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 greatest problems of 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
The symptoms of endometriosis are varied and can mimic various 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 during deep penetration in sexual intercourse, indicative of 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 tiredness disproportionate to effort, present in up to 50% of patients, related 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 surface of the peritoneum
- 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.The anatomic stage does not correlate with the intensity of pain
DIAGNÓSTICO DIFERENCIAL
Diagnóstico Diferencial
Adenomyosis
- Globular and enlarged uterus on examination
- Predominant menorrhagia
- Dysmenorrhea in women aged 35 years or older
- Iron-deficiency anemia from heavy bleeding
Testes Diagnósticos
- Transvaginal ultrasonography
- Pelvic magnetic resonance imaging
Complement to chronic pain management in combination with hormonal treatment
IBS with Pelvic Pain
Leia mais →- Pain that improves with defecation
- Altered bowel habit
- Absence of deep dyspareunia
- Rectal bleeding
- Weight loss
Testes Diagnósticos
- Rome IV criteria
- Colonoscopy if alarm signs
Modulation of intestinal visceral hypersensitivity
Interstitial Cystitis
Leia mais →- Intense urinary urgency and frequency
- Suprapubic pain that relieves with voiding
- Negative urine cultures
- Macroscopic hematuria
Testes Diagnósticos
- Cystoscopy with hydrodistension
- Urine culture
Reduction of 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
Testes Diagnósticos
- Transvaginal ultrasonography
- Gynecologic examination
- STD serologies
Adjuvant in chronic residual pain after treatment of the infectious focus
Pelvic Floor Myofascial Dysfunction / Levator Ani Syndrome
Leia mais →- Perineal/rectal pain and pain in the deep pelvic region
- Worsens with prolonged sitting posture
- No clear relation with the menstrual cycle
Testes Diagnósticos
- Physical examination with palpation of pelvic floor muscles
- Specialized pelvic physical therapy assessment
Myofascial release and trigger points of 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 is characterized by invasion of the myometrium. Clinical differentiation is based 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, although coexistence is common. Hormonal treatment (mainly dienogest and the levonorgestrel IUD) is effective for both. Medical acupuncture contributes to the management of chronic pain not responsive to hormones.
IBS with Pelvic Pain
Irritable bowel syndrome and endometriosis are frequently confused — studies show that 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 bowel pattern of IBS.
The differential key is the relationship of symptoms to the menstrual cycle: in endometriosis, intestinal symptoms worsen during menstruation; in IBS, the pattern is more diffuse and related 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 is based on the history of acute PID episodes, the 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 be useful in chronic residual pain after control of the infectious focus.
Treatment
The treatment of endometriosis 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), continuous combined contraceptives. They suppress ovulation and estrogenic stimulation of the 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. Use 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 investigated as a complementary therapy for the pain associated with endometriosis. 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 conclusion, and larger subsequent trials are necessary.
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 in a multimodal approach. It is especially valued by patients who seek to reduce medication burden or to complement hormonal treatment with nonpharmacologic interventions.
Prognosis
Endometriosis is a chronic disease without definitive cure, but with control possible in the majority of cases. Continuous hormonal treatment can keep the disease in clinical remission. Spontaneous resolution is rare while ovarian function is active.
Regarding 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 desire future pregnancy.
After menopause, most patients experience significant improvement of symptoms with the fall in estrogen levels. 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, there is a risk of recurrence in 5-10% of cases.
Endometriosis only affects older women
Endometriosis can begin in adolescence, soon after menarche. Diagnostic delay makes it appear to be a disease of older women, but symptoms frequently begin in youth.
Severe pain means extensive disease
There is no correlation between pain intensity and anatomic extent. Superficial implants can cause intense 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 with experience in endometriosis. Early diagnosis and adequate treatment can prevent disease progression and preserve fertility.
Frequently Asked Questions
Endometriosis is the presence of tissue similar to the endometrium outside the uterus, causing chronic inflammation and pain. The 7- to 10-year delay in diagnosis occurs because menstrual pain is frequently normalized by society, there is no accessible diagnostic biomarker, and the symptoms mimic other conditions such as IBS and cystitis.
The acupuncturist physician acts mainly on central sensitization — the mechanism that perpetuates pain beyond the ectopic implants. The mechanisms include activation of descending inhibitory pain pathways, reduction of inflammatory cytokines (TNF-alpha, IL-6), and regulation of the autonomic nervous system. It does not act directly on the implants.
No. Hormonal treatment (dienogest, levonorgestrel IUD, contraceptives) acts on the implants by reducing estrogenic stimulation. Acupuncture complements by modulating chronic pain, especially the noncyclic component mediated by central sensitization. The combination of the two approaches is more effective than either alone.
A 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 necessary 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 after complete excision. Repeated surgeries can cause more adhesions. The current trend is to minimize surgeries and prioritize long-term clinical treatment.
It can. Infertility is present in 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 conclusion. Larger subsequent trials are necessary. The favorable safety profile justifies considering acupuncture as a complement to conventional treatment in the context of 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 intense dysmenorrhea, deep dyspareunia, catamenial dyschezia, and can compromise adjacent organs.
Start with a gynecologist — preferably one with experience in endometriosis. For complex cases (suspicion of deep endometriosis, infertility, treatment failure), evaluation at a specialized center is recommended. The acupuncturist physician can be incorporated into multimodal care for the management of chronic pain.
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