It’s not always just endometriosis.

Digestive issues and so-called Endo-Belly bloating are very common in patients with endometriosis, but not all are caused directly by the disease itself. Small Intestinal Bacterial Overgrowth (SIBO) and “leaky gut” can create bloating, abdominal pain, diarrhea, or constipation that overlap with endo symptoms. Chronic inflammation from gut dysbiosis can also worsen pelvic pain and fatigue. By identifying and treating underlying gut imbalances, symptoms often improve and whole-body health is supported.

Mast cell activation plays a role in inflammation and pain signaling. Some patients with endometriosis also have acute or chronic Mast Cell Activation Syndrome (MCAS) or mastocytosis, which can intensify pain, fatigue, and allergic-type symptoms. This immune system overactivity can make endo symptoms feel worse and harder to control. Recognizing and calming mast cell activity can be a key part of improving overall well-being.

Endometriosis is not primarily an autoimmune disease itself, but it shares features with autoimmunity — including chronic inflammation and immune dysregulation. Many patients with endo are also diagnosed with conditions like thyroid disease, lupus, or rheumatoid arthritis. These overlapping illnesses can complicate symptoms and require coordinated care. By screening for autoimmune conditions, we can build a plan that addresses the bigger picture.

Some patients with endometriosis also carry chronic infections such as Lyme disease or related coinfections. These can create widespread pain, fatigue, and neurological symptoms that overlap with or intensify endo symptoms. Both conditions involve immune dysregulation and chronic inflammation, making them difficult to distinguish without careful testing. Addressing underlying infections can reduce total body inflammation and make endometriosis care more effective.

Exposure to mold toxins (mycotoxins) can trigger a wide range of symptoms: fatigue, brain fog, pelvic pain, bladder irritation, and more. For endometriosis patients, mold-related illness may worsen immune imbalance and heighten inflammatory flares. Because symptoms are nonspecific, mold illness is often overlooked or dismissed, leading to years of suffering. Identifying and treating mold exposure can play a key role in reducing overall symptom burden and supporting recovery.

Pelvic venous congestion is a condition where enlarged, varicose-like dilated veins in the pelvis cause chronic pain. The pain can feel very similar to endometriosis—worsening with standing, at the end of the day, or after sexual activity. Some patients may even be misdiagnosed with endo when pelvic vein issues are the main driver. Careful imaging and evaluation help distinguish the two and guide treatment.  Combined imaging as well as surgical findings can help determine if this is part of overall pelvic pain causation. 

May-Thurner Syndrome is a vascular condition where a large pelvic vein is compressed, leading to leg heaviness, swelling, or pelvic discomfort. Its symptoms can mimic or compound endometriosis-related pain. Because it’s not widely recognized, many patients go years without diagnosis. Screening for this condition using imaging ensures that vascular causes of pain are not overlooked.

Groin or abdominal wall hernias may present with pelvic or lower abdominal pain that overlaps with endometriosis symptoms. Sometimes, endometriosis itself is found inside or around a hernia sac. Because hernia pain can mimic deep endo pain, it’s important to evaluate carefully. Repairing a hernia in the right setting can significantly reduce pain and improve quality of life.  Repair may or may not be recommended at the time of endo excision because it often requires placement of a synthetic  mesh which has its own risk vs benefit considerations.  

Pelvic masses are often benign, but sometimes endometriosis is mistaken for a tumor, or vice versa. Endometriosis can also rarely transform into certain types of ovarian cancer, especially clear cell or endometrioid types. It’s important not to miss these possibilities in evaluation. For that reason, we use careful imaging and, when necessary, surgical assessment to distinguish between benign disease and malignancy.  This is more often an issue in older patients but can occur when younger, especially if there is a family history of cancer or genetic abnormalities are found. 

Many patients with endometriosis have a history of multiple surgeries, which can result in adhesions — internal scar tissue that binds organs together.  Adhesions and fibrosis can also occur as your body tries to clear endometriosis lesions. These adhesions and fibrosis can cause pain, bowel obstruction, and infertility, often mimicking recurrent endometriosis. Differentiating adhesion pain from true disease recurrence is crucial in planning further treatment. Specialized surgical techniques and the highest level surgeon are often required to safely release adhesions, especially in extremely distorted scarred fibrotic anatomy. Part of the problem is that there is no way to predict how much scarring or fibrosis may be found.  After surgery has started  is not the time to start looking for a surgeon or assistant/consultant that can handle the hardest cases.  

Both endometriosis and adenomyosis are inflammatory conditions.  The nearby pelvic floor muscles can tighten or spasm in response to this, creating another reason for pain.  Over time, this leads to pelvic floor dyssynergia — where the muscles fail to relax properly during bowel movements or intercourse. The result is constipation, pain, and worsening pelvic tension. Pelvic floor physical therapy is a critical part of finding and working with pelvic floor  trigger points. 

Chronic pelvic pain can sometimes be driven not only by inflammatory endo lesions triggering nerve endings on the peritoneum (peripheral sensitization), but by nerve hypersensitivity or small fiber neuropathy (nerves themselves are damaged). Patients may also experience burning, tingling, or widespread pain that continues even after surgery. This represents central sensitization — when the nervous system becomes “stuck in pain mode.” Managing neuropathic pain is essential to restoring function and quality of life.

Some endometriosis patients develop fibromyalgia or ME/CFS, both characterized by widespread pain and profound fatigue. These syndromes reflect immune and mitochondrial dysfunction, which can make endometriosis symptoms more debilitating. Without recognition, patients may undergo unnecessary repeat surgeries when systemic support is what’s needed most. Integrating care for these conditions can dramatically improve daily function.

Ehlers–Danlos and related hypermobility disorders affect connective tissue strength and elasticity. Many patients experience pelvic pain, bowel dysfunction, and organ prolapse that mimic or compound endometriosis symptoms. Because connective tissue is more fragile, surgery and recovery can be more complex. EDS frequently overlaps with mast cell disorders and autonomic issues, creating a cluster of conditions that amplify pain and fatigue.  Some forms of EDS diagnosis are clinical and some are genetic and it’s critical to know the difference to minimize your risks. 

Dysautonomia is an autonomic nervous system dysfunction, often showing up as POTS — dizziness, rapid heartbeat, and fatigue when standing. These symptoms can be mistaken for anxiety or dismissed as unrelated, but they often coexist with endometriosis. Autonomic imbalance can intensify pain flares and make recovery after surgery more difficult. Recognizing this overlap is important to provide whole-person care and symptom relief.

Bladder pain syndrome is extremely common in endometriosis patients, yet often missed. It causes urinary frequency, urgency, and pelvic pain that overlap with endo symptoms, making diagnosis challenging. In some cases this is purely because there is a lot of endo growing on or into the bladder.  But even after successful excision surgery, bladder pain can persist. This may mean IC is part of the problem. Tailored bladder-directed therapies are often required for complete relief.

Hormonal imbalances are common in endometriosis patients, particularly thyroid disorders and overlapping polycystic ovary syndrome (PCOS). These conditions contribute to fatigue, irregular cycles, and fertility challenges. Chronic stress and adrenal dysfunction further amplify pain and inflammatory pathways. Screening for endocrine overlap allows for more precise and comprehensive treatment planning without tunnel vision focusing blindly on endo itself.