best exercise plan for you.

b. Balanced Diet: A well-balanced anti-inflammatory antioxidant diet plays a crucial role in
managing fatigue and supporting overall health. Incorporate a variety of fruits, vegetables,
whole grains (whole food plant-based diet), and lean proteins into your meals. These provide
essential nutrients which work together, including iron and other vitamins, which can help
combat anemia-related fatigue. Limiting processed foods, sugary snacks, and caffeine can also
promote more stable energy levels throughout the day. Given that endo is inflammatory and
the damage that is caused is based on reactive oxygen species oxidation, it is critical to keep
inflammation low and anti-oxidation high. Your body is a very complex laboratory which also
works like a symphony orchestra when tuned properly. It needs the right fuel, and an expert
nutritional “conductor” can help select and tune up the right plan for you.

c. Adequate Hydration: Drinking enough water throughout the day is important for maintaining
optimal energy levels. Dehydration can exacerbate fatigue, so aim to consume at least eight
glasses of water daily. Carry a refillable water bottle with you as a reminder to stay hydrated.
This is not directly related to endo but is a forgotten baseline critical need to maintain a slightly
alkaline, antioxidant and anti-inflammatory status.

Stress Management:

a. Mindfulness and Relaxation Techniques: Practicing mindfulness meditation, deep breathing
exercises, or progressive muscle relaxation can help reduce stress and improve energy levels.
Find a quiet and comfortable space and allocate a few minutes each day for relaxation
exercises. There is a lot of choose from including various forms of yoga, Tai Chi, Qigong,
mindfulness, biofeedback techniques like Heart Math, meditation and so on. These days there
are various mobile apps and online resources available to guide you through some these
techniques. But it is important to select something that resonates with you. If you are not “into
it”, it won’t help.

b. Engage in Activities You Enjoy: Participating in activities that bring you joy, and relaxation can
help alleviate stress and combat fatigue. Whether it’s reading, listening to music, taking a warm
bath, or spending time in nature, make time for activities that help you unwind and recharge.
Do something that makes you laugh. This all has psycho-biological proof behind it.

c. Prioritize Self-Care: Self-care is essential in managing fatigue and overall well-being. Set aside
regular time for self-care activities such as taking a bubble bath, getting a massage, practicing
gentle yoga, or indulging in a hobby you love. Remember that self-care looks different for
everyone, so find activities that resonate with you and make them a priority.

Support Networks:

a. Seek Emotional Support: Living with endometriosis is emotionally challenging. Connecting
with others who share similar experiences through support groups or online communities can
provide valuable emotional support, validation, and information. Sharing experiences, seeking
advice, and knowing you are not alone can help in managing fatigue and the overall impact of
endometriosis. Everyone is different and some of the solutions you hear about may not work
for you, but it is good to hear about them. The only prudent caveat might be that if something
sounds too good to be true in this setting, check it out through trusted credible sources and
your endo specialist.

b. Involve Loved Ones: Educate your loved ones about endometriosis and how it affects your
energy levels. Communicate your needs and limitations so that they can offer support and
understanding. Having a strong support system can make a significant difference in managing
fatigue and coping with the challenges of endometriosis.

c. Consider Counseling: If fatigue and the emotional impact of endometriosis are strongly
impacting your mental well-being, consider seeking professional counseling or therapy.
Everyone needs help at some point in their life. A mental health professional can provide
guidance, coping strategies, and a safe space to process your emotions.


By implementing these management strategies, you can better cope with fatigue and improve
your quality of life. Remember that everyone’s experience with endometriosis is unique, and it
may take time to find the strategies that work best for you. Seek support from an
endometriosis specialist and other practitioners noted above, make lifestyle modifications,
prioritize self-care, and build a strong support network. Ideally, seek out an endo specialist who
is not only a surgeon but is also either trained in integrative holistic care or has a team that
provides these valuable support and treatment options. With the right tools and resources, you
can more effectively manage fatigue and navigate the challenges of living with endometriosis.


Johnson NP, Hummelshoj L; World Endometriosis Society Montpellier Consortium. Consensus
on current management of endometriosis. Hum Reprod. 2013;28(6):1552-1568.

Nnoaham KE, Hummelshoj L, Kennedy SH, et al. World Endometriosis Research Foundation
Women’s Health Symptom Survey Consortium. World Endometriosis Research Foundation
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Hadfield R, Mardon H, Barlow D, Kennedy S. Delay in the diagnosis of endometriosis: a survey of
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Vercellini P, Vigano’ P, Somigliana E, et al. Endometriosis: pathogenesis and treatment. Nat Rev
Endocrinol. 2014;10(5):261-275.

Ferrero S, Esposito F, Abbamonte LH, et al. Quality of life in women with endometriosis: a
narrative overview. Minerva Ginecol. 2019;71(6):464-478.

Mathias SD, Kuppermann M, Liberman RF, et al. Chronic pelvic pain: prevalence, health-related
quality of life, and economic correlates. Obstet Gynecol. 1996;87(3):321-327.

Hartwell D, Jones K, Hinshaw K, et al. Sleep disturbances and fatigue in women with
endometriosis. Am J Obstet Gynecol. 2019;221(6):638.e1-638.e14.

Vitale SG, La Rosa VL, Rapisarda AMC, et al. Impact of endometriosis on quality of life and
psychological well-being. J Psychosom Obstet Gynaecol. 2017;38(4):317-319.

Giudice LC. Clinical practice. Endometriosis. N Engl J Med. 2010;362(25):2389-2398.

La Rosa VL, De Franciscis P, Barra F, et al. Sleep quality in women with endometriosis: a
systematic review and meta-analysis. J Clin Med. 2020;9(6):1834.

Panir K, Schjenken JE, Robertson SA, et al. Immune interactions in endometriosis. Expert Rev
Clin Immunol. 2019;15(6):649-662.

Koga K, Takamura M, Fujii T, et al. Dysfunction of innate immune system in the development of
endometriosis. Reprod Med Biol. 2018;17(1):49-55.

Agarwal SK, Chapron C, Giudice LC, et al. Clinical diagnosis of endometriosis: a call to action. Am
J Obstet Gynecol. 2019;220(4):354.e1-354.e12.


Understanding and Managing Endo Belly: A Comprehensive Guide

Endo belly is a term used to describe the painful abdominal bloating experienced by individuals with endometriosis. It is characterized by severe distension and discomfort, often resembling the appearance of pregnancy. This article aims to provide a comprehensive guide to understanding and managing endo belly, including its causes, symptoms, and treatment options. We will delve into the underlying mechanisms of endo belly, explore various management strategies, and discuss the importance of seeking medical advice for an accurate diagnosis and personalized treatment plan.

What is Endo Belly?

Endo belly refers to the extreme bloating and distension of the abdomen in individuals with endometriosis. Unlike mild and temporary bloating associated with the menstrual cycle, endo belly is more severe and can cause significant physical and emotional distress. It is often accompanied by pain, tenderness, and a feeling of fullness. Many individuals with endo belly describe their abdomen as looking pregnant, which can profoundly impact their self-image and overall quality of life.

The Causes of Endo Belly

The exact causes of endo belly are not fully understood, but there are several factors that contribute to its development. Endometriosis, a condition in which tissue similar to the lining of the uterus grows outside the uterus, plays a key role in the development of endo belly. The endometrial-like tissue can cause inflammation in the abdomen, leading to swelling, water retention, and bloating. Additionally, endometriosis can lead to the formation of ovarian cysts, which further contribute to abdominal distension. Gastrointestinal issues, such as constipation and gas, are also commonly associated with endometriosis and can contribute to the development of endo belly.

Symptoms of Endo Belly

The main symptom of endo belly is severe abdominal bloating, particularly during or before the menstrual period. The abdomen may feel tight, hard to the touch, and tender. Many individuals with endo belly report that their abdomen expands throughout the day, making it difficult to button their pants or wear fitted clothing. Other gastrointestinal symptoms, such as gas pain, nausea, constipation, and diarrhea, may accompany endo belly.

Diagnosis and When to Seek Medical Help

If you are experiencing severe and persistent abdominal distension or suspect that you may have endo belly, it is important to seek medical help for a proper diagnosis. Endo belly can mimic other health conditions, so consulting with a healthcare professional specializing in endometriosis or pelvic pain is crucial. The diagnostic process may involve:

  • A pelvic exam.
  • Imaging tests such as ultrasounds.
  • A thorough evaluation of your symptoms and medical history.

Early diagnosis and intervention can lead to more effective management and improved quality of life.

Managing Endo Belly: Strategies and Treatment Options

Various strategies and treatment options are available to manage endo belly and alleviate its symptoms. The choice of treatment depends on the severity of symptoms and individual needs. Here are some approaches that can help:

  • Pain Management

Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to manage pain and inflammation associated with endo belly. Over-the-counter NSAIDs, such as ibuprofen, can provide temporary relief. However, it is essential to consult with a healthcare professional before starting any medication.

  • Hormonal Therapy

Hormonal therapy is commonly used to manage endometriosis symptoms, including endo belly. Birth control pills, hormonal patches, and intrauterine devices (IUDs) can help regulate hormonal fluctuations and reduce the growth of endometriosis tissue. Gonadotropin-releasing hormone (GnRH) agonists or antagonists may also be prescribed to suppress the production of certain hormones and alleviate symptoms.

  • Dietary Changes

Making dietary changes can have a significant impact on managing endo belly. Avoiding trigger foods that can contribute to inflammation, such as caffeine, refined sugars, alcohol, and processed foods, may help reduce bloating and discomfort. Incorporating a diet rich in fruits, vegetables, lean proteins, and high-fiber options can promote gut health and reduce inflammation.

  • Heat Therapy

Applying heat to the abdomen can provide relief from pain and muscle tension associated with endo belly. A hot water bottle or heating pad can be used to soothe cramps and relax the abdominal muscles. Heat stimulates sensory receptors, blocking pain signals and providing instant pain relief.

  • Pelvic Floor Physiotherapy

Pelvic floor physiotherapy can be beneficial for individuals with endo belly. A pelvic floor physiotherapist can provide exercises and techniques to improve pelvic muscle strength and flexibility, alleviate pain, and promote proper alignment and breathing. Manual therapy techniques may also be used to release muscle tension and restore mobility.

  • Surgical Intervention

In severe cases of endometriosis, surgical intervention may be necessary to remove endometrial tissue and alleviate symptoms. Laparoscopic surgery is often the preferred approach, as it is minimally invasive and allows for precise removal of endometriotic lesions and scar tissue. However, surgery is not a cure for endometriosis, and a comprehensive treatment plan should include other management strategies to address symptoms and prevent recurrence.

Coping with Endo Belly: Self-Care and Emotional Support

Coping with endo belly involves not only managing physical symptoms but also addressing the emotional impact it can have on individuals. Here are some self-care strategies and emotional support options to consider:

  • Mindfulness and Meditation

Practicing mindfulness and meditation can help reduce stress and anxiety associated with endo belly. Deep breathing exercises and guided meditation can promote relaxation and provide a sense of calm.

  • Support Groups and Counseling

Joining a support group or seeking counseling can provide a safe space to share experiences, seek guidance, and receive emotional support from others who understand the challenges of living with endo belly. Professional counseling can also help individuals navigate the emotional aspects of their condition and develop coping mechanisms.

  • Body-Positive Practices

Embracing a body-positive mindset and practicing self-acceptance can help individuals with endo belly feel more confident and comfortable in their bodies. Wearing loose-fitting clothing, engaging in activities that promote body awareness and self-care, and reframing negative self-talk can contribute to a healthier body image.


Endo belly is a distressing symptom experienced by individuals with endometriosis. Understanding its causes, symptoms, and available management strategies is essential for effectively addressing this condition. Seeking medical help, implementing lifestyle changes, and exploring various treatment options can significantly improve the quality of life for individuals living with endo belly. Remember, each person’s experience with endo belly is unique, and finding a personalized approach to managing symptoms is key. With the right support, empowerment, and self-care, individuals with endo belly can navigate the challenges of this condition and live their lives to the fullest.

Additional Information: It is important to consult with a healthcare professional before implementing any treatment or management strategies mentioned in this article.


Finding an Endometriosis Specialist: Your Guide to Effective Treatment

Living with endometriosis can be an incredibly challenging experience. The chronic pelvic pain and other symptoms associated with this condition can profoundly impact a person’s daily life. If you suspect that you may have endometriosis, it is crucial to find an endometriosis specialist who can provide you with the proper diagnosis and treatment. This comprehensive guide will explore the significance of seeking a specialist, how to find the right doctor for you, and the key factors to consider during your search.

Understanding the Importance of an Endometriosis Specialist

Endometriosis is a complex condition requiring the expertise of a specialist with in-depth knowledge and experience in diagnosing and treating it effectively. While your family doctor or regular gynecologist may provide primary care, they may not possess the specialized skills required to manage endometriosis comprehensively. This is why seeking out an endometriosis specialist is essential. These specialists have a thorough understanding of the disease, including its symptoms, causes, and treatment options. They are equipped with the latest surgical techniques and have experience dealing with the complexities of endometriosis cases.

Read more: How are Endo Specialists Different than Typical Gynecologists?

Comprehensive Knowledge and Expertise

Endometriosis specialists possess a comprehensive understanding of the condition, including its underlying causes, symptoms, and potential complications. They stay updated with the latest research and advancements in the field, allowing them to offer the most current and effective treatment options. Their extensive knowledge ensures they can accurately diagnose endometriosis and develop personalized treatment plans tailored to each individual’s needs.

Surgical Skills and Techniques

Surgery is often a crucial component of endometriosis treatment, especially in cases where the condition has progressed or when conservative measures have proven ineffective. Endometriosis specialists are highly skilled in performing minimally invasive surgeries, such as laparoscopy, which allows for precise visualization and removal of endometriosis tissue. These specialists have mostly undergone additional training and certification in minimally invasive gynecologic surgery, ensuring they possess the necessary expertise to perform complex surgical procedures.

Read more: Red Flags About a Potential Endometriosis “Expert”

Complementary Approaches and Holistic Care

In addition to surgical interventions, endometriosis specialists also recognize the importance of a holistic approach to care. They understand that managing endometriosis involves more than just addressing physical symptoms. These specialists often work collaboratively with other healthcare professionals, including pelvic floor physical therapists, fertility specialists, counselors, pain specialists, massage therapists, and nutritionists. This multidisciplinary approach ensures that all aspects of a person’s well-being are addressed, promoting comprehensive and effective treatment.

Finding an Endometriosis Specialist

Now that we understand the significance of seeking out an endometriosis specialist, let’s explore some practical steps you can take to find the right doctor for you.

Find the best endometriosis specialists.

Step 1: Start with Your Current Healthcare Provider

Begin by discussing your symptoms and concerns with your primary care physician or gynecologist. They can provide valuable guidance, recommend specialists in your area, and facilitate the referral process. Your current healthcare provider may also have access to your medical history, which can help inform the specialist about your unique situation.

Step 2: Research and Referrals

Expand your search by conducting thorough research and seeking referrals from trusted sources. Online platforms like iCareBetter can be an excellent resource for finding vetted surgeons and endometriosis experts. Additionally, reach out to support groups or online communities dedicated to endometriosis. These communities often have members who can share their personal experiences and recommend healthcare providers in your area.

Step 3: Consider the Specialist’s Expertise

When evaluating potential endometriosis specialists, consider their areas of expertise and experience. Look for doctors who have a specific focus on endometriosis and have a track record of successfully treating this condition. Consider factors such as their surgical skills, knowledge of complementary approaches, and their willingness to listen and involve you in your healthcare decisions.

Step 4: Verify Certifications and Credentials

Ensure that the specialist you are considering has undergone additional training and maintains up-to-date knowledge in laparoscopic surgery.

Step 5: Establish a Connection

Building a strong doctor-patient relationship is crucial when managing a complex condition like endometriosis. During your initial consultation, pay attention to how the specialist communicates and interacts with you. Do they take the time to listen to your concerns? Do they explain complex medical terms in a way that you can understand? Trust your intuition and choose a specialist who makes you feel comfortable, heard, and supported.

Step 6: Check Insurance Coverage

Before finalizing your decision, ensure that your health insurance provider covers the specialist and any potential treatments or procedures they may recommend. Review your insurance policy or visit your provider’s website to determine the coverage options available to you. It is essential to understand the financial implications of your treatment plan to avoid any unexpected costs. Unfortunately, many top endometriosis specialists are out of network for your insurance, but you can still seek help from your insurance or other resources to have the funding to go through treatment.

Read more: What was your out-of-pocket cost for endometriosis surgery?

Taking Control of Your Endometriosis Journey

Finding an endometriosis specialist is a significant step towards taking control of your endometriosis journey. With their specialized knowledge, surgical expertise, and holistic approach to care, these specialists can provide the support and guidance you need to manage your condition effectively. Remember, seeking a second or third opinion is always an option if you feel uncertain or would like to explore different treatment approaches. Empower yourself with knowledge, trust your instincts, and never settle for anything less than the best care for your endometriosis.


Understanding Cervical Endometriosis: Symptoms, Diagnosis, and Treatment

In endometriosis, cells that are similar to endometrium grow outside of it. A place that can have endometriosis is the cervix of the uterus.

Cervical endometriosis is a condition that can cause several different symptoms. Symptoms include spotting, pelvic pain, irregular periods, and bleeding or pain during sex. These symptoms can be difficult to diagnose as they can also indicate other conditions, but if you experience any of these, it is important to discuss them with your doctor.

While cervical endometriosis is rare, research has shown that it can impact the quality of life of individuals who experience it. This highlights the need for more research and awareness about this condition.

Diagnosis and Treatment:

There are several ways that cervical endometriosis can be diagnosed, including pelvic exams, Pap smears, colposcopy, and biopsy. It is important to note that the diagnosis of cervical endometriosis can be difficult. Your doctor might also suggest additional tests, including imaging scans or laparoscopic surgery.

Treatment options for cervical endometriosis vary depending on the severity of symptoms and fertility goals. Hormonal therapy, such as birth control pills, can be an effective way to manage cervical endometriosis. Surgery may be recommended if hormonal therapy is not enough to manage symptoms or if there is a desire for pregnancy.

Cervical endometriosis is a rare but significant condition that can impact the quality of life for many women. Treatment options vary and depend on individual needs and goals. It is essential to talk with your doctor about any symptoms you may be experiencing or if you have any concerns. Research efforts and awareness of cervical endometriosis are crucial to help those who experience this condition. Hopefully, this blog post has shed light on this important topic.

More resources:

How to Get an Endometriosis Diagnosis

Find an Endometriosis Specialist for Diagnosis, Treatment, & Surgery

A Guide to Endometriosis Surgery and Its Success Rate


Living with Peritoneal Endometriosis: Symptoms, Causes, and Management

Endometriosis is a painful condition that affects millions of people worldwide. Endometriosis affects the peritoneum, the outer layer of tissue that lines the pelvic cavity. Peritoneal endometriosis can be a debilitating disease that can significantly affect a person’s quality of life, causing severe pain, inflammation, and infertility. This post will delve into the world of peritoneal endometriosis, discussing its symptoms, causes, and management options.

What is Peritoneal Endometriosis?

Peritoneal endometriosis involves the peritoneum, the membrane that lines the abdominal cavity. This tissue can form lesions and nodules, leading to inflammation, pain, and infertility. There are two types of peritoneal endometriosis: pigmented or non-pigmented and superficial or deeply infiltrating. Pigmented endometriosis is characterized by dark-colored lesions, which can be easier to spot visually during surgery. Superficial peritoneal endometriosis is found on the surface of the peritoneum, while deeply infiltrating peritoneal endometriosis penetrates the tissue beneath the surface of the peritoneum.

Prevalence and Impact

Peritoneal endometriosis is estimated to affect around 60-70% of individuals with endometriosis, making it the most common subtype of endometriosis. The symptoms of peritoneal endometriosis can significantly impact a person’s quality of life, leading to chronic pain, fatigue, and even depression. 


The exact cause of peritoneal endometriosis remains unknown, but several theories exist, including Coelomic metaplasia and retrograde menstruation.

Diagnosis and Treatment

Diagnosing peritoneal endometriosis can be challenging, as symptoms can be similar to other conditions, such as irritable bowel syndrome or pelvic inflammatory disease. Diagnosis often involves a medical history, physical examination, and imaging tests such as pelvic ultrasound. However, the most definitive way to diagnose peritoneal endometriosis is through laparoscopy, a surgical procedure allowing doctors to visualize the peritoneum directly and take biopsies if necessary.

The treatment of peritoneal endometriosis can depend on the severity of symptoms and a woman’s desire for fertility preservation. Treatment options include analgesics to relieve pain, hormonal therapy, and surgery to remove lesions or nodules. Hormonal treatment can consist of medications such as birth control pills or gonadotropin-releasing hormone agonists, which can be effective in reducing pain and inflammation. Surgery, meanwhile, can involve a laparoscopic procedure where the lesions or nodules are removed.

Peritoneal endometriosis can be a challenging condition to live with, affecting a woman’s physical, emotional, and social well-being. However, with the right diagnosis and management, women with peritoneal endometriosis can find relief and improve their quality of life. More research and awareness are needed to better understand this condition and develop effective treatments. If you suspect you may have peritoneal endometriosis, speak to your healthcare provider and seek appropriate medical attention. Remember, you are not alone, and there is help available.

More resources:

How to Get an Endometriosis Diagnosis

Managing Endometriosis: What You Need to Know 

Find an Endometriosis Specialist for Diagnosis, Treatment, & Surgery


Understanding and Coping with Endometriosis Ovulation Pain

Endometriosis can significantly impact daily life, particularly during ovulation. While ovulation pain is common for many women, endometriosis often produces heightened discomfort and crampy pelvic pain. The following unpacks the nature of this pain, its symptoms, and provides many effective coping strategies.

What Does Ovulation Pain Feel Like?

Ovulation pain, also known as “mittelschmerz”, typically manifests as a sharp or cramping sensation in the lower abdomen. For those with endometriosis, this pain can be more intense and prolonged. Understanding the nature of this pain helps in identifying and managing it effectively. The sensation may vary from mild twinges to severe cramping, often localized to one side of the pelvis, or the other, depending on which ovary is releasing an egg (Hudson, 2016).

Symptoms and Duration of Ovulation Pain: How Long Does it Last?

Cramping during ovulation can vary from mild to severe, often accompanied by other symptoms such as nausea, bloating, and fatigue. The duration of ovulation pain can range from a few minutes to several hours, and in some cases, it may last for one or two days. Identifying these symptoms early can aid in better pain management. Women with endometriosis may also experience simultaneous back pain, headaches, and gastrointestinal issues during this period (Kosia et al., 2021). Tracking the duration and intensity of the pain can provide valuable insights for medical consultations. Keeping a pain diary can help in understanding patterns and triggers, which is essential for effective management (Taylor, 1995).

Mittelschmerz Symptoms

Mittelschmerz, the German term for “middle pain,” refers to ovulation pain occurring midway through the menstrual cycle. Symptoms include localized abdominal pain, often on one side, and can be accompanied by light vaginal bleeding or discharge. Women with endometriosis may experience exaggerated mittelschmerz symptoms, requiring more intensive management. Symptoms may also include sharp, intermittent pain that can sometimes radiate to the thighs and lower back (Pearlin & Schooler, 1978).

Nausea During Ovulation

Nausea is a much less commonly discussed symptom of ovulation, but it can occur, especially in women with endometriosis. Hormonal fluctuations and pain can contribute to feelings of nausea, impacting daily activities. Anti-nausea medications and dietary adjustments may be beneficial in managing this symptom (Mitchell et al., 2011).

Coping Strategies for Endometriosis and Ovulation Pain

  1. Pain Management: Over-the-counter pain relievers can be effective. For severe pain, you may need stronger medications or hormonal treatments. Nonsteroidal anti-inflammatory drugs (NSAIDs), like ibuprofen, are often recommended for their efficacy in reducing inflammation and pain (Ostell, 1991).  However, the types of NSAIDs can also make a difference.  So review your NSAID pain options and select accordingly. 
  2. Heat Therapy: Applying a heating pad to the lower abdomen can help relax muscles and reduce pain. Heat therapy is a simple yet effective method to alleviate cramping and discomfort. Be careful not to burn skin by interposing something, like a towel, between the heat pad source and the skin.  
  3. Red Light Therapy: Red light therapy involves the use of low-level wavelengths of light to penetrate the skin and promote cellular function. This therapy can help reduce inflammation and pain associated with endometriosis and ovulation (Adamenko, 2020).
  4. TENS Units: Transcutaneous Electrical Nerve Stimulation (TENS) units deliver small electrical impulses to the affected area, helping to block pain signals and promote the release of endorphins, which are natural pain relievers. TENS units can be particularly useful for managing chronic pain conditions like endometriosis (Putri & Kushartati, 2015).
  5. Diet and Exercise: Maintaining a balanced diet and regular exercise routine can help manage symptoms. Foods rich in anti-inflammatory properties, such as leafy greens and fish, may alleviate pain. Regular physical activity can improve overall well-being and reduce the severity of symptoms (Kremer & Quednau, 2002).
  6. Stress Reduction: Techniques such as yoga, meditation, and deep-breathing exercises can help reduce stress, which in turn can lessen pain intensity. Mindfulness practices have shown promise in managing chronic pain and improving quality of life.
  7. Holistic and Integrative Approaches:
    • Herbals/Botanicals:
      • Turmeric: Known for its anti-inflammatory properties, turmeric can help reduce pain and inflammation.
      • Ginger: Another anti-inflammatory herb, ginger can help alleviate pain and nausea.
      • Vitex (Chaste Tree Berry): Often used for hormonal balance, it can help reduce symptoms of endometriosis (Kosia et al., 2021).
    • Aromatherapy:
      • Lavender: Known for its calming properties, lavender oil can help reduce stress and pain.
      • Peppermint: Can help alleviate nausea and headaches.
      • Clary Sage: May help balance hormones and reduce menstrual pain (Mitchell et al., 2011).
    • Acupuncture: This traditional Chinese medicine practice involves inserting thin needles into specific points on the body to relieve pain and promote healing. Acupuncture can help reduce the severity of ovulation pain and improve overall well-being (Davies, 1993).
  8. Medical & Surgical Interventions: To get an accurate diagnosis, get to the root cause and treat endo-associated ovulatory pain, minimally invasive surgical options may be considered to excise endometriosis tissue and provide relief, which is often rapid. Hormonal therapies, such as birth control pills, gonadotropin-releasing hormone (GnRH) agonists, and progestin therapy, can help manage symptoms by regulating or halting menstruation but an produce many symptoms as side effects, some of which can be long-lasting.  The most prudent course of action is to consult and be under the care of an endometriosis specialist. 

Updated Post: July 09, 2024


Everything You Need to Know About Umbilical Endometriosis

Endometriosis is a common yet often misunderstood condition that affects many people worldwide. While most people associate endometriosis with pelvic pain and menstrual issues, it can also manifest in unusual and unexpected parts of the body. One of those unusual locations is the umbilicus, or belly button, where endometrial cells can grow and cause a range of symptoms. In this blog post, we will delve into the world of umbilical endometriosis and explore its symptoms, causes, diagnosis, and treatment. Whether you have been recently diagnosed with umbilical endometriosis or are just curious about this condition, keep on reading to learn more.

Symptoms of Umbilical Endometriosis

Umbilical endometriosis can present differently in each person. However, there are some typical signs and symptoms that you should watch out for:

You may experience pain or discomfort in the belly button, which can range from mild to severe during or outside your period.

Your navel might appear swollen, red, or tender, especially if pressed.

You may notice bleeding or discharge from your belly button, which can be light or heavy and have a foul smell.

Some people with umbilical endometriosis might also have pelvic endometriosis and complain of painful sex, bowel movements, urination pain, infertility, or constipation.

Causes of Umbilical Endometriosis

The cause of umbilical endometriosis is not entirely clear and probably multifactorial. However, researchers have proposed a few mechanisms that might contribute to it. For instance, retrograde menstruation is when some menstrual blood flows backward instead of out of the body, which could transport endometrial cells to the umbilicus through the lymphatic or vascular system. Peritoneal metaplasia refers to the process of normal cells transforming into endometrial cells due to hormonal or environmental factors, which could occur near the umbilicus. Surgery-related umbilical endometriosis can result from accidental implantation of endometrial cells during laparoscopy or c-section.

Diagnosis and Treatment of Umbilical Endometriosis

If you suspect that you have umbilical endometriosis, the first step is to see a gynecologist who has experience with endometriosis. The doctor will likely examine your belly button, ask about your medical history and symptoms, and order some tests to confirm the diagnosis. These tests may include blood tests, imaging scans, like ultrasound or MRI, or a biopsy to remove a tissue sample for analysis. If the diagnosis is confirmed, you can discuss the best treatment options with your doctor. The treatment depends on the severity of your symptoms, age, desire for fertility, and overall health. The treatment may include pain relief medication, hormonal therapy, surgery, or a combination of these. Removing the endometrial tissue through surgery, like excision, is often the most effective and long-term solution for umbilical endometriosis.

Umbilical endometriosis is a rare yet significant manifestation of endometriosis that can cause discomfort, pain, and distress for affected patients. While the condition is not entirely understood, research has shed some light on possible causes and treatments. If you experience any of the symptoms we described earlier, do not ignore them or assume they are normal. Instead, seek medical advice from a specialist who can provide you with a proper diagnosis and treatment plan. Remember that you are not alone in this journey, and many people have successfully managed their umbilical endometriosis with the proper care and support.


What is the Best Doctor to See for Endometriosis? A Comprehensive Guide

Endometriosis is a painful condition where tissue similar to the lining of the womb grows in other places in the body, such as the ovaries and fallopian tubes. It affects millions of people worldwide and causes a range of symptoms, including pelvic pain, heavy periods, pain during sex, and infertility. If you suspect you may have endometriosis, it’s essential to see the right doctor to get an accurate diagnosis and effective treatment. But who is the best doctor to see for endometriosis? In this blog, we’ll explore the different types of doctors who can help manage endometriosis and discuss the pros and cons of each approach.

Diagnosing and treating endometriosis:

Diagnosing endometriosis can be challenging, as symptoms can vary widely from person to person and can mimic other conditions such as irritable bowel syndrome or pelvic inflammatory disease. The gold standard for diagnosing endometriosis is laparoscopy, a minimally invasive surgery. However, before this step, your doctor will perform a pelvic exam and may order an ultrasound scan or MRI to assess your condition.

The first doctor you’ll likely see for endometriosis is a gynecologist, a doctor who specializes in female reproductive health. Gynecologists with great experience treating endometriosis have expertise in diagnosing and treating endometriosis. They can offer a range of treatments, such as pain management techniques, hormone therapy, and surgery to remove endometrial tissue. They can also provide advice on fertility preservation options for women who want to conceive in the future.

While seeing a gynecologist is essential for managing endometriosis, more is needed. Some patients may benefit from seeing additional specialists or seeking alternative therapies. For example, a physical therapist can help with spasms and other pelvic dysfunctions. A pain specialist can help manage the chronic pain associated with endometriosis, while a gastroenterologist can evaluate and treat any gastrointestinal symptoms. A urologist can address endometriosis-related bladder and urinary tract issues, while a psychologist can offer support for mental health concerns like anxiety or depression. Some patients may also benefit from seeing an integrative medicine practitioner who can help manage symptoms through traditional medicine and complementary therapies like acupuncture, yoga, or meditation.

Find an Endometriosis Specialist for Diagnosis, Treatment, & Surgery

While seeing multiple doctors can be overwhelming, it’s important to remember that endometriosis is a complex condition that requires a multi-disciplinary approach. Each specialist brings unique skills and expertise to the table, and working collaboratively with your healthcare team can improve your outcomes and enhance your quality of life.

In conclusion, gynecologists with experience in endometriosis are the first doctors to see for endometriosis. However, the most effective approach for treating endometriosis is to work with a team of specialists who can provide comprehensive care and support. A gynecologist is an essential part of this team and can offer diagnosis, treatment, and management of endometriosis symptoms. However, seeing additional specialists or exploring complementary therapies may benefit some patients. As always, it’s important to advocate for yourself and seek the care you need to live your best life with endometriosis.


Understanding the Relationship between Sex and Endometriosis

Endometriosis is a painful condition that affects millions of women around the world. It occurs when tissue similar to the lining of the uterus grows outside of the uterus, causing inflammation, pain, and other symptoms. The pain can be so severe that it can affect women’s daily activities, including their sex lives. For many women, sex and endometriosis do not mix well. In fact, many women report that sex exacerbates their symptoms. In this blog post, we will explore the relationship between sex and endometriosis, explore some sex tips for managing endometriosis, and discuss the psychological and emotional effects of the condition.

How endometriosis can affect sex life

Endometriosis tissue can attach to the ovaries, fallopian tubes, or other pelvic organs and can cause pain, swelling, and sometimes infertility. It can cause pain during or after sex, painful periods, and chronic pain. This can make it challenging for women to enjoy their sexual partners or have comfortable sex. During sexual activity, endometriosis can cause pain, especially during deep penetration or certain positions. It can also cause pain during orgasms.

Read more: Endometriosis Pain after Orgasm: What You Need to Know

Pain during sex can be due to adhesions, scar tissue, or inflammation in the pelvic area. Endometriosis tissue can also grow in the vagina or cervix, making intercourse painful. In addition, vaginal dryness can exacerbate the problem, and many women taking hormone medicines for endometriosis may experience a decrease in libido, which can further affect their sex drives.

Ways to manage pain from endometriosis

If you are struggling with painful sex due to endometriosis, there are things you can do to manage your symptoms. Firstly, you should communicate with your partner about your symptoms and pain levels. This can help your partner know how to support you and modify sex positions to ease the pain. Additionally, you can try different positions to find the ones more comfortable for you. Lubricants and non-penetrating sexual acts might also be some strategies to think about.

Endometriosis can also affect women’s emotional and psychological health, leading to depression, anxiety, and other mental health issues. This can further affect women’s sex lives by reducing their interest in sex, increasing their fear or anxiety during sex, and making it difficult to enjoy intimacy. It is important to seek professional help if you are experiencing any mental health issues related to endometriosis. Counseling, therapy, or medication can help you manage your emotional and psychological symptoms, leading to a healthier sex life.

In addition to planning sexual activity, you can also manage pain from endometriosis by using pain-relieving medications or hormone therapy. Your doctor may also recommend surgery to remove endometriosis tissue or other affected organs. 

Sex and endometriosis may not always mix well, and many women may find it difficult to enjoy intimacy due to pain and other symptoms. However, with the right communication, management strategies, and emotional support, women with endometriosis can still have a satisfying sex life. It is important to communicate with your partner, try different positions, and seek professional help if the condition affects your emotional and psychological health. Remember, endometriosis does not define your worth or your ability to enjoy intimacy. With the right support, you can still have meaningful, fulfilling relationships and happy sex lives.

Read more:

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Endometriosis and Pelvic Pain Floor Dysfunction

Pelvic pain and abnormal pelvic floor muscle (PFM) tension are common among individuals with endometriosis and can persist even after surgical removal of endometriosis lesions. Since endometriosis is a hormonally dependent, inflammatory disease that affects several physiological systems, multiple factors could contribute to chronic pelvic pain (CPP). 

Pain management methods that target myofascial pain are becoming more popular among practitioners since myofascial sources could continue to cause CPP even after surgical and hormonal treatment. Pelvic pain can also result from musculoskeletal disorders that may go unnoticed during a traditional pelvic exam. Screening the inferolateral pelvic floor musculature during a routine pelvic exam is useful for identifying spasms and trigger points contributing to, or resulting from, a patient’s pelvic pain. 

Nonrelaxing pelvic floor dysfunction may present with nonspecific symptoms such as pain, and problems with defecation, urination, and sexual function, which can adversely affect the quality of life. Proper evaluation can facilitate the diagnosis of spasms or trigger points, and physical therapy often significantly improves the quality of life in these cases.

Pelvic pain in women with different stages of endometriosis can be strongly associated with bladder/pelvic floor tenderness and painful bladder syndrome, independent of endometriosis-related factors. This suggests the involvement of myofascial or sensitization pain mechanisms for some patients suffering from deep dyspareunia. Pelvic floor physical therapy (PT) has proved to be helpful in women with myofascial or pelvic floor pain. This type of PT aims to release tightness in muscles by manually “releasing” it; treatment is directed at the abdomen, vagina, hips, thighs, and lower back muscles. This requires a specially trained physical therapist.

It is imperative for women to recognize and treat pelvic pain with physical therapy and other interventions to alleviate pain and improve their quality of life.



Sciatic Nerve Endometriosis: Uncommon or Not?

Sciatic nerve endometriosis is widely considered a rare occurrence, but leg pain in patients with endo is relatively common, up to 50%.  Why?  Is it being underdiagnosed?  Since endometriosis itself is often misdiagnosed or diagnosed years after initial symptoms, the true incidence of direct and indirect sciatic nerve symptoms caused by endo is also suspect. 

The sciatic nerve is located very deep within the pelvis but not inside the intraperitoneal area where the uterus is situated. Instead, the sciatic nerve is found in the “retroperitoneum,” the deep anatomic region behind the peritoneum, containing bones, muscles, and major nerves. It exits the pelvis right behind the Piriformis muscle, which is part of the pelvic floor. 

Endometriosis mainly involves intraperitoneal pelvic structures and organs such as the bladder, cul-de-sac, large and small bowel sections, uterus, ovaries, and Fallopian tubes.  In advanced cases, it can extend into the midline retroperitoneum by involving the recto-vaginal septum.  However, endometriosis has been identified in atypical and distant locations by unclear means of spread, and a certain percentage is deeply infiltrating.  In the latter case, the retroperitoneum, sciatic nerve, and pelvic floor muscles are anatomically very close and vulnerable to direct deep infiltration or indirect spread (e.g., lymphatic system).   The precise prevalence of endometriosis that grows outside the pelvic intraperitoneal cavity by location, including the sciatic nerve area, remains to be discovered due to the limited number of published studies on the subject. 


Lower back, leg, and buttock pain, which may or may not extend down your leg, may indicate the presence of direct sciatic endometriosis or indirect inflammation-related pressure on the nerve. The symptoms may be the same or very similar since the endometriosis is either directly growing and pressing on or involving the sciatic nerve or leading to pelvic floor inflammation and scarring, which also affect the sciatic (and other nerves) and trigger pain signals.  The latter is typically called Piriformis syndrome.  

Sciatic endometriosis may or may not be uncommon. Still, it must always be included in the “differential diagnosis” (identifying root causes of symptoms) of pain and signs in the region or area where sciatic nerve sensation fibers are known to extend. 

Testing and Diagnosis:

Lab tests are generally not helpful in diagnosing sciatic endometriosis. A CA-125 level (an ovarian cancer tumor marker) or hsCRP (generalized inflammatory marker) can be elevated in endometriosis due to inflammation but are not specific for endometriosis, let alone sciatic nerve involvement. 

Arguably the best imaging study for possible endo-related extraspinal sciatica is the MRI.  It may reveal whether an endo lesion is directly growing in or around the nerve, most frequently at the sciatic notch, or compressing it, such as inflammation causing Piriformis syndrome. However, unless endometriosis has already been confirmed from prior surgery, these scans will only sometimes help diagnose endo or endometriosis-related sciatica. But the running message is this.  Given the diagnostic uncertainty of endometriosis, extra pelvic symptoms should never be dismissed as unrelated when an endo diagnosis is being considered.

Symptoms and Findings:

Pain may or may not be cyclical, similar to rectal pain caused by endometriosis. It may start before menstruation and persist for several days after a period has ended. The pain may be accompanied by motor deficits (weakness or gait/walking issues), foot drop, and discomfort or tingling radiating down the back of the leg from the buttock. Walking, especially long distances, may exacerbate these symptoms. Deep buttock tenderness may also be present, specifically in the area of the sciatic notch where the sciatic nerve passes. If left untreated, sciatic endometriosis may lead to long-term nerve damage, as any prolonged direct pressure or inflammation around a major nerve can cause this.

A doctor or pelvic floor therapist may identify “deficits” (abnormalities) in the sciatic nerve distribution during a physical examination. For example, Lasègue’s test, which is a straight leg raise test when lying on your back, may point to sciatic involvement by endo.  Localized deep tenderness over the sciatic notch might also be present, although it can be difficult to reproduce. On the other hand, a regular pelvic exam may be normal, depending on the extent of endometriosis in the pelvis.  

Treatment of Sciatic Endometriosis:

The treatment of sciatic endometriosis will most likely begin with surgery. In fact, it may be the only definitive treatment. But this is not always the case.  Endometriosis excision of an endometriosis lesion in this area is the gold standard, just as in other areas.  But if direct sciatic involvement by endo is suspected, choosing the right surgeons is especially crucial. The sciatic nerve is located so deep within the pelvis that a general gynecologist most likely has never encountered it during surgery. Endo-excision surgeons do not typically operate in this retroperitoneal area either. Gynecologic oncologists, who often work on lymph nodes or remove cancer in the region, are more likely to be familiar with the anatomy. However, if the nerve is more likely to be directly affected by endo based on imaging, a neurosurgeon should also be part of the team. Therefore, a gynecologic oncologist and/or an endo excision surgeon very experienced in advanced endo and a neurosurgeon are likely the best options for this aspect of endometriosis excision surgery.

Given that some percentage of endo-related sciatica may be due to pelvic floor inflammation and dysfunction, as opposed to direct endo growth on or near the nerve, pelvic floor physical therapy is worth trying first.  If it is effective and if imaging does not show evidence of deep infiltrating endo that might be directly involving the sciatic nerve, then radical and more risky retroperitoneal surgery to get to that area may be safely deferred.  

In cases where direct involvement is suspected and surgery is not immediately feasible, a short-term medical treatment regimen with anti-inflammatory and possibly anti-estrogenic properties may be beneficial. Adopting an anti-inflammatory diet may also help. Pelvic floor physical therapy and medical support therapy, including vaginal Valium, may offer additional temporary benefits. The bottom line is that treatment for pain along sciatic nerve distribution should be tailored to each individual’s needs and integrated into a comprehensive, personalized medical-surgical treatment plan.  

The first confirmed case of sciatic endometriosis was reported in 1946 by Schlicke. The primary takeaway from this fact is that sciatic endometriosis has been a known entity for over half a century.  Since then, other cases have been documented in medical journals.  However, overall, it is still considered a rare condition. But given the percentage of endo patients who report leg pain, this may not be so, especially when endo-induced Piriformis syndrome is added to the mix.  If endometriosis has already been diagnosed or strongly suspected and sciatic nerve distribution pain is part of the symptoms, a consultation with an expert who focuses on advanced endometriosis patients may save you a lot of grief.   


Yanchun, L., Yunhe, Z., Meng, X., Shuqin, C., Qingtang, Z., & Shuzhong, Y. (2018). Removal of an endometrioma passing through the left greater sciatic foramen using a concomitant laparoscopic and transgluteal approach: case report. BMC Women’s Health, 19(1), 95.

Missmer SA, Bove GM. A pilot study of the prevalence of leg pain among women with endometriosis. J Bodyw Mov Ther. 2011; 15:304–308.

Osório, F., Alves, J., Pereira, J., Magro, M., Barata, S., Guerra, A., & Setúbal, A. (2019). Obturator internus muscle endometriosis with nerve involvement: a rare clinical presentation. Journal of Minimally Invasive Gynecology, 25(2), 330-333.

Possover, M.  Laparoscopic morphological aspects and tentative explanation of the aetiopathogenesis of isolated endometriosis of the sciatic nerve: a review based on 267 patients   Facts Views Vis Obgyn. 2021 Dec; 13(4): 369–375.

S. Chen, W. Xie, J. A. Strong, J. Jiang, and J.-M. Zhang. Sciatic endometriosis induces mechanical hypersensitivity, segmental nerve damage, and robust local inflammation in rats. Eur J Pain. 2016 Aug; 20(7): 1044–1057.

Lemos, N., D’Amico, N., Marques, R., Kamergorodsky, G., Schor, E., & Girão, M. J. (2016). Recognition and treatment of endometriosis involving the sacral nerve roots. International Urogynecology Journal, 27(1), 147-150.

Vilos, G.A., Vilos, A. W., & Haebe, J. J. (2002). Laparoscopic findings, management, histopathology, and outcomes in 25 women with cyclic leg pain. The Journal of the American Association of Gynecologic Laparoscopists, 9(2), 145-151.

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Spotting the Signs of Endometriosis Returning

Endometriosis is a painful and challenging condition. While there is no cure for this condition, treatments are available to manage the symptoms, making it easier for patients to lead healthy lives. However, endometriosis can recur, and it is crucial to identify the signs and symptoms to avoid complications. In this post, we will discuss the symptoms of endometriosis recurrence and how to spot them early enough so you can seek medical attention.

Painful Periods

One of the signs of endometriosis returning is pain during your period. This pain can range from minor discomfort to excruciating cramps that require you to take painkillers. If you notice that your periods are more painful than usual or that the pain increases over time, it may be a sign that your endometriosis is returning. Keep a record of your symptoms, including any changes in frequency, intensity, and duration of your period, so you can discuss them with your doctor.

Pelvic Pain

Another sign of endometriosis recurrence is persistent pelvic pain or discomfort. This pain can be mild, moderate, or severe and may come and go, depending on hormonal fluctuations. Some patients may also experience pain during sex or ovulation. If you notice persistent pelvic pain, scheduling an appointment with your doctor to discuss your treatment options is essential.


Endometriosis can cause fatigue due to the pain and stress that comes with the condition. If you notice that you are more exhausted than usual, despite enough rest, it could be a sign that your endometriosis is returning. Speak with your doctor and seek support from a therapist or counselor to manage the mental impact of endometriosis.

Gastrointestinal Symptoms

Endometriosis can affect the digestive system, causing symptoms such as bloating, constipation, or diarrhea. These symptoms may worsen during or after your period, and they may not improve with changes to your diet or bowel habits. If you notice gastrointestinal symptoms, mentioning them to your doctor is essential, as they may be a sign of endometriosis recurrence.

Other Symptoms for Endometriosis Recurrence

Endometriosis presents itself in many ways. We mentioned some of it here, but there are undoubtedly many other symptoms that can help diagnose the recurrence of endometriosis. You should keep track of your well-being and mention any unusual symptoms or abnormalities to your doctor.

Endometriosis can cause severe pain and discomfort and impact your quality of life. While timely diagnosis and treatment can help manage the symptoms and prevent complications, there are risks of recurrence after surgery. The signs of recurrence are pelvic pain, period pain, fatigue, gastrointestinal symptoms, and other symptoms. If you notice any signs of endometriosis returning, speak with your doctor.

Please share the signs of endometriosis returning that you had experienced.


Managing Stress with Endometriosis: A Guide for Patients

Endometriosis is a chronic condition that affects approximately 10% of women between 15-50 and other genders. This condition is characterized by the growth of tissue similar to endometrium outside of the uterus, leading to painful menstrual cramps, heavy bleeding, and infertility. Living with endometriosis can be extremely challenging due to its physical and emotional toll on an individual. Stress can exacerbate symptoms of endometriosis and make coping with the condition even more difficult. In this blog post, we will discuss the effects of stress on endometriosis and provide some tips on managing stress for individuals with this condition.

Stress is a common issue that affects patients with endometriosis. When you experience stress, your body releases the hormone cortisol, which can trigger inflammation and potentially exacerbate endometriosis symptoms. Stress also affects our immune system, making fighting diseases and infections harder for our bodies. To help manage stress, it’s essential to develop healthy coping mechanisms. Some practical techniques include meditation, yoga, deep breathing, or guided imagery.

Exercise is another effective way to manage stress and improve endometriosis symptoms. Physical activity has been shown to release endorphins, which are natural painkillers, and reduce inflammation. However, it’s essential to be cautious when exercising if you have endometriosis. High-impact activities like running or jumping can trigger pain and discomfort. Instead, try low-impact exercises like swimming, walking, or cycling.

It’s also essential to pay attention to what you eat when managing endometriosis and stress. A diet rich in anti-inflammatory foods can help reduce inflammation and improve endometriosis symptoms. Include foods like leafy greens, berries, fatty fish, and nuts in your diet to provide your body with the necessary nutrients. Avoid caffeine, sugar, and processed foods that can exacerbate inflammation and trigger hormonal imbalances.

Getting enough sleep is also essential for managing stress and endometriosis. Lack of sleep can lead to fatigue, mood swings, and anxiety. Try to establish a regular sleep schedule and avoid using electronic devices before bed, as they can disrupt your sleep pattern. Creating a relaxing bedtime routine, like taking a warm bath or reading a book in bed, can help promote a peaceful sleep environment and reduce stress.

Finally, seeking support from others can help alleviate stress and improve endometriosis symptoms. Talking to a therapist can provide you with tools to manage stress and emotional challenges. Joining a support group or online community can also help you connect with other people who experience similar challenges and find comfort in sharing experiences.

Living with endometriosis can be challenging, but managing stress can help alleviate symptoms and improve the overall quality of life. Incorporating healthy habits like exercise, a nutritious diet, and stress-reducing activities into your everyday routine can reduce anxiety and inflammation and promote physical and emotional wellness. Remember that you are not alone in this journey, and seeking support from others can help alleviate stress and provide you with the necessary tools to manage endometriosis.

Read more: Managing Endometriosis


Understanding Thoracic Endometriosis

As a patient, you may already know that endometriosis is not just a painful condition of the uterus. It is an abnormal tissue growth similar to the endometrium that can occur in other body parts. One such place is the thoracic cavity, the space in your chest containing your heart, lungs, and other vital organs. Endometriosis in the thoracic cavity is called thoracic endometriosis.

Thoracic endometriosis is not a common condition, but it can be serious. It can cause chest pain and shortness of breath and, in severe cases, can lead to lung collapse. If you have been experiencing unexplained chest pain or breathing difficulties, this may be caused by thoracic endometriosis. In this blog, we will explain what thoracic endometriosis is, what causes it, and how it can be treated.

What is thoracic endometriosis?

As mentioned earlier, thoracic endometriosis is when endometriosis tissue grows in the thoracic cavity. This tissue can grow on your lungs, diaphragm, chest wall, or any other part of your thoracic cavity. In severe cases, it can even cause the lung to collapse.

Thoracic endometriosis can cause a range of symptoms, which include:

  • Chest pain
  • Shortness of breath
  • Dry cough
  • Fatigue

What causes thoracic endometriosis?

The exact cause of thoracic endometriosis is still unknown. However, there are several theories that suggest it may be caused by:

  • The coelomic metaplasia theory suggests that endometriosis cells can develop from germ cells in the thoracic cavity.
  • The lymphovascular spread theory suggests that the endometrial cells can latch onto lymph nodes or vessels, which then transport them to the thoracic cavity.
  • The retrograde menstruation theory refers to the backward flow of menstrual blood through the fallopian tubes and into the pelvic cavity. But it can not explain how the cells reach the thoracic space from the pelvic cavity.

How can thoracic endometriosis be treated?

The treatment of thoracic endometriosis will depend on the severity of your condition, your symptoms, and other factors such as age and desire for future fertility.

Here are some common treatments for thoracic endometriosis:

  • Palliative therapy: 

Pain medication: Over-the-counter pain medication such as ibuprofen or naproxen can help relieve mild to moderate pain.

Hormonal therapy: Hormone therapy can help reduce the amount of estrogen in your body, slowing down the growth of endometrial tissue. Hormone therapy can include birth control pills, gonadotropin-releasing hormone (GnRH) agonists, progestins, or danazol.

  • Removing the lesions with excision surgery

Surgery may be necessary if your thoracic endometriosis is severe or causing significant symptoms. Surgery can help remove the endometriosis tissue, repair any damage it may have caused, and restore normal lung function.

Thoracic endometriosis is a rare but serious condition that can cause chest pain, shortness of breath, and other symptoms. If you are experiencing any of these symptoms, seeking medical attention right away is important. Although the exact cause of thoracic endometriosis is still unknown, various treatment options are available to help manage your symptoms and improve your quality of life. Remember to speak to your doctor about any concerns about thoracic endometriosis.

Managing Endometriosis: What You Need to Know 

The Different Tests Used to Diagnose Endometriosis 


Breaking the Cycle: Understanding Endometrioma Recurrence After Surgery

Endometriomas, commonly known as ovarian “chocolate cysts,” occur in 20 to 40% of endometriosis patients. Abnormal implantation and growth of endometrial-like tissue can cause these cysts to form on the ovaries, which can cause more pain, discomfort, and fertility issues. With each cycle, the cyst bleeds into itself, just like what occurs typically inside the uterus.  Except that uterine endometrial tissue is expelled during menses vaginally, whereas endometriotic blood is trapped inside the ovarian cyst and with each cycle, the cyst slowly gets larger.  So, this blood also becomes old and turns brown over the years, resembling chocolate.  While surgery can be an effective treatment for endometriomas, the recurrence of these cysts after surgery is a common problem. We will explore why this occurs and what can be done to reduce the risk of recurrence. 

Several factors contribute to the recurrence of endometriomas after surgery. One of the main factors is the nature of the condition itself. The presence of endometriomas may signal more aggressive endo disease, and this chronic and progressive inflammatory disease on the ovary can continue to grow. Endometriosis tissue might be left behind after surgery because it can be buried deep in the ovary and even be microscopic.  So, the nature of the disease is to grow back in various parts of the ovary, superficial and deep. 

Surgically removing an ovary will certainly prevent endo from growing back in that area and that was the standard approach for many decades. However, in recent years, there has been a shift towards more conservative surgical techniques for treating endometriomas. These techniques aim to remove as much of the endometriosis tissue as possible while preserving as much of the ovary as possible. This is called a cystectomy and is often used for the removal of other ovarian cysts such as dermoids (teratomas) or cystadenomas (benign ovarian tumors).  The problem is that, unlike these other cysts, endometriomas are more inflammatory and the edges are irregular, so they do not easily separate from ovarian tissue.  So, microscopically incomplete removal is common even if it appears that the entire cyst was removed.  

Another surgical factor contributing to recurrence is rupture of the endometriotic cyst during the surgical removal. Rupture can release not only old blood but also endometriosis cells and tissue into the pelvis.  It’s crucial to repeat that it is not just old blood that is spilled.  This can lead to a higher risk of recurrence of endo on the ovary and elsewhere because these spilled cells can create new implants.

Here is an important side note. Although rare, endo can degenerate into a type of cancer or increase the risk of ovarian cancer.  The older you are and the more there is a concerning family history, the more an atypical looking endometrioma may be more than that.  If an early cancer is ruptured, the treatment can be more difficult.  How rare? It is on the order of 1% or less increased risk.  But given that there are millions of women with endo, even a fraction of 1% means thousands at risk.  If you are at higher risk due to age, genetics, or family history, especially if the imaging shows the endometrioma is not typical, getting a consult with a gynecologic oncologist may be prudent. 

A study published in the Journal of Minimally Invasive Gynecology found that the recurrence rate for endometriomas was significantly higher in cases where the cyst had ruptured during surgery than cases where the cyst was removed intact. The study found that the recurrence rate for ruptured cysts was 50%, compared to a recurrence rate of 8% for intact cyst removal.   

Having said all the above, while it seems like removing the endometrioma intact is a no-brainer strategy, this is far easier said than done.  As we mentioned before, these cysts do not readily separate from the ovary, can be stuck to surrounding structures like the uterus or bowel, and can be very thin walled.  So, even in a skilled surgeon’s hands, this often leads to inadvertent rupture.  But read on.  There are still things an expert surgeon can do to minimize this risk of rupture and spill inside the pelvis. So, spoiler alert #1 is to make sure you are under the care of an expert endometriosis surgeon.  But there is more to it, much more. 

Non-Surgical Recurrence Factors

Endometriomas are largely estrogen-dependent, meaning that they grow and spread in response to the hormone estrogen.  So, suppose at least one of the ovaries is left behind. In that case, the estrogen can stimulate growth of any endometriosis tissue left behind on the ovary or anywhere else that any endo implants may be hiding.  

To address this main hormonal non-surgical risk factor, there are several proactive steps that women can take to reduce endo recurrence. One of the most important steps is maintaining a healthy lifestyle, reducing total estrogen. This includes eating a healthy diet, getting regular exercise, reducing stress, using probiotics to metabolize excess estrogen, and avoiding exposure to toxins that can act as xenoestrogens. These steps can help to balance estrogen and progesterone in the body and reduce the risk of endometriosis growth and recurrence.

In many cases, pharmaceutical hormone therapy may be recommended to reduce the risk of recurrence. However, hormone therapy is not suitable for everyone and may have serious side effects.  Work with an endo specialist on this. 

There is much more to the non-surgical risk for recurrence and other proactive steps can be taken.  I

Surgical Innuendoes

Laparoscopy has been a standard for endometriosis surgery for over 40 years.  It was invented almost a hundred years ago, but video cameras achieved acceptable quality only during the latter part of the 20th century.  While this is still the standard bearer for most endo surgery, the more complex the surgery the more one can strongly argue that a 2-dimensional camera (no depth perception) and instruments that are like inflexible chopsticks with graspers and scissors at the end are just too clunky and plain inadequate for finesse meticulous surgery.    

Robotic surgery is a newer surgical tool and technique that has become increasingly popular over the past decade, with very good reasons.  It is minimally invasive, just like laparoscopy and the incisions are just as hidden in expert surgeons’ hands.  However, this technique involves the use of several robotic arms that are controlled by a surgeon to perform minimally invasive surgery.  This is where the magic happens. The robotic arms are equipped with exchangeable tiny instruments that wrist or flex like human hands and a magnified 3-D camera, which allows incredibly precise visualization and depth perception.  Also, even the slightest tremor in a surgeon’s hand is not transmitted to the instrument like it is in regular laparoscopy.  In fact, with traditional laparoscopy, any tremor or inadvertent motion of the surgeon’s hand is amplified at the instrument tip.   So robotic surgery translates into less trauma to the body, more accurate dissection, and less blood loss, all of which may mean faster recovery.   For simple cases, there may not be much of a difference.  But, unfortunately, it is not possible to predict what might be found in the pelvis until the surgery actually starts.  So, having the robotic equipment available and an expert surgeon in its use is quite helpful to cover all options.      

One of the key advantages of robotic surgery for treating endometriomas is that, in expert hands, it may allow for more complete removal of lesions, especially endometriomas. This is simply because the robotic camera and equipment are more precise and technologically far superior to laparoscopic equipment. Of course, at the end of the day, in most cases, the level of expertise of the surgeon trumps equipment.  But in any given complex and anatomically distorted surgical situation an uber expert in robotics will likely fare better than an uber expert in laparoscopy.   

In advanced endo, endometriomas are often stuck to each other in the middle (“kissing ovaries”), pulling the rectum up into an inflammatory mess.  Deeper they are also stuck to the uterosacral ligaments supporting the uterus, which also pulls the ureters dangerously close to harm’s way (a few millimeters at most).  Removing these endometriomas intact and avoiding damage to the rectum or ureters requires both an uber good surgeon and the very best technology, which is embodied in robotics.  Suppose the surgeon is good at retroperitoneal surgery (deep tissues behind the peritoneum where the ureters are). In that case, it is possible to mobilize the whole ovary or ovaries up out of the pelvis without rupture.  Then, even if it appears that removing endometriomas might result in rupture (extreme inflammation), a special containment bag can be placed underneath to catch the fluid and endometriosis cells in the event of a rupture.  Finally, if all else fails, a very controlled evacuation of an endometrioma using specialized suction equipment is better than overt rupture.  Unfortunately, most surgeons, even some advanced surgeons, are incapable of or do not routinely employ these steps.  The result is higher risk of recurrence if there is uncontrolled spill. 

In conclusion, the rupture of endometriomas during surgical removal can significantly increase the risk of recurrence. Careful and precise surgical techniques, such as those used in robotic surgery, may help to reduce the risk of cyst rupture and subsequent recurrence. However, other factors, such as hormonal imbalances, the presence of endometrial implants, and lifestyle and environmental factors, should also be considered when developing a treatment plan. 

Get in touch with Dr. Steve Vasilev


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What You Need to Know About Endometriosis and Intimacy

Endometriosis is a common health condition that affects millions of women of reproductive age. This condition can cause extreme pain, cramping, and fatigue and affect a woman’s intimate relationships. Women diagnosed with endometriosis need to understand its effects on their intimate life and how to manage these symptoms.

The Effects of Endometriosis on Intimacy

Endometriosis can have a negative impact on physical intimacy in many ways. The pain associated with the condition can make it difficult for some women to be comfortable enough for sex at any time. And the accompanying fatigue can leave them feeling too tired for sex. In addition, endometriosis often causes pelvic inflammation, which can make penetration painful or even impossible. The emotional toll of endometriosis can also take its toll; depression and anxiety may arise due to physical pain or fear that sex will be painful.

Managing Endometriosis-Related Intimacy Issues

The good news is that there are ways to manage endometriosis-related intimacy issues. One way is to talk openly with your partner about your symptoms so they understand what you’re going through. Explaining exactly how endometriosis affects you and what challenges you face regarding physical intimacy is key to ensuring your partner fully understands the situation. It’s also important to practice self-care; this could mean anything from getting plenty of restful sleep each night or taking time out of your day for relaxation activities such as yoga or meditation. Additionally, talking with your doctor about treatments available for managing your symptoms may be beneficial in managing any pain or inflammation related to endometriosis during intercourse.

Living with endometriosis does not have to mean living without physical intimacy—it just means finding new ways of managing its effects on your relationships. Talking openly with your partner about how it affects you, practicing self-care, and talking with your doctor about treatments available are all great ways of managing the symptoms associated with endometriosis and fostering healthy intimacy in relationships while living with this condition.


All You Need to Know About Endometriosis Lesions

Endometriosis is when tissue similar to the endometrium grows outside of it. This disorder can cause pain, infertility, and other issues. In this blog post, we’ll explore what endometriosis lesions are, how we diagnose them, and what treatments are available.

What Are Endometriosis Lesions?

Endometriosis lesions are small areas of tissue that form when endometrial-like cells grow outside the uterus. These lesions can develop anywhere in the body but are most common in the pelvic area. They usually range from 1 cm to 5 cm in size and can appear in different colors, such as red, white, or blue spots.

How Are Endometriosis Lesions Diagnosed?

You should see your doctor if you have any symptoms associated with endometriosis—such as chronic pelvic pain or heavy menstrual bleeding. Your doctor will likely perform an ultrasound or MRI scan to look for any signs of endometriosis lesions. If these tests reveal an area with an endometriosis lesion, they may also recommend a laparoscopy to get a better look at it. During the laparoscopy, your doctor will make a small incision in your abdomen and then insert a thin tube with a lighted camera attached to it so they can take pictures of any lesions inside your body.

What Treatments Are Available for Endometriosis Lesions?

Once you’ve been diagnosed with endometriosis lesions, your doctor will likely recommend one or more treatments depending on your symptoms’ severity. Treatments can include pain management, hormonal manipulation, lifestyle changes, and diet programs. However, the ultimate therapy for removing the disease is surgery. This surgery is often done through laparoscopic surgery and can help reduce symptoms significantly if successful.

Endometriosis lesions are relatively common and often cause pain, discomfort, and other issues for those who suffer from them. Fortunately, many treatment options are available for those diagnosed with this condition, ranging from over-the-counter medications to hormone therapy and even surgery if necessary. Suppose you have endometriosis lesions or any other symptoms associated with this condition. In that case, it’s important to speak with your doctor so they can provide you with an accurate diagnosis and appropriate treatment plan as soon as possible.

The Different Tests Used to Diagnose Endometriosis 

How to Get an Endometriosis Diagnosis


The Endometriosis Roller Coaster: Understanding Recurrence and How to Prevent It

The Endometriosis Roller Coaster: Understanding Recurrence and How to Prevent It

Surgery is a cornerstone for initial diagnosis of endometriosis and is an effective treatment option. But, it is not a guaranteed cure, because endometriosis can recur after surgery.  What? Why? 

The reasons for endo recurrence are complex and multifactorial and involve a combination of factors.  These include incomplete removal of the endometriosis tissue, hormonal imbalances, immune influences, toxin influences, molecular influences and probably even more we still do not fully understand. So, while thorough and meticulous initial excision is key, a poor excision is not the only reason for recurrence and progression.  Let’s look at these factors in more detail, and, more importantly, explore what you might be able to proactively do to help reduce the recurrence risk.   

Incomplete Excision:

Incomplete removal of endometriosis lesions is probably the most common cause of recurrence after surgery.  Endo can be difficult to remove completely, especially if it has grown deep into the pelvic tissues and organs, and if an affected uterus and/or ovaries are being preserved. Of course, expert surgeons are trained to optimize excision and minimize recurrence.  But in some cases, the remaining lesions can be obscured by inflammation or microscopic and not visible to the surgeon, making it difficult or impossible to remove no matter what level skillset the surgeon has.  If even a small amount of endometriosis is left behind after surgery, it can and probably will grow back over time.  The more that is left behind, potentially the faster it may grow back.  However, this is not a linear growth relationship because of the factors we explore below.  Some lesions simply grow slower than others for various reasons, and some might not grow at all to a symptom-producing level.   

So, what can be done to improve the chances of initially optimal surgery?  We’ll explore the pros and cons of available tools below.  But first, what about the surgeon?  Depending on your situation and resources available to you, some combination of advanced surgeons will be key to your treatment in most cases. The details about your options are as follows.   

Published research generally favors excision (removal) over fulguration (burning) of endometriosis implants, especially in deep infiltrating endo and for endometriomas. While there is some debate over this, fulguration near delicate structures like the ureters or bowel can be very unsafe and fulguration generally causes more scarring or fibrosis.  Fibrosis itself may increase pain as your body heals, even if all the endo itself was destroyed.  

So, the first step is to make sure that your potential surgeon is trained and capable of excision surgery and not just fulguration.  There are a number of pathways to this.  General gynecologists that are trained to perform thorough excisions are very far and few between.  So the trail leads to gynecologists that have had additional training in excision and minimally invasive surgery.  Who are they?  

Most advanced endo excision surgeons have trained in a one to three year minimally invasive surgery or “MIGS” fellowship. These are not regulated or accredited by any boards but are usually sponsored by the AAGL (American Association of Gynecologic Laparoscopists). This means the training is usually quite good, but not all mentors are created equal and there is no board required standardization.  Hence, some surgeons graduate being far better at excision than others.  So, you should still do your due diligence about the surgeon you select, based on as much information as possible, including their background, their results, what patients say, and so on.  

The other consideration is that this MIGS training, at least in the United States, may not include bowel and urologic surgery and usually does not provide  the credentials to obtain hospital privileges in these procedures.  So, an excision surgeon will often work with general surgeons, urologists and others as a team to cover the bowel and urinary tract aspects of surgery.  This can be very effective, but in some centers, logistic coordination of multiple surgeons works better than in others.   Unless this coordination is well worked out, it might be better to seek someone that is trained to do all or most excision without requiring a large team of supporting surgeons.

The other main way that gynecologic surgeons get advanced complex surgical training is through a three to four year gynecologic oncology fellowship accredited by the American Board of Obstetrics and Gynecology (ABOG) and American Council for Graduate Medical Education (ACME). This training includes the ability to operate on any organ in the abdomen and pelvis, including the diaphragm.  However, the training focus is on cancer and not much, if anything, on the pathophysiology of endometriosis.  So, while this surgical training leads to the absolute pinnacle of gynecologic surgeon expertise, not many of them understand and/or know how to treat endometriosis beyond what they learned in residency.  So, in some cases, an excisionist works with a gynecologic oncologist instead of a general surgeon or urologist.  On the other hand, a relative handful of gynecologic oncologists do focus on advanced endometriosis. 

If chest endo is strongly suspected on imaging, a thoracic surgeon is required as part of the team for formal lung surgery.  Similarly, if large nerves such as the sciatic nerve to the leg is likely to be involved on imaging, a neurosurgeon may also be part of a team or backup.   

Regarding fertility issues, an ABOG/ACGME board-accredited fellowship leading to specialization in Reproductive Endocrinology also exists and such physicians may be involved in your care with advanced technologies such as in vitro fertilization (IVF).  This was historically a more surgically focused specialty in the United States.  Today it is not, but some REI specialists have retained an interest in things surgical and may be trained in excision surgery.    

Determining the surgical strategy in your specific case can influence the outcome as well.  Related potential contributors to endometriosis recurrence after surgery include age, disease severity, and the type of planned surgical procedure performed. Older patients and those with more severe endometriosis are at higher risk of recurrence after surgery, unless perhaps the uterus and both ovaries are removed.  Patients who undergo conservative surgery, which aims to preserve fertility by removing as little normal tissue as possible, may also be at higher risk of recurrence compared to those who undergo more aggressive surgery.  This depends on the disease locations and the skill of the surgeon.  Conservative surgery can still result in removal of all visible endometriosis in many cases, with the right surgeon and right equipment.  So, discussion of your ranked, and possibly competing, priorities with your surgeon is essential for the best outcome.   For example, is the main goal pain relief or is it fertility preservation?  Or is it both? What is most important to you?  Being on the same page with your main surgeon, especially if there is a team involved with potential multiple opinions, is crucial to get the results you want. 

Hormonal Influences:

Hormonal imbalances play a crucial role in the development and recurrence of endometriosis. Endometriosis is believed to be strongly influenced by an excess of estrogen in the body, which can cause the endometrial-like tissue to grow outside the uterus. Hormonal therapies such as hormonal contraceptives, progestins, and gonadotropin-releasing hormone (GnRH) agonists and antagonists can be used to manage these hormonal imbalances.  The problem is that Mother Nature is infinitely smarter than the best doctor(s) and some of these therapies are worse than the disease, in terms of symptoms and side effects.  It really depends on the individual situation. 

Even after menopause, whether natural or by surgical excision of the ovaries, estrogen does not completely disappear.  Endo affected tissues can produce estrogen locally, other hormones and toxins you take in can convert to estrogen in your fat cells and, of course, hormonal replacement are all additional sources which can contribute to endometriosis recurrence. 

So, if the hormonal imbalances are not addressed, the endometriosis tissue can grow back after surgery.  But what does that really mean and what can you do to favorably influence this risk factor?   

One thing is for sure, doing something beyond surgery is better than nothing.  Anything you can do to reduce your estrogen load is first priority and use of progestins to balance this overload may also be recommended.  Whether or not to go for complete ovarian shutdown of estrogen production (GnRH analogs) is situation specific but usually not ideal due to the significant health effects of basically being in menopause.  The newer variations which provide some estrogen giveback are better but still have their limitations.  More often the pharmaceutical solution is oral contraceptives, which is far easier to handle in terms of potential side effects.   

One of the easiest things you can do yourself to reduce excess estrogen fairly quickly is to make sure your gut microbiome is functioning optimally.  This requires a close look at your diet, avoiding toxic junk food, and using probiotics and prebiotics.  When your gut bacteria are working well they metabolize the excess estrogen in your body and this leaves your body through bowel movements.  If not, excess estrogen is reabsorbed, recirculated and contributes to estrogen load.  

Another natural strategy is to lose weight.  Your fat cells store xenoestrogens from the toxins we all take in daily and slowly release this estrogen back into the bloodstream.  Also, the more fat cells you have the more other hormones are converted to estrogens which are also released into your blood stream. Weight loss is not a rapid proposition, but the best time to get started is yesterday.   

Reducing stress through mind-body techniques can also reduce estrogen levels.  Reducing alcohol intake improves your liver’s ability to break down estrogen.  Finally, some supplements, notably seaweed, can reduce estrogen in your body.  Others that top the list are Vitamin D, Magnesium, Milk Thistle, Omega 3 fatty acids (fish oil), Vitamin B6 and DIM (diindolylmethane).  DIM is found in cruciferous veggies, so you can up that intake easily through diet.  

Only after doing some of these things should you get radical on altering your hormones through medical pharmaceuticals.  There is a whole range of hormonal strategies including more natural compounded preparations.  Having said that, work with your doctor for the best strategy for your specific situation.   This is not something you should do on your own beyond diet and lifestyle modification.  The main take home message is that there is plenty of data which supports doing something to balance your estrogen and progesterone after surgery to reduce recurrence.   

Immune Influences:

The immune system plays a critical role in the development and progression of endometriosis. Endometriosis implants produce inflammatory factors that attract immune cells to the site, which can cause inflammation and pain. However, immune cells can also help to fight recurrence.  

Surgery may temporarily disrupt the balance between pro-inflammatory and anti-inflammatory immune cells, but acute inflammation helps with healing and this is self-limited in almost all cases.  This type of inflammation you do not want to interfere with in the short term.  On the other hand, inflammation can contribute to recurrence if it is allowed to become chronic.   Research suggests that immune-modulating therapies such as immunosuppressive agents and immunomodulatory cytokines could be effective in preventing the recurrence of endometriosis after surgery.  However, there are no reliable pharmaceutical treatments along this line yet.  On the other hand, research suggests that natural killer cells (NK) are deficient in endo patients.  An integrative nutritional approach to enhancing NK number and function is mushroom consumption.  Work with an integrative specialist on this.  

A recent sub-theory for endo development and recurrence is the “bacterial contamination hypothesis”.  This is based on the role of bacterial endotoxin (lipopolysaccharide, LPS) stimulating the pelvic inflammatory immune response.  Since patients with a history of pelvic infection, chronic endometritis and SIBO are known to have higher incidence of endometriosis, the commonality is a bacterial endotoxin (LPS).  So, regardless of whether the bacterial LPS got there via intestinal translocation (micro-leaking) or retrograde menstruation, its presence is potentially key in stimulating endo growth and regrowth.  Along these lines, treatment with either natural or pharmaceutical antibiotics may help attenuate chronic low level infection related inflammation. 

This is certainly not mainstream thought but plausible and based on at least animal model evidence with some human study support as well.  Attention to keeping your microbiome healthy and minimizing leaky gut as well as vigilance for any gynecologic infections may be prudent and is low risk. 

Toxin Influences:

Exposure to toxins and pollutants can also contribute to the development and recurrence of endometriosis. Certain toxins, such as dioxins and polychlorinated biphenyls (PCBs), have been shown to disrupt hormone levels, acting mainly as xenoestrogens, and increase the risk of endometriosis growth.  Therefore, lifestyle modifications such as avoiding environmental toxins and adopting a healthy diet may be beneficial in preventing the recurrence of endometriosis after surgery.  

Molecular Influences:

Recent research has shown that molecular changes in endometriosis implants may also contribute to the development and recurrence of endometriosis. Mutations in certain genes involved in regulating inflammation and hormone levels are examples.  Environmental and inflammatory influences can also upregulate hormone receptors, which means less estrogen is required to stimulate regrowth from micro-foci of endometriosis.   All these changes can be genetic mutations or epigenetic influences which turn normal and abnormal genes on and off. 

There is a lot of molecular crosstalk that regulates hormonal, inflammatory, immune, neurologic and other processes.  This is the glue that interconnects all of these factors that affect progression of endo and symptom causation.   

If your endo recurrence seems to be too rapid after a good excision surgery, or you have multiple recurrences and especially if you are older and/or have a family history of cancer or endo, please consider the following.  While rare, endo can degenerate into cancer or increase ovarian cancer risk and, even before that might happen, some gene mutations (e.g. ARID1A, KRAS, PIK3CA) can contribute to a more aggressive variant of endometriosis.  To determine if this is a contributor to your disease, genetic counseling and testing may be a good idea. 

Surgical Equipment Influences:

Minimally invasive surgery is the gold standard of endometriosis surgery these days, not surgery though a big incision called a laparotomy.  Having said that, after multiple prior surgeries, a surgeon may try to convince you that a laparotomy is what you need because you probably have too many scars or fibrosis and, therefore, minimally invasive surgery may be too risky.  While this may be true in very rare cases, it is not true in the vast majority of cases and you should probably seek other opinions.  Laparotomy surgery often leaves behind much more scarring than minimally invasive surgery.  There is always a possibility you may need yet another surgery, so find an expert to minimize all risks for this surgery and possibly subsequent ones. 

Minimally invasive surgery may mean laparoscopy or it may mean robotically assisted laparoscopy, depending on the surgeon you choose.  While laparoscopy has been around much longer, there are major technologic differences.  For simple to moderate cases, either is fine. However, for more complex cases and recurrence, you should understand the technical differences and what they mean.  Imaging may suggest but it is often not possible to accurately predict how much disease is present, or how much anatomic distortion there is, until the actual surgery starts.  But you can bet that if you are facing a repeat surgery, the anatomy may be more distorted than the first time.   

The following represents the opinion of this author surgeon who has used both laparoscopy and robotics over the past three decades, but, due to the reasons noted, has converted almost exclusively to robotics.  Having said that, it is important to understand that at the end of the day the skill of the surgeon trumps the equipment in most cases.  However, at some point, better technology does offer some clear advantages for most surgeons, should they choose to avail themselves of it.  Herein lies the problem.  Many have chosen to only dabble in robotics or ignore it altogether as an option.  So, beware of any surgeon who says that robotics is just a fad or training wheels for laparoscopy.  This is likely a surgeon who never took the time to master the superior technology offered by robotics to appreciate the difference.  The final major argument against robotics is that it costs too much or takes a little longer.  This does not affect the patient whatsoever because the costs to you are exactly the same.  In terms of surgery length, that is measurable in minutes.  So, wouldn’t you rather have a difficult surgery done properly or simply be the first one in the post-anesthesia recovery area?

  • Benefits of Robotic Surgery over Laparoscopy

Robotic surgery is a minimally invasive surgical technique that uses robotic arms to help perform the surgery with more precision. This offers several benefits over traditional laparoscopy that may help to reduce the risk of endometriosis recurrence. These benefits include more precise removal of endometriosis implants, less damage to surrounding tissue, reduced risk of complications, and possibly a shorter recovery time. 

  • Precise Instrumentation

Robotic surgery allows for more precise surgical movements, especially in delicate and anatomically distorted areas, reducing the risk of incomplete excision. The robotic arms move with reliably greater precision, dexterity and control than laparoscopic instruments.  During laparoscopy the surgeon is directly controlling the straight inflexible instruments with graspers and scissors at the tip.  This means that any undue exaggerated movements or tremors are amplified by the time they get to the tips, located twelve to seventeen inches away.  That is a long distance.  Try writing with a pen that long.  This does not happen with robotics which is micro-controlled.  In addition, the instruments at the tips of the robotic apparatus are wristed, meaning they are flexible and move like tiny human hands.  This also allows for more precision in difficult anatomical areas and in the presence of scar or fibrosis.   

Traditional laparoscopic instruments are limited by the possible motions at the surgical tips.  These motions are cutting, pushing, pulling and tearing, can be awkwardly unreliable and are reminiscent of eating with chopsticks.  One can certainly get good at it, but there are limitations. No question, the better the surgeon and the more that anatomy is normal, the smoother the surgery. However, at the end of the day, this can never match the smooth reliability of robotics. 

Due to the more precise control of instruments, robotic surgery can help reduce the risk of damage to surrounding tissues and organs. This helps reduce complications (e.g inadvertent damage to bowel, ureters or blood vessels) and, in this manner, enhances and accelerates the healing process. 

  • Superior 3-Dimensional Optics

Robotics offers a 3-D magnified camera, which means there is depth perception as compared to laparoscopy.  In other words, you can see minute differences in how far one object is compared to one right next to it. There are laparoscopic simulated 3-D options available (3-D glasses as opposed to real binocular lenses as found in robotics), but most surgeons use a 2–D camera.  Using this, the surgeon cannot appreciate the distances accurately.  So, without depth perception, the surgeon can’t precisely tell the separation between tissues in a highly distorted anatomical situation. For example, there may be a section of bowel stuck to an endometrioma, or the blood vessels to the ovary may be obscured in inflammation. Dissecting this all safely is facilitated by a 3-D view. You can prove to yourself why 3-D is better. Put an eye patch on and try to (very carefully) try to do things around the house with only one eye to help you navigate. You will find that you underestimate or overestimate the distance between objects when you try to pick them up and might even bump into things too often. Hence you should not try this experiment without someone to help keep you steady. Humans are created with and are best equipped to function with 3-D vision, powered by two eyeballs. We can accommodate to 2-D but it is not natural or optimal.  This means with traditional laparoscopy your surgeon is operating with a handicap and, regardless of skill, that may make all the difference in some cases. 


In conclusion, endometriosis recurrence after surgery is a complex issue. Incomplete excision due to surgeon experience or technology differences, hormonal imbalances, immune influences, toxin influences, and molecular influences can all contribute to endometriosis recurrence after surgery.  Take time to digest all of this information and seek the best endometriosis specialist and surgeon available to you for your specific needs.  

Get in touch with Dr. Steve Vasilev

More articles from Dr. Steve Vasilev:

Endometriosis And Menopause; Everything You Need To Know

How to tell the difference between endometriosis and ovarian cancer

What would happen to the signs and symptoms of endometriosis after menopause?


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Endometriosis and Adenomyosis: Decoding Their Contribution To Pelvic Pain

Endometriosis and adenomyosis affect millions of women worldwide. While they share certain similarities, they also exhibit differences in their pathophysiology, clinical presentation, and management. Let’s compare and contrast endometriosis and adenomyosis, shedding light on their associations and highlighting relevant references.


Both endometriosis and adenomyosis involve the growth of endometrial-like tissue outside the uterine cavity. This ectopic tissue remains responsive to hormonal changes, leading to inflammation, pain, and other similar symptoms that can significantly interfere with the quality of life (1).

Both conditions predominantly affect women of reproductive age and are associated with dysmenorrhea (painful periods), dyspareunia (painful intercourse), and infertility (2). The exact cause of these conditions remains unclear, but a combination of genetic, hormonal, and immune factors is thought to be involved in both (3). Both can also continue beyond or even be present initially after menopause.


  1. Anatomical location 

While both endometriosis and adenomyosis involve the growth of ectopic endometrial-like tissue, they differ in anatomical location. Endometriosis is characterized by the presence of endometrial-like tissue outside the uterus, commonly on the ovaries, fallopian tubes, the peritoneum (pelvic and abdominal skin-like lining), and other organs (4). In contrast, adenomyosis is defined by the invasion of endometrial-like tissue into the myometrium (muscular wall) of the uterus (5).

  1. Prevalence

Endometriosis affects approximately 10% of women of reproductive age, while adenomyosis is thought to impact between 20% and 35% of women in this age group (6). But the true prevalence of both conditions may be underestimated due to the invasive nature of diagnostic procedures and non-specific symptoms (7).

  1. Diagnosis

The gold standard for diagnosing endometriosis is surgery using laparoscopy or robotics, both minimally invasive surgical procedures that allow for direct visualization and, if necessary, excision of endometrial-like tissue lesions (8). In contrast, adenomyosis is typically suspected using imaging techniques such as transvaginal ultrasound or magnetic resonance imaging (MRI). It can usually only be confirmed by the pathologist when the uterus is removed (9). An accurate preoperative biopsy is very difficult, although removal of discrete adenomyomas, leaving the uterus behind, is sometimes possible when the adenomyosis is not diffuse throughout the myometrium of the uterus.

  1. Treatment

Both conditions are managed with a combination of medical and surgical therapies, depending on the severity of symptoms and reproductive goals. Hormonal therapies, including oral contraceptives, progestins, and gonadotropin-releasing hormone (GnRH) agonists and antagonists, are commonly used to manage symptoms in both endometriosis and adenomyosis (10). Integrative measures, including anti-inflammatory and anti-oxidant hormone-modulating nutrition and lifestyle modification, can also help not just control symptoms but also contribute to treating the root causes. 

However, surgical approaches differ between the two conditions. In endometriosis, the preferred surgical intervention is laparoscopic and robotic excision of the ectopic tissue (11). For adenomyosis, hysterectomy (removal of the uterus) may be considered in severe cases where fertility preservation is not a concern (12). Again, in some cases, when discrete adenomyomas are identified by imaging, they can be removed while leaving the uterus intact—this decision of removing the uterusis a highly individualized issue. 


It is not uncommon for endometriosis and adenomyosis to coexist in the same patient. One study found that the prevalence of adenomyosis was significantly higher among women with endometriosis (13). The coexistence of these conditions may exacerbate symptoms and pose additional challenges in diagnosis and management (14).

Both endometriosis and adenomyosis have been linked to a variety of other health conditions, some of which include:

  1. Chronic pelvic pain: Women with either endometriosis or adenomyosis may experience chronic pelvic pain, which can be debilitating and significantly impact daily life (15).
  1. Uterine fibroids: Although they are distinct conditions, adenomyosis and uterine fibroids (leiomyomas) can coexist in the same patient, further complicating the diagnosis and treatment (16). 
  1. Autoimmune and inflammatory diseases: Women with endometriosis have an increased risk of developing autoimmune and inflammatory disorders, such as rheumatoid arthritis, systemic lupus erythematosus, and inflammatory bowel disease (17). This association is less well-established for adenomyosis but has been suggested in some studies (18).
  1. Mental health: Both endometriosis and adenomyosis have been linked to mental health issues, including depression, anxiety, and decreased quality of life due to chronic pain and infertility (19).

Research and Future Directions

There is a growing body of research focused on understanding the pathophysiology, diagnosis, and treatment of endometriosis and adenomyosis. Some key areas of interest include:

  1. Biomarkers: Identifying specific biomarkers for endometriosis and adenomyosis could greatly improve the diagnostic process and allow for earlier intervention, potentially improving patient outcomes (20).
  1. Non-invasive imaging techniques: The development of more accurate, non-invasive imaging techniques for diagnosing both endometriosis and adenomyosis is a priority for researchers, as this would reduce the need for invasive diagnostic procedures (21).
  1. Novel treatment approaches: Researchers are exploring novel treatment approaches, such as targeted hormonal therapies, immunomodulators, and anti-inflammatory agents, to improve symptom management and fertility outcomes in both endometriosis and adenomyosis (22).
  1. Genetic and epigenetic factors: Investigating the genetic and epigenetic factors that contribute to the development and progression of endometriosis and adenomyosis may lead to a better understanding of these conditions and inform future therapeutic strategies (23).

Get in touch with Dr. Steve Vasilev

More articles from Dr. Steve Vasilev:

Endometriosis And Menopause; Everything You Need To Know

How to tell the difference between endometriosis and ovarian cancer

What would happen to the signs and symptoms of endometriosis after menopause?


  1. Vercellini P, Viganò P, Somigliana E, Fedele L. (2014). Endometriosis: pathogenesis and treatment. Nat Rev Endocrinol. 10(5): 261-75.
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  3. Zondervan KT, Becker CM, Koga K, Missmer SA, Taylor RN, Viganò P. (2018). Endometriosis. Nat Rev Dis Primers. 4(1): 9.
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The Importance of Endometriosis Awareness Month

Every March, the world comes together to recognize and raise awareness for endometriosis. This global health issue affects hundreds of millions of humans worldwide yet is rarely discussed due to a lack of education and knowledge. Endometriosis Awareness Month allows us to learn more about this debilitating condition and how it impacts those who suffer from it.

What Is Endometriosis?

Endometriosis is a chronic disorder affecting up to 10% of women worldwide. Endometriosis can impact other genders as well. This disease occurs when tissue similar to the lining of the uterus grows outside the uterus and on other organs in the body, such as the ovaries, bladder, bowels, and abdomen. While endometriosis can occur at any age, it most commonly impacts women between 15-50 years old.

Common Symptoms

The most common symptom of endometriosis is pelvic pain. This pain can range from mild cramping or discomfort to severe period pain lasting days or weeks. Other symptoms include heavy periods (with large clots), painful bowel movements or urination during menstrual cycles, painful sex, fatigue, and infertility. Unfortunately, these symptoms are often misdiagnosed as menstrual cramps or irritable bowel syndrome (IBS).

Endometriosis Treatment Options & Management Strategies

Endometriosis cannot be cured, but treatment options are available to help manage its symptoms. These include surgical removal of endometrial growths, hormone therapy, pain management, and dietary changes. Additionally, lifestyle modifications like stress reduction techniques and exercise can help alleviate some symptoms of endometriosis.

Endometriosis Awareness Month is important in educating everyone about this chronic disorder that affects hundreds of millions globally. We must learn more about endometriosis so that those suffering from this condition can get the proper diagnosis and care they need. Together we can make a difference in raising awareness for this disease!


Integrative Therapies for Endometriosis

While there is no known cure for endometriosis, several mainstream treatment options can help manage the symptoms and improve quality of life. These are primarily focused on surgery and hormonal therapy.   Research is ongoing to find additional multidisciplinary treatment options on the basis of immunomodulation, anti-inflammatory therapy, and molecular pathway signal alteration. Absent curative mainstream therapy, an approach that has gained popularity in recent years to help reduce symptoms and treat some underlying endo pathology, is “integrative therapy,” which adds a holistic natural component. 

What is integrative therapy?

Integrative therapy is an approach to healthcare that takes into account the whole person, including their physical, emotional, and spiritual health. It involves combining conventional medical treatment with complementary therapies such as nutrition, supplementation, botanicals, acupuncture, massage, yoga, and much more. Integrative therapy aims to address the underlying causes of a person’s health concerns rather than simpl