What Is Endometriosis?
Endometriosis is a chronic inflammatory disease characterized by the presence of tissue similar to the endometrium (inner lining of the uterus) outside the uterine cavity. These ectopic implants respond to the hormones of the menstrual cycle, causing chronic inflammation, pain, and adhesions.
It affects approximately 6-10% of women of reproductive age — about 190 million women globally. The most common implantation sites are the ovaries, pelvic peritoneum, uterosacral ligaments, and rectovaginal septum. In rare cases, it can affect distant organs such as the diaphragm and pleura.
Diagnostic delay is one of the biggest problems in endometriosis — on average, 7 to 10 years elapse between symptom onset and definitive diagnosis. This delay results from societal normalization of menstrual pain and the lack of noninvasive diagnostic biomarkers.
Chronic Disease
Endometriosis is a chronic estrogen-dependent disease that requires long-term management. There is no definitive cure, but it is controllable.
Diagnostic Delay
Diagnosis takes an average of 7-10 years, resulting in disease progression and unnecessary suffering.
Pain and Infertility
The two main impacts are chronic pelvic pain (in 70-80%) and infertility (in 30-50% of affected women).
Pathophysiology
The most accepted theory for the origin of endometriosis is retrograde menstruation (Sampson theory): during menstruation, fragments of endometrium reflux through the fallopian tubes into the peritoneal cavity, where they implant and grow. Although 90% of women have retrograde menstruation, only a minority develop endometriosis — indicating that immunologic and genetic factors determine susceptibility.
Endometriotic implants establish an inflammatory microenvironment in the peritoneum. Macrophages, dysfunctional NK cells, and lymphocytes release cytokines (IL-1, IL-6, IL-8, TNF-alpha), growth factors (VEGF), and prostaglandins that promote implant survival, neoangiogenesis, and neurogenesis — the formation of new sensory nerve fibers that amplify pain.
Central sensitization explains why pain in endometriosis does not correlate well with the anatomic extent of the disease. Small peritoneal implants can cause intense pain, while bulky ovarian endometriomas can be asymptomatic. Chronic noxious stimulation reprograms the central nervous system, creating generalized visceral and somatic hyperalgesia.
Symptoms
Endometriosis symptoms are varied and can mimic many other conditions. The classic triad is progressive dysmenorrhea, deep dyspareunia, and chronic pelvic pain. However, up to 20-25% of women with endometriosis are asymptomatic.
Clinical Manifestations
- 01
Progressive dysmenorrhea
Menstrual cramping that worsens over the years, does not respond well to NSAIDs, and impacts daily activities.
- 02
Chronic pelvic pain
Noncyclic pelvic pain present for more than 6 months, which can be constant or intermittent.
- 03
Deep dyspareunia
Pain on deep penetration during intercourse, suggesting implants in the rectovaginal septum or uterosacral ligaments.
- 04
Infertility
Present in 30-50% of cases. Results from adhesions, tubal dysfunction, endometrial alterations, and follicular inflammation.
- 05
Catamenial dyschezia
Pain on defecation during menstruation, suggesting implants in the rectovaginal septum or bowel.
- 06
Cyclic urinary symptoms
Dysuria, urgency, or hematuria that worsens during menstruation, indicating bladder involvement.
- 07
Chronic fatigue
Persistent fatigue disproportionate to effort, present in up to 50% of patients and linked to systemic inflammation.
Diagnosis
The definitive diagnosis historically requires surgical visualization (laparoscopy) with histopathologic confirmation. However, current ESHRE guidelines recommend that diagnosis can be clinical, based on symptoms and imaging studies, without the need for surgical confirmation to start treatment.
Transvaginal ultrasonography with bowel preparation and pelvic magnetic resonance imaging are capable of detecting deep endometriosis and endometriomas with good accuracy. CA-125 may be elevated, but it has low sensitivity and specificity, and is not recommended as a stand-alone diagnostic test.
🏥Endometriosis Classification
- 1.Superficial peritoneal endometriosis: implants on the peritoneal surface
- 2.Ovarian endometrioma: ovarian cysts containing endometriotic content ("chocolate cysts")
- 3.Deep infiltrating endometriosis: implants that penetrate more than 5 mm below the peritoneal surface
- 4.Revised ASRM classification: stages I (minimal), II (mild), III (moderate), IV (severe)
- 5.Anatomic stage does not correlate with pain intensity
DIFFERENTIAL DIAGNOSIS
Differential Diagnosis
Adenomyosis
- Globular and enlarged uterus on examination
- Predominant menorrhagia
- Dysmenorrhea in women aged 35 years or older
- Iron-deficiency anemia from heavy bleeding
Diagnostic Tests
- Transvaginal ultrasonography
- Pelvic magnetic resonance imaging
Complement to chronic pain management alongside hormonal treatment
IBS with Pelvic Pain
Read more →- Pain that improves with defecation
- Altered bowel habit
- Absence of deep dyspareunia
- Rectal bleeding
- Weight loss
Diagnostic Tests
- Rome IV criteria
- Colonoscopy if alarm signs
Modulation of intestinal visceral hypersensitivity
Interstitial Cystitis
Read more →- Intense urinary urgency and frequency
- Suprapubic pain that relieves with voiding
- Negative urine cultures
- Macroscopic hematuria
Diagnostic Tests
- Cystoscopy with hydrodistension
- Urine culture
Reduced bladder hypersensitivity and pelvic pain modulation
Chronic Salpingitis
- History of pelvic inflammatory disease
- Bilateral adnexal pain
- Fever or discharge in the acute phase
- Fever and adnexal mass — tubo-ovarian abscess
Diagnostic Tests
- Transvaginal ultrasonography
- Gynecologic examination
- STD serologies
Adjuvant for chronic residual pain after treatment of the infectious focus
Pelvic Floor Myofascial Dysfunction / Levator Ani Syndrome
Read more →- Perineal/rectal pain and pain in the deep pelvic region
- Worsens with prolonged sitting posture
- No clear relation with the menstrual cycle
Diagnostic Tests
- Physical examination with palpation of pelvic floor muscles
- Specialized pelvic physical therapy assessment
Myofascial release and trigger-point work on the pelvic floor musculature
Adenomyosis
Adenomyosis is the condition closest to endometriosis and frequently coexists with it. While endometriosis implants endometrial tissue outside the uterus, adenomyosis involves invasion of the myometrium. Clinical differentiation rests on more prominent menorrhagia in adenomyosis and a globular uterus on examination.
Pelvic magnetic resonance imaging is the imaging study of choice to differentiate the two conditions, though coexistence is common. Hormonal treatment (mainly dienogest and the levonorgestrel IUD) is effective for both. Medical acupuncture helps manage chronic pain unresponsive to hormones.
IBS with Pelvic Pain
Irritable bowel syndrome and endometriosis are frequently confused — studies show up to 50% of women with endometriosis are initially diagnosed with IBS. Catamenial dyschezia (pain on defecation during menstruation) is an important clinical marker of rectovaginal endometriosis that differs from the IBS bowel pattern.
The differential key is how symptoms relate to the menstrual cycle: in endometriosis, intestinal symptoms worsen during menstruation; in IBS, the pattern is more diffuse and tied to diet and stress. Visceral convergence between bowel and pelvis explains the frequent clinical overlap.
Chronic Salpingitis
Chronic salpingitis, resulting from previous episodes of pelvic inflammatory disease, can cause chronic pelvic pain with a pattern similar to endometriosis. Clinical distinction rests on a history of acute PID episodes, more bilateral pain, and the absence of the typical cyclic pattern of endometriosis.
Screening for STDs (Chlamydia trachomatis, Neisseria gonorrhoeae) is fundamental in the differential diagnosis. Adequate antibiotic treatment of acute episodes prevents chronicity. Acupuncture can help with chronic residual pain after the infectious focus is controlled.
Treatment
Endometriosis treatment depends on the patient's goals — pain control, fertility preservation, or both. The approach combines hormonal treatment to suppress implant growth, surgical treatment when indicated, and multimodal pain management.
Hormonal Treatment (First Line)
Progestins (dienogest 2 mg/day, levonorgestrel IUD) and continuous combined contraceptives. They suppress ovulation and estrogenic stimulation of implants. Effective for pain in 60-80% of cases.
GnRH Analogues and Antagonists
GnRH analogues (leuprolide, goserelin) or oral GnRH antagonists (elagolix, relugolix) — suppress ovarian function. Pairing them with add-back therapy (estradiol + norethindrone or equivalent) from the outset prevents bone loss and allows longer use as indicated by the gynecologist.
Surgical Treatment
Laparoscopy for excision or ablation of implants, resection of endometriomas, lysis of adhesions. Indicated for refractory disease, infertility, or organ obstruction.
Multimodal Pain Management
Pelvic physical therapy, cognitive behavioral therapy, neuromodulators (amitriptyline, gabapentin), acupuncture. Essential to address central sensitization and chronic pain.
Acupuncture as Treatment
Acupuncture is being investigated as a complementary therapy for endometriosis-related pain. The Cochrane review on acupuncture for endometriosis (Zhu et al., 2011) identified very limited evidence (based on 1 RCT, Wayne 2008) suggesting possible benefit — the evidence remains insufficient for firm conclusions, and larger subsequent trials are needed.
Proposed mechanisms — still under investigation — include modulation of central sensitization by activation of descending inhibitory pain pathways, possible reduction of inflammatory cytokines (TNF-alpha, IL-6), release of endorphins, and modulation of the autonomic nervous system. Acupuncture has been investigated as potentially relevant for the noncyclic chronic pain component, in which central sensitization appears to play an important role.
Acupuncture does not act on endometriotic implants themselves but can contribute to pain control within a multimodal approach. It is especially valued by patients who want to reduce medication burden or complement hormonal treatment with nonpharmacologic interventions.
Prognosis
Endometriosis is a chronic disease without a definitive cure, but control is possible in most cases. Continuous hormonal treatment can keep the disease in clinical remission. Spontaneous resolution is rare while ovarian function is active.
As for fertility, women with mild to moderate endometriosis can conceive naturally, while severe cases may require in vitro fertilization. Early reproductive counseling is essential for patients who want a future pregnancy.
After menopause, most patients experience significant symptom improvement as estrogen levels fall. However, hormone replacement therapy can reactivate the disease in a minority of cases.
Myths and Facts
Myth vs. Fact
Pregnancy cures endometriosis
Pregnancy can temporarily relieve symptoms through hormonal suppression, but it does not cure the disease. Symptoms frequently return after delivery and breastfeeding.
Hysterectomy cures endometriosis
Hysterectomy without oophorectomy does not guarantee cure, since peritoneal implants can persist under ovarian stimulation. Even with oophorectomy, recurrence occurs in 5-10% of cases.
Endometriosis only affects older women
Endometriosis can begin in adolescence, soon after menarche. Diagnostic delay makes it look like a disease of older women, but symptoms frequently start in youth.
Severe pain means extensive disease
Pain intensity does not correlate with anatomic extent. Superficial implants can cause severe pain through local neurogenesis, while large endometriomas can be asymptomatic.
When to Seek Help
If you suspect endometriosis, seek evaluation with a gynecologist — preferably one experienced in endometriosis. Early diagnosis and adequate treatment can prevent disease progression and preserve fertility.
Frequently Asked Questions
Endometriosis is the presence of endometrium-like tissue outside the uterus, causing chronic inflammation and pain. The 7- to 10-year diagnostic delay happens because society frequently normalizes menstrual pain, there is no accessible diagnostic biomarker, and symptoms mimic other conditions such as IBS and cystitis.
The medical acupuncturist works mainly on central sensitization — the mechanism that perpetuates pain beyond the ectopic implants. Mechanisms include activating descending inhibitory pain pathways, reducing inflammatory cytokines (TNF-alpha, IL-6), and regulating the autonomic nervous system. It does not act directly on the implants.
No. Hormonal treatment (dienogest, levonorgestrel IUD, contraceptives) acts on implants by reducing estrogenic stimulation. Acupuncture complements it by modulating chronic pain, especially the noncyclic component mediated by central sensitization. Combining the two approaches is more effective than either alone.
Reassessment after 8 to 12 initial sessions is recommended. The response is gradual, with growing benefits over 3 to 6 months of regular treatment. Periodic maintenance (biweekly or monthly) may be needed to sustain benefits in cases of established central sensitization.
No. Surgery can relieve pain and improve fertility by excising implants, but it does not cure the disease. The recurrence rate is 20 to 40% within 5 years of complete excision. Repeated surgeries can cause more adhesions. The current trend is to minimize surgeries and prioritize long-term clinical treatment.
It can. Infertility affects 30 to 50% of women with endometriosis, resulting from adhesions, tubal dysfunction, endometrial alterations, and follicular inflammation. Women with mild to moderate endometriosis frequently conceive naturally; severe cases may require in vitro fertilization.
The Cochrane review on acupuncture for endometriosis (Zhu et al., 2011) identified very limited evidence (based on 1 RCT, Wayne 2008) suggesting possible benefit on pelvic pain and dysmenorrhea — the evidence remains insufficient for firm conclusions. Larger subsequent trials are needed. The favorable safety profile justifies considering acupuncture as a complement to conventional treatment within shared decision-making.
No. Pregnancy can temporarily relieve symptoms through hormonal suppression during pregnancy and breastfeeding. However, the disease frequently returns after cycle normalization. In addition, recommending pregnancy as "treatment" is ethically inadequate and can pressure women who do not yet desire to become pregnant.
It is the most severe form of endometriosis, with implants that penetrate more than 5 mm below the peritoneal surface. It frequently affects the rectovaginal septum, uterosacral ligaments, bowel, and bladder. It causes severe dysmenorrhea, deep dyspareunia, and catamenial dyschezia, and can compromise adjacent organs.
Start with a gynecologist — preferably one experienced in endometriosis. For complex cases (suspected deep endometriosis, infertility, treatment failure), evaluation at a specialized center is recommended. A medical acupuncturist can be incorporated into multimodal care for chronic pain management.
Related Reading
Deepen your knowledge with related articles