How to Recognize Endometriosis Symptoms

What are the First Signs and Symptoms of Endometriosis: Everything You Need to Know

Sharp, stabbing, burning, throbbing, and aching are all adjectives people use to describe endometriosis pain. Endometriosis is a condition that, for some women, can cause excruciating uterus pain—often described as feeling like the insides are being pulled out of the body. Even worse, for many patients, endometriosis pain medication does not cut through or provide relief. As a result, an endometriosis diagnosis can be very serious and life-changing.

As an introduction to the disorder, here is a concise overview of the signs and symptoms of endometriosis, its causes, complications, and treatment options. First, let’s cover what endometriosis is.

What is the Endometrium?

The endometrium, also known as the endometrial lining, is the tissue that forms the “wallpaper” or lining of the uterus, which is the pear-shaped organ that houses a growing baby. During pregnancy and menstruation, the endometrium plays vital roles.

What is Endometriosis Pain?

Endometriosis is pronounced (en-doe-me-tree-O-sis). It is a medical condition in which tissue similar to what normally lines the inner walls of the uterus (the endometrium) grows outside the uterus. Often very painful and even debilitating, it may involve the ovaries, fallopian tubes, bowels, vagina, cervix, and the tissues that line the pelvis. In rare cases, it can also affect other organs, such as the bladder, kidneys, or lungs.

Signs and Symptoms of Endometriosis Pain

Not all women experience the same symptoms of endometriosis or the same degree of intensity. Some women may not experience any symptoms at all. It is also important to understand that symptom severity is not a reliable indicator of disease progression—some women with advanced stages have no symptoms, while others with mild cases endure many. Common endometriosis pain symptoms include painful periods (dysmenorrhea), infertility, diarrhea during the period, pain during intercourse, heavy or abnormal menstrual flow, abdominal or pelvic pain after vaginal sex, painful urination during or between menstrual periods, painful bowel movements during or between menstrual periods, and gastrointestinal problems such as bloating, diarrhea, constipation, and/or nausea.

Mechanisms of Signs and Symptoms of Endometriosis

Painful Periods (dysmenorrhea)

Cyclic release of multiple inflammatory factors activates nerve fiber growth, leads to cell damage and fibrosis, and exacerbates pain during periods.

Infertility

The overall mechanisms can include tubal blockage, local inflammation, uterine muscle dysfunction, local hormonal alterations, and more.

Diarrhea During Menstrual Periods

Diarrhea may result from endometriosis growing directly on the rectal muscle or from inflammatory substances produced by endometriosis. Local production of inflammatory molecules can lead to hypermotility of the sigmoid and rectum muscles, which can manifest as cramping and diarrhea.

Pain During Intercourse (Dyspareunia)

Endometriosis implants are often hyperinnervated (containing more nerve endings than usual) and can produce pain with pressure. The act of intercourse can apply this pressure to the upper vaginal area and uterosacral ligaments, which are common locations of endometriosis implants. Once this pain occurs and local inflammation further causes tension in the pelvic floor, the muscles surrounding the vagina can contract, worsening the problem.

Heavy or Abnormal Menstrual Flow

Endometriosis can affect bleeding patterns by increasing stress from pain or by damaging the ovaries, which can change local hormonal function.

Abdominal or Pelvic Pain After Vaginal Sex

Uterine and pelvic floor spasms are a normal part of orgasms. When these areas are hypersensitive due to endometriosis, spasms can lead to continued contractions and pain that persists. In addition, rectal fusion to the posterior vaginal wall can cause more direct pain and inflammation because pulling on the vaginal area tugs on the rectal wall. Any event that agitates the pelvis and causes minor trauma can also trigger increased molecular signaling that amplifies the problem.

Painful Urination During or Between Menstrual Periods (Dysuria)

Painful and frequent urination is a common symptom of endometriosis. Endometriosis cells and responding inflammatory cells produce inflammatory molecular signals that accumulate in the area of injury. These signals affect all pelvic organs, including the bladder, leading to bladder wall spasms. Moreover, interstitial cystitis is common in endometriosis patients and can also be a factor. In the worst-case scenario, endometriosis lesions implant inside the bladder, which can cause cyclic bleeding from the bladder (hematuria).

Painful Bowel Movements During or Between Menstrual Periods (Dyschezia)

Endometriosis causes inflammation and fibrosis (scarring) as the body attempts to heal. This inflammation and fibrosis can severely alter pelvic anatomy and distort the rectal course, gluing it to the uterus, cervix, and posterior vaginal wall. This angulation can cause constipation and difficulty evacuating stool, while inflammatory signals cause the rectal muscles to hyper-contract. These mechanisms lead to painful bowel movements that worsen during cyclic increases in inflammatory molecules. In the worst-case scenario, endometriosis can grow through the rectal wall over time, causing cyclic rectal bleeding.

Gastrointestinal Problems, Including Bloating, Diarrhea, Constipation, and Nausea

Intestinal symptoms of endometriosis can be direct or indirect, or related to conditions like small intestinal bacterial overgrowth (SIBO). Even without direct implants on the bowel, endometriosis inside the abdomen and pelvis can cause enough inflammation to irritate the intestine and cause symptoms. Direct implants on the bowel can further worsen symptoms.

Causes of Endometriosis

One cause of endometriosis is the direct transplantation of endometrial cells into the abdominal wall during a medical procedure, such as a cesarean section. Beyond this known cause, several theories exist about how it develops. One theory proposes that, during the menstrual cycle, a reverse process takes place in which tissue backs up through the fallopian tubes into the abdominal cavity, where it attaches and grows. Another theory is a genetic link, based on studies showing that if someone has a family member with endometriosis, they are more likely to have it as well. A third hypothesis suggests that endometrial tissues can travel and implant in other body parts via blood or lymphatic channels, similar to how cancer cells spread. A fourth theory proposes that cells throughout the body have the ability to transform into endometrial cells.

Complications of Endometriosis

If left untreated or in advanced stages, endometriosis can cause complications such as infertility or subfertility, chronic pelvic pain that can result in disability, and anatomic disruption of involved organ systems, including adhesions, ruptured cysts, and even renal failure.

Diagnosis of Endometriosis

Diagnosis starts with assessing signs and symptoms, followed by imaging studies such as MRI and ultrasonography. However, confirmation or exclusion of endometriosis is only possible with surgical biopsy and histopathology, with laparoscopy serving as the gold-standard surgical modality for diagnosis in all cases.

Treatment for Endometriosis

Endometriosis benefits from a multidisciplinary, holistic approach. Pain is often the most significant complaint, so many interventions focus on pain control. Options to help temporarily ease pain can be used alone or alongside medical and/or surgical treatments. Alternative therapies may also be used in conjunction with other interventions. It is essential to discuss any treatment options with a physician before implementing them. Medical and/or surgical treatments are individualized and depend on factors such as symptom type and severity, the extent of disease, overall health, and desire for pregnancy; in some cases, pain management alone may be appropriate, while in others, medical therapy is considered.

Specialists Involved in Multidisciplinary Care

• Nutritionist
• Physical therapist
• Endometriosis surgeon
• Mental health therapist
• Pain management specialist

Options to Help Temporarily Ease Pain

• Exercise
• Meditation
• Breath work
• Heating pads
• Rest and relaxation
• Prevention of constipation

Alternative Therapies That May Be Used in Conjunction With Other Interventions

• Homeopathy
• Immune therapy
• Allergy management
• Nutritional approaches
• Traditional Chinese medicine

Be sure to discuss any of these treatment options with a physician before implementing them.

The Right Medical Treatment For You

• Desire for pregnancy
• The extent of the disease
• Type and severity of symptoms
• Patient opinions and preferences
• Overall health and medical history
• Expectations of the course of the disease
• Patients’ tolerance level for medications, therapies, and/or procedures

In some cases, management of pain might be the only treatment. In others, medical options may be considered. Typical non-surgical, medical treatments for endometriosis include:

• “Watch and Wait” approaches in which the disease course is monitored and treated accordingly
• Pain medication, ranging from non-steroidal anti-inflammatory drugs (NSAIDs) to other over-the-counter and/or prescription analgesics
• Hormonal therapy, such as:
• • Progestins
  • Oral contraceptives with both estrogen and progestin to reduce menstrual flow and block ovulation
  • Danazol (a synthetic derivative of the male hormone testosterone)
  • Gonadotropin-releasing hormone antagonist therapy, which stops ovarian hormone production

Surgical Treatment Options for Endometriosis

Despite their effectiveness in symptom control, pain medications can have significant side effects, do not halt disease progression, and may be followed by symptom recurrence once stopped. By contrast, surgery can lead to long-term relief and can prevent further tissue damage. Treatment planning should be a shared decision based on individual desires, goals, and abilities.

Almost all endometriosis surgical procedures are laparoscopic or robotic. These minimally invasive surgeries use small tubes with lights and cameras inserted into the abdominal wall, allowing the surgeon to visualize internal organs and remove endometriosis.

Excision of Endometriosis

In this technique, the surgeon cuts out as much or all of the endometriosis lesions from the body, aiming to avoid leaving lesions behind while preserving normal tissues. This technique is widely adopted by highly skilled endometriosis surgeons who are world leaders.

Ablation of Endometriosis

In this technique, the surgeon burns the surface of endometriosis lesions and leaves them in the body. Most top experts highly criticize this method. Ablation is most popular with surgeons who have not received enough training to perform excision and therefore are not comfortable doing it.

Hysterectomy

This surgery removes the uterus and sometimes the ovaries. Many surgeons consider hysterectomy an outdated and ineffective treatment for endometriosis and reject performing it unless there is a clear indication, such as adenomyosis.

Laparotomy

This procedure involves cutting and opening the abdomen without thin tubes and is more extensive than laparoscopy. Very few surgeons still perform laparotomy because of its complications, and almost none of the top endometriosis surgeons use laparotomy for endometriosis.

Multidisciplinary Care

Along with effective surgical treatment, patients should work with endometriosis experts in physical therapy, mental health, nutrition, and pain management to achieve the best possible outcome.