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Endometriosis: Symptoms, causes, and treatments

by Tamer Seckin, MD | Posted on June 23, 2020

What is endometriosis?

Endometriosis is a chronic disease in which endometrial-like tissue is found outside of the uterus. This tissue, which normally lines the uterine cavity, is associated with monthly menstruation and is often characterized by abnormally painful and heavy periods, as well as pelvic pain, severe cramps, and pain with sex (dyspareunia). Endometriosis lesions are estrogen-dependent, benign, inflammatory, stem-cell driven, and at times progressive.

Endometriosis affects an estimated 176 million women worldwide [1]. A leading cause of infertility and chronic pelvic pain, it has also been linked to other health concerns, including certain autoimmune diseases and cancers, fibroids, adenomyosis, and interstitial cystitis. It is one of the leading causes for laparoscopic surgery and hysterectomy in the United States. The economic impact of endometriosis is staggering: businesses lose billions of dollars each year in compromised productivity and absenteeism because of the disease.

Where does occur?

  • Typical: Endometriosis typically develops on the pelvic structures including the ovaries, fallopian tubes, bladder, and bowels (intestines).
  • Common: It is common for endometriosis to develop on the top of the vagina (anterior cul-de-sac) and in the peritoneal cavity between the rectum and the posterior wall of the uterus (posterior cul-de-sac).
  • Rare: Endometriosis can spread to the diaphragm, lungs, kidney, appendix, and, surprisingly, the gastrocnemius (calf muscles).

Endo Stages

American Society of Reproductive Medicine Severity Classifications

StagesAmerican Society of Reproductive Medicine Severity Classifications
Stage I Minimal
Stage II Mild
Stage III Moderate
Stage IV Severe


Because the four stages of the disease do not necessarily have any correlation to a patient’s symptoms or the nature of the infiltration itself, we often use a more descriptive system:

Dr.Seckin's Preferred ClassificationDescription
Early peritoneal
  • Infiltration of the lining of the abdomen (peritoneum)
Ovarian endometriomas
  • Large, fluid-filled "chocolate" cysts that form on, and even encapsulate, the ovaries
Cul-de-sac obliteration
  • Infiltration of the tissue lining the back wall of the uterus and rectum (posterior cul-de-sac), an extension of the peritoneum
Deep infiltrating endometriosis (DIE)
  • Invasive endo that penetrates to the bladder and bowel wall
Frozen pelvis
  • In this rare condition, deep infiltrative lesions attach to pelvic ligaments, nerves, and muscle tissue. As a result, pelvic organs can be partially or entirely cemented
retrograde menstruation
A high rate of retrograde menstruation is a popular theory in justifying the cause of the disease [2]. Endometrial cells are carried through the refluxed menstrual debris, which travels through the fallopian tubes


There is no known exact cause of endometriosis but several different plausible theories exist, including retrograde menstruation, Meyer's theory, and more. We remain open to newly developing ideas.

Risk factors

It is important to note that while the following risk factors increase one’s likelihood for endometriosis, there are many cases in which women are diagnosed without any of the following:

  • Family history, especially mother or sister
  • Average age range 25-40
  • History of menstruation complications (i.e. long menstrual cycles, frequent periods)
  • Not having children
  • High consumption of fats and red meat
  • Heavy alcohol intake

How does it affect pregnancy & fertility?

  • Likely responsible for one-third of infertility cases [3]
  • The longer a woman has endometriosis, the more risk she has of infertility
  • Up to 70% of women with mild to moderate endometriosis are still capable of conceiving

How can it lead to infertility?

  • Adhesions on or near the ovaries, uterus and fallopian tubes impede the transfer of the egg to the fallopian tube
  • Ovarian implants prevent the release of the egg
  • The decrease in the number and quality of healthy eggs [4]

What is adenomyosis? How is adenomyosis different?

  • Adenomyosis can be thought of as endometriosis strictly within the uterine muscle, whereas endometriosis is outside the uterus
  • 50% of adenomyosis patients also have endometriosis

What conditions can it be related to?

Part of the reason why endometriosis is such a complex and dangerous condition is that it can lead to several other related conditions, including:

  • Adenomyosis
  • Adhesions
  • Ovarian cysts
  • Bowel endometriosis
  • Chronic pelvic pain
  • Infertility

What can it be misdiagnosed as?

Endometriosis can mask itself as a number of conditions. It is often misdiagnosed and mistreated for the following conditions:

  • IBS
  • Appendicitis
  • Hemorrhagic cysts
  • Need for hysterectomy
  • A normal period or "just a bad period"
  • "In your head"


→ click for more endometriosis symptoms and signs

What are the symptoms?

What are the signs and symptoms that should concern me of endometriosis?

  • Painful menstrual cramps (dysmenorrhea or "killer cramps")
  • Heavy menstrual bleeding (menorrhagia)
  • Chronic pelvic pain
  • Pain with intercourse (dyspareunia)
  • Abdomen pain and bowel dysfunction including painful bowel movements, diarrhea, bloating, gas, or cramps
  • Bladder dysfunction, such as painful urination
  • Weakness, numbness, or pain in nerves (neuropathy)
  • Fatigue
  • Infertility
  • Personality changes (depression, stress, apathy)


What is the first step towards diagnosing?

Before pursuing imaging, you should speak with a GYN physician who is familiar with diagnosing endometriosis and can provide a comprehensive pelvic exam. A physical exam and a discussion about your symptoms and medical history will help a physician determine if imaging tests are necessary.

What imaging tests are used to identify?

In order to properly diagnose a patient with endometriosis and determine whether surgery is needed, one or both of the following imaging tests must be conducted:

  • Ultrasound/Sonogram
  • MRI

What procedures and tests help definitively diagnose it during surgery?

In an operating room, a well-trained and experienced GYN surgeon will be able to visualize any anatomical abnormalities or endometriosis lesions through the following procedures:

  • Hysteroscopy
  • Laparoscopy
  • While a physical exam and other imaging tests can give insight into whether or not a patient may have endometriosis, the only way to definitively diagnose endometriosis is through laparoscopic excision surgery. This must be accompanied by a biopsy sample that is sent to pathology in order to confirm a diagnosis of the disease.


There is currently no cure for endometriosis but there are surgical and non-surgical treatment options for pain and infertility caused by the disease.

Non-surgical methods to relieve symptoms:

It is important to note that the following methods are not treatments for the disease itself, but rather control a patient’s pain and symptoms. They provide relief, not treatment.

  • Endometriosis Inflammation, Endometriosis Antioxidant DietPainkillers
  • Acupuncture
  • Birth Control
  • Anti-inflammatory Diet
  • Medicated IUD

Surgical procedures:

There are a variety of surgical treatments that a patient can undergo to treat endo depending on the severity, stage, and quantity of the endometrioma lesions.

Laparoscopic Deep Excision Surgery The "gold standard" for removing all endometriosis in the body, ranging from lesions on the ovaries to the intestine
Myomectomy Removal of fibroids, necessary only when fibroids develop
Hysterectomy Removal of the uterus, which is only needed in cases of diffuse endometrioma tissue in the uterus such as with adenomyosis

Our Approach

How does our care differ?

Even for a standard OB/GYN, endo is not an easy condition to diagnose. Our practice provides a number of advantages [5]:

  • Over 20 years of experience identifying, diagnosing, and treating endo
  • Over 20 years of experience in laparoscopic deep excision surgery
  • Strong preference for laparoscopic deep excision surgery
  • Strong preference for excision surgery over robotics or laser ablation
  • Only performing hysterectomies or oophorectomy as last resorts, which is often rare
  • Patented technology, including the Aqua Blue Contrast technique (ABC)
  • High-quality surgical imaging

As a patient, your health and wellbeing come first. With decades of experience, we know that this is the most important aspect in treating the disease. Every patient is different and therefore every patient's unique story and symptoms must be heard.

Patient Story

constant pain and suffering from endometriosis

Menoka M. was experiencing severe pelvic pain for the past seven years and was not diagnosed with endo for nearly five years. After seeing many doctors and having several surgeries, Menoka found us and was soon scheduled for laparoscopic deep excision surgery. Read about Menoka's journey here, as well as how she is doing now.

You can read more stories of patients with endo, of varying stages, in our testimonial section.

Ready for a Consultation?

Our endometriosis specialists are dedicated to providing patients with expert care. Whether you have been diagnosed or are looking to find a doctor, they are ready to help.

Our office is located on 872 Fifth Avenue New York, NY 10065.
You may call us at (212) 988-1444 or have your case reviewed by clicking here.


  1. What is endometriosis? Endometriosis Foundation of America
  2. Sampson, J.A., Metastatic or Embolic Endo, due to the Menstrual Dissemination of Endometrial Tissue into the Venous Circulation. Am J Pathol, 1927. 3(2): p. 93-110 43.
  3. D'Hooghe, T.M., et al., Endo and subfertility: is the relationship resolved? Semin Reprod Med, 2003. 21(2): p. 243-54.
  4. Goud, P.T., et al., Dynamics of nitric oxide, altered follicular microenvironment, and oocyte quality in women with endo. Fertil Steril, 2014. 102(1): p. 151-159 e5.
  5. Seckin, T., The Doctor Will See You Now: Recognizing and Treating Endometriosis. 2016.


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