Endometriosis

Endometriosis is a disease in which tissue similar to the lining of the uterus grows elsewhere in the body.<ref>Template:Cite web</ref> It occurs in humans and a limited number of other mammals that have a menstruation cycle, notably primates.<ref> Template:Cite journal</ref> The tissue most often grows on or around the ovaries and fallopian tubes, on the outside surface of the uterus, or the tissues surrounding the uterus and the ovaries.<ref name="WH2014">Template:Cite web</ref> It can also grow on other organs in the pelvic region like the bowels, stomach or bladder.<ref>Template:Cite web</ref> Rarely, it can also occur in other parts of the body.<ref name="WH2014" />

Symptoms can be very different from person to person, varying in range and intensity. About 25% of individuals have no symptoms,<ref name="Bulletti2010" /> while for some it can be a debilitating disease.<ref>Template:Cite web</ref> Common symptoms include pelvic pain, heavy and painful periods, pain with bowel movements, painful urination, pain during sexual intercourse, and infertility.<ref name="Bulletti2010">Template:Cite journal</ref><ref>Template:Cite web</ref> Nearly half of those affected have chronic pelvic pain, while 70% feel pain during menstruation.<ref name="Bulletti2010" /> Up to half of affected individuals are infertile.<ref name="Bulletti2010" /> Besides physical symptoms, endometriosis can affect a person's mental health and social life.<ref name="Cul2013">Template:Cite journal</ref>

Diagnosis is usually based on symptoms and medical imaging;<ref name="WH2014" /> however, a definitive diagnosis is made through laparoscopy (keyhole surgery).<ref name="WH2014" /> Other causes of similar symptoms include pelvic inflammatory disease, irritable bowel syndrome, interstitial cystitis, and fibromyalgia.<ref name="Bulletti2010" /> Endometriosis is often misdiagnosed and many patients report being incorrectly told their symptoms are trivial or normal.<ref name="Cul2013" /> Patients with endometriosis see an average of seven physicians before receiving a correct diagnosis.<ref>Template:Cite journal</ref>

Worldwide, around 10% of the female population of reproductive age (190 million women) are affected by endometriosis.<ref name="WHO Fact Sheet">Template:Cite web</ref> Asian women are more likely than White women to be diagnosed with endometriosis.<ref name="zondervan32212520" /><ref name="Velarde">Template:Cite journal "Compared with Caucasian women, Asian women are more likely to be diagnosed with endometriosis (odds ratio (OR) 1.63, 95% CI 1.03–2.58) (14). Filipinos, Indians, Japanese, and Koreans are among the top Asian ethnicities who are more likely to have endometriosis than Caucasian women (17)."</ref> The exact cause of endometriosis is not known. Possible causes include problems with menstrual period flow, genetic factors, hormones, and problems with the immune system.<ref name="WH2014" />

While there is no cure for endometriosis, several treatments may improve symptoms.<ref name="Bulletti2010" /> This includes pain medication, hormonal treatments or surgery. The recommended pain medication is usually a non-steroidal anti-inflammatory drug (NSAID), such as naproxen. Taking the birth control pill continuously or using a hormonal IUD (coil) is another first-line treatment. Other types of hormonal treatment can be tried if the pill or IUD are not effective.Template:Sfn Surgical removal of endometriosis may be used to treat those whose symptoms are not manageable with other treatments, or to treat infertility.<ref name="WH2025" />

Subtypes

Endoscopic image of a ruptured endometrioma (chocolate cyst) in left ovary

Endometriosis can be subdivided into four categories:<ref name=":7" />

Superficial peritoneal endometriosis

Small spots of endometriosis grow on the surface layer that covers the organs inside the abdomen or pelvis (the peritoneum)

Deep infiltrating endometriosis

Lesions grow into the tissue beneath the lining of the pelvis or into the muscle layers of pelvic organs like the bowel, bladder, or ureter

Endometriomas (ovarian)

Cysts that grow in the ovaries

Extrapelvic endometriosis

Lesions outside of the pelvic regions, such as in the lungs or diaphragm

Health care providers may call areas of endometriosis by different names, such as implants, lesions, or nodules. Larger lesions may be seen within the ovaries as endometriomas or "chocolate cysts"; "chocolate" because they contain a thick brownish fluid, mostly old blood.<ref name="pmid20436318">Template:Cite journal</ref>

Endometriosis most commonly affects the ovaries, the fallopian tubes between the ovaries and the womb, the outer surface of the womb and the tissues that hold the womb in place. Less common pelvic sites are the rectum, bladder, bowel, vulva, vagina and cervix<ref name="WH2025">Template:Cite web</ref> Deep infiltrating endometriosis occurs when endometriosis grows more than 5 mm beneath the peritoneal surface.<ref name="Van den Bosch Van Schoubroeck 2018 pp. 16–24" /> It can infiltrate the muscles around organs.<ref name=":7" /> The prevalence of deep infiltrating endometriosis is estimated to be 1–2% in women of reproductive age.<ref name="Van den Bosch Van Schoubroeck 2018 pp. 16–24">Template:Cite journal</ref> Deep endometriosis often looks like nodules, and can include fibrosis and adhesions.<ref name=":7" />

Rarely, endometriosis appears in outside of the pelvis, such as the lungs, brain, and skin.<ref name="WH2025" /> Diaphragmatic endometriosis is rare, almost always on the right hemidiaphragm, and may cause the cyclic pain of the right shoulder or neck during a menstrual period.<ref name="Andres2020p373">Template:Cite journal</ref> Scar endometriosis can rarely form on the abdominal wall as a complication of surgery, most often following a ceasarean section or other pelvic surgery.<ref>Template:Cite journal</ref>

Signs and symptoms

Pain and infertility are common symptoms, although 20–25% of affected women are asymptomatic.<ref name=Bulletti2010/> The presence of pain symptoms is associated with the type of endometrial lesions, as 50% of women with typical (peritoneal) lesions, 10% of women with cystic ovarian lesions, and 5% of women with deep endometriosis do not have pain.<ref name="Koninckx Ussia Mashiach Vilos 2021 pp. 1035–1036">Template:Cite journal</ref>

Pelvic pain

A major symptom of endometriosis is recurring pelvic pain. The pain can range from mild to severe cramping or stabbing pain that occurs on both sides of the pelvis, in the lower back and rectal area, and even down the legs. The amount of pain a person feels correlates weakly with the extent or stage (1 through 4) of endometriosis, with some individuals having little or no pain despite having extensive endometriosis or endometriosis with scarring, while others may have severe pain even though they have only a few small areas of endometriosis.<ref name="Stratton2011">Template:Cite journal</ref> The most severe pain is typically associated with menstruation. Pain can also start a week before a menstrual period, during, and even a week after a menstrual period, or it can be constant. The pain can be debilitating and result in emotional stress.<ref>Template:Cite journal</ref> Symptoms of endometriosis-related pain may include:

• Dysmenorrhea (64%)<ref name="ovarianendo">Template:Cite journal Text was copied from this source, which is available under a Creative Commons Attribution 4.0 International License Template:Webarchive.</ref> – painful, sometimes disabling cramps during the menstrual period; pain may get worse over time (progressive pain), also lower back pains linked to the pelvis
• Chronic pelvic pain – typically accompanied by lower back pain or abdominal pain
• Dyspareunia – painful sexual intercourse
• Painful urination during period<ref name="NIH">Template:Cite web</ref>
• Mittelschmerz – pain associated with ovulation<ref>Template:Cite journal</ref>

Compared with patients with superficial endometriosis, those with deep disease appear to be more likely to report shooting rectal pain and a sense of their insides being pulled down.<ref name="Ballard">Template:Cite journal</ref> Individual pain areas and intensity appear to be unrelated to the surgical diagnosis, and the area of pain is unrelated to the area of endometriosis.<ref name=Ballard/>

Infertility

About a third of women with infertility have endometriosis.<ref name=Bulletti2010/> Among those with endometriosis, about 40% are infertile.<ref name=Bulletti2010/> The pathogenesis of infertility varies by disease stage: in early-stage disease, it is hypothesised to result from an inflammatory response that impairs various aspects of conception, whereas in later stages, distorted pelvic anatomy and adhesions contribute to impaired fertilisation.<ref>Template:Cite web</ref>

Other

Bowel endometriosis may include symptoms like diarrhea, constipation, tenesmus, dyschezia, and, rarely, rectal bleeding. Other symptoms include chronic fatigue, nausea and vomiting, migraines, low-grade fevers, heavy (44%) and/or irregular periods (60%), and hypoglycemia.<ref name="ovarianendo"/><ref>Template:Cite journal</ref><ref name="NIH" /> Endometriosis may also affect the nearby colon, which in rare situations may progress to partial obstruction, requiring emergency surgery.<ref>Template:Cite journal</ref>

Thoracic endometriosis occurs when endometrium-like tissue implants in the lungs or pleura around the lungs. When it occurs in the lungs, common signs and symptoms are blood discharge from the lungs during menstruation and nodules which become bigger during menstruation. When it is found in the pleura, symptoms may be a collapsed lung during or outside of menstruation and bleeding into the pleural space. Further symptoms are a cyclical cough and cyclical shoulder pain. Most often, the endometriosis is found in the right lung.Template:Sfn

Stress may be a contributing factor or a consequence of endometriosis.<ref name=stress>Template:Cite journal</ref>

Complications

Physical health

Ovarian endometriosis may complicate pregnancy through decidualization, abscess formation, and/or rupture.<ref name="Ueda">Template:Cite journal</ref> Women with endometriosis also face a significantly increased risk of experiencing ante- and postpartum hemorrhage<ref name="ESHRE2015">Template:Cite web</ref> as well as a 170% increased risk of severe pre-eclampsia<ref name="PMID28181672" /> during pregnancy. Endometriosis can also impact a woman's fetus or neonate, increasing the risks for congenital malformations, preterm delivery, and higher neonatal death rates.<ref name="PMID28181672">Template:Cite journal</ref>

Sciatic endometriosis, also called catamenial or cyclical sciatica, is a rare form where endometriosis affects the sciatic nerve. Diagnosis is usually confirmed through MRI or CT-myelography.<ref name="Gandhi Wilson Liang Weissbart pp. 3–9">Template:Cite journal</ref>

A 20-year study involving 12,000 women with endometriosis found that individuals under 40 are three times more likely to develop heart problems compared to their healthy peers.<ref>Template:Cite journal</ref>

Endometriosis increases the risk of developing ovarian and thyroid cancers compared to women without the condition, and slightly increases the risk of breast cancer.<ref name="Kvaskoff Mahamat-Saleh Farland Shigesi pp. 393–420">Template:Cite journal</ref>

The mortality rates associated with endometriosis are low, with unadjusted and age-standardized death rates of 0.1 and 0.0 per 100,000, respectively.<ref name="GBD2015Pre">Template:Cite journal</ref>

Mental health

"Endometriosis is associated with an elevated risk of developing depression and anxiety disorders".<ref>Template:Cite journal</ref> Studies suggest this is partially due to the pelvic pain experienced by endometriosis patients. Template:Blockquote Mental health concerns like depression and anxiety can also result due to poor diagnostic procedures related to cultural norms where women's concerns are devalued or ignored, especially by medical professionals.<ref>Culley L, Law C, Hudson N, Denny E, Mitchell H, Baumgarten M, et al. (1 November 2013). "The social and psychological impact of endometriosis on women's lives: a critical narrative review". Human Reproduction Update. 19 (6): 625–39. doi:10.1093/humupd/dmt027. hdl:2086/8845. PMID 23884896.</ref><ref>Nnoaham KE, Hummelshoj L, Webster P, d'Hooghe T, de Cicco Nardone F, de Cicco Nardone C, et al. (August 2011). "Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries". Fertility and Sterility. 96 (2): 366–373.e8. doi:10.1016/j.fertnstert.2011.05.090. PMC 3679489. PMID 21718982.</ref>

Risk factors

Genetics

Endometriosis is a heritable condition influenced by both genetic and environmental factors,<ref name="Fauser2011">Template:Cite journal</ref> a genetic disorder of polygenic/multifactorial inheritance<ref name="GOE-2004">Template:Cite journal</ref> acquired via affected genes from either a person's father or mother. For example, children or siblings of women with endometriosis are at higher risk of developing endometriosis themselves; low progesterone levels may be genetic, and may contribute to a hormone imbalance.<ref>Template:Cite web</ref> Individuals with an affected first-degree relative have an approximate six-fold increase incidence of endometriosis.<ref>Template:Cite journal</ref>

Inheritance is significant but not the sole risk factor for endometriosis. Studies attribute 50% of the risk to genetics, the other 50% to environmental factors.<ref name="Montgomery2020">Template:Cite journal</ref> It has been proposed that endometriosis may result from multiple mutations within target genes, in a mechanism similar to the development of cancer.<ref name=Fauser2011/> In this case, the mutations may be either somatic or heritable.<ref name=Fauser2011/>

A 2019 genome-wide association study (GWAS) review enumerated 36 genes with mutations associated with endometriosis development.<ref name="Vassilopoulou2019">Template:Cite journal</ref> Nine chromosome loci were robustly replicated:<ref>Template:Cite journal</ref><ref name="Gene94025">Template:Cite web</ref><ref name="Gene2335">Template:Cite web</ref><ref name="Sapkota Steinthorsdottir Morris Fassbender p.">Template:Cite journal</ref>

Chromosome	Gene/cytoband	Gene Product	Function
1	WNT4/1p36.12	Wingless-type MMTV integration site family member 4	Vital for the development of the female reproductive organs
2	GREB1/2p25.1	Growth regulation by estrogen in breast cancer 1/Fibronectin 1	Early response gene in the estrogen regulation pathway/Cell adhesion and migration processes
2	ETAA1/2p14	(ETAA1 Activator Of ATR Kinase) is a protein-coding gene.	Diseases associated with ETAA1 include Adult Lymphoma and Restless Legs Syndrome
2	IL1A/2q13	Interleukin 1 alpha (IL-1α) is encoded by the IL1A gene.	Interleukin 1 alpha (IL-1α) is encoded by the IL1A gene.
4	KDR/4q12	KDR is the human gene encoding kinase insert domain receptor, also known as vascular endothelial growth factor receptor 2 (VEGFR-2)	Primary mediator of VEGF-induced endothelial proliferation, survival, migration, tubular morphogenesis and sprouting<ref>Template:Cite web</ref>
6	ID4/6p22.3	Inhibitor of DNA binding 4	Ovarian oncogene, biological function unknown
7	7p15.2	Transcription factors	Influence transcriptional regulation of uterine development
9	CDKN2BAS/9p21.3	Cyclin-dependent kinase inhibitor 2B antisense RNA	Regulation of tumour suppressor genes
12	VEZT/12q22	Vezatin, an adherens junction transmembrane protein	Tumor suppressor gene

There are many findings of altered gene expression and epigenetics, but both of these can also be a secondary result of, for example, environmental factors and altered metabolism. Examples of altered gene expression include that of miRNAs.<ref name=Fauser2011/>

Environmental toxins

Some factors associated with endometriosis include:

• Prolonged exposure to naturally synthesized estrogen; for example, from late menopause<ref name="Clinical practice. Endometriosis">Template:Cite journal</ref> or early menarche<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref>
• Obstruction of menstrual outflow; for example, in Müllerian anomalies<ref name="Clinical practice. Endometriosis"/>

Potential toxins:

• Dioxins - Several studies have investigated the potential link between exposure to dioxins and endometriosis, but evidence is equivocal, and potential mechanisms are poorly understood.<ref name="pmid17981650">Template:Cite journal</ref> A 2004 review of studies of dioxin and endometriosis concluded that "the human data supporting the dioxin-endometriosis association are scanty and conflicting",<ref>Template:Cite journal</ref> and a 2009 follow-up review also found that there was "insufficient evidence" in support of a link between dioxin exposure and developing endometriosis.<ref>Template:Cite journal</ref>
• Endocrine-disrupting chemicals (EDCs)- A wider class of hormonally active agents, to which dioxin belongs, consists of both natural and manmade compounds, e.g., bisphenols, phthalates, pesticides (chlorpyrifos, hexachlorobenzene) and polychlorinated biphenyls (PCBs).<ref name="Ahn-2023">Template:Cite journal</ref> Dietary uptake represents a significant source of EDC exposure via consumption of food, water and beverages, but exposure can also occur through ingestion of EDC dust and inhalation of its gases or particles in the air.<ref name="Ahn-2023" /> Most EDCs are lipophilic, allowing them to bioaccumulate in adipose tissue (body fat) and increase in concentration.<ref name="Rumph2020" /> Bisphenol A (BPA), bisphenol S (BPS), phthalates, pesticides and PCBs all have a suspected linkage to endometriosis,<ref name="Ahn-2023" /> though have not been definitively proven as being causative.<ref name="Rumph2020">Template:Cite book</ref>

Autoimmune and autoinflammatory conditions

Endometriosis patients show a significantly increased risk of autoimmune, autoinflammatory, and mixed-pattern psoriatic diseases, with two studies in 2025 pointing to the connection. One of the studies suggested that the chances of receiving a diagnosis of at least one of the autoimmune conditions for those with endometriosis was around twice that of a control cohort. The linked conditions include rheumatoid arthritis, multiple sclerosis, coeliac disease, osteoarthritis, and psoriasis. This reinforces the view that there is a genetic correlation between endometriosis and osteoarthritis, rheumatoid arthritis, and multiple sclerosis (MS), and a potential causal link to rheumatoid arthritis. The work suggests a shared biological basis between endometriosis on one side, and autoimmune and autoinflammatory diseases, on the other. This suggests that certain autoimmunne treatment pathways could be repurposed to provided alternative therapy options for those with endometriosis.<ref name="NewScienceClark">Template:Cite journal</ref><ref name="Shigesi"> Template:Cite journal </ref><ref name="AzizBeaton"> Template:Cite journal</ref>

Mechanism

Six characteristics of endometriosis: estrogen dependency, retrograde menstruation, angiogenesis, local inflammation, oxidative stress and stem cells

While the exact cause of endometriosis remains unknown, many theories have been presented to understand and explain its development. These concepts do not necessarily exclude each other. The pathophysiology of endometriosis is likely to be multifactorial and to involve an interplay between several factors.<ref name="Fauser2011" />

Formation

The main theories for the formation of the ectopic endometrium-like tissue include retrograde menstruation, Müllerianosis, coelomic metaplasia, vascular dissemination of stem cells, and surgical transplantation, which were postulated as early as 1870. Each is further described below.<ref name="zondervan32212520" /><ref name="vanderLinden1996">Template:Cite journal</ref><ref name="hufnagelpmc4986990">Template:Cite journal</ref>

Retrograde menstruation theory

During menstruation, some menstrual blood, tissue, and fluid can flow backward through the fallopian tubes into the pelvic area (the peritoneal cavity). This backward flow (called retrograde menstruation) is thought to be the main reason why endometriosis develops inside the pelvic cavity. However, this explanation alone is not enough, because almost all women have some backward flow of menstrual fluid, but only some of them develop endometriosis.<ref name="Horne2022" />

Evidence in support of the theory are based on retrospective epidemiological studies that an association with endometrial implants attached to the peritoneal cavity, which would develop into endometrial lesions and retrograde menstruation; and the fact that animals like rodents and non-human primates whose endometrium is not shed during the estrous cycle don't produce naturally endometriosis contrary to animals that have a natural menstrual cycle like rhesus monkeys and baboons.<ref name="Malvezzi Marengo Podgaec Piccinato p.">Template:Cite journal</ref>

Endometriosis has shown up in people who have never experienced menstruation including men, female fetuses, and prepubescent girls.<ref>Template:Cite journal</ref> Further theoretical additions are needed to complement the retrograde menstruation theory to explain why cases of endometriosis show up in the brain<ref>Template:Cite journal</ref> and lungs.<ref>Template:Cite journal</ref>

Researchers are investigating the possibility that the immune system may be unable to cope with the cyclic onslaught of retrograde menstrual fluid. In this context there is interest in studying the relationship of endometriosis to autoimmune disease, allergic reactions, and the impact of toxic materials.<ref name="Lino">Template:Cite journal</ref><ref>Template:Cite journal</ref>

Endometriotic lesions differ in their biochemistry, hormonal response, immunology, and inflammatory response compared to the endometrium.<ref name="zondervan32212520" /><ref name="pmid12372441">Template:Cite journal</ref> This is likely because the cells that give rise to endometriosis are a side population of cells.<ref name="Fauser2011" /> Similarly, there are changes in, for example, the mesothelium of the peritoneum in people with endometriosis, such as loss of tight junctions. It is unknown if these are causes or effects of the disorder.<ref name="Young2013">Template:Cite journal</ref>

In rare cases, when an imperforate hymen persists to menarche, menstrual outflow can be obstructed, leading to retention of blood within the vagina and uterus (hematocolpos/hematometra) and, in some cases, into the Fallopian tubes. Symptoms (e.g., pelvic or abdominal pain) may be nonspecific, contributing to delayed recognition. Prolonged obstruction can produce retrograde menstruation, a mechanism widely discussed in reviews of endometriosis pathogenesis.<ref name="Lee2019">Lee KH, Hong JS, Jung HJ, et al. "Imperforate Hymen: A Comprehensive Systematic Review." J Clin Med. 2019;8(1):56.</ref><ref name="Bulun2022">Bulun SE, Yilmaz BD, Sison C, et al. "Endometriosis caused by retrograde menstruation." Fertil Steril. 2022;118(4):713–732.</ref><ref name="Lamceva2023">Lamceva J, Popovska S, Jovanovska V, et al. "The Main Theories on the Pathogenesis of Endometriosis." Biomedicines. 2023;11(3):776.</ref>

Other theories

• Stem cells: Endometriosis may arise from stem cells from bone marrow and potentially other sources. In particular, this theory explains endometriosis found in areas remote from the pelvis, such as the brain or lungs.<ref name="hufnagelpmc4986990" /> Stem cells may be from local cells such as the peritoneum (see coelomic metaplasia below) or cells disseminated in the bloodstream (see vascular dissemination below) such as those from the bone marrow.<ref name="vanderLinden1996" /><ref name="hufnagelpmc4986990" /><ref name="sampson27ajogdoi">Template:Cite journal</ref>
• Vascular dissemination: Vascular dissemination is a 1927 theory that has been revived with new studies of bone marrow stem cells involved in pathogenesis.<ref name="hufnagelpmc4986990" /><ref name="sampson27ajogdoi" />
• Müllerianosis: A theory supported by foetal autopsy is that cells with the potential to become endometrial, which are laid down in tracts during embryonic development called the female reproductive (Müllerian) tract, as it migrates downward at 8–10 weeks of embryonic life, could become dislocated from the migrating uterus and act like seeds or stem cells.<ref name="vanderLinden1996" /><ref name="signorile2009">Template:Cite journal</ref>
• Coelomic metaplasia: Coelomic cells which are the common ancestor of endometrial and peritoneal cells may undergo metaplasia (transformation) from one type of cell to the other, perhaps triggered by inflammation.<ref name="vanderLinden1996" /><ref name="aafp1999">Template:Cite journal</ref>
• Vasculogenesis: Up to 37% of the microvascular endothelium of ectopic endometrial tissue originates from endothelial progenitor cells, which result in de novo formation of microvessels by the process of vasculogenesis rather than the conventional process of angiogenesis.<ref>Template:Cite journal</ref>Template:Clarify
• Neural growth: An increased expression of new nerve fibres is found in endometriosis, but does not fully explain the formation of ectopic endometriotic tissue and is not definitely correlated with the amount of perceived pain.<ref name="MorottiVincent2014">Template:Cite journal</ref>Template:Clarify
• Autoimmune: Graves disease is an autoimmune disease characterized by hyperthyroidism, goiter, ophthalmopathy, and dermopathy. People with endometriosis had higher rates of Graves' disease. One of these potential links between Graves disease and endometriosis is autoimmunity.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref>
• Oxidative stress: Influx of iron is associated with the local destruction of the peritoneal mesothelium, leading to the adhesion of ectopic endometriotic cells.<ref name=":3" /> Peritoneal iron overload has been suggested to be caused by the destruction of erythrocytes, which contain the iron-binding protein hemoglobin, or a deficiency in the peritoneal iron metabolism system.<ref name=":3">Template:Cite journal</ref> Oxidative stress activity and reactive oxygen species (ROS) (such as superoxide anions and peroxide levels) are reported to be higher than normal in people with endometriosis.<ref name=":3" /> Oxidative stress and the presence of excess ROS can damage tissue and induce rapid cellular division.<ref name=":3" /> Mechanistically, there are several cellular pathways by which oxidative stress may lead to or may induce proliferation of endometriotic lesions, including the mitogen activated protein (MAP) kinase pathway and the extracellular signal-related kinase (ERK) pathway.<ref name=":3" /> Activation of both of the MAP and ERK pathways lead to increased levels of c-Fos and c-Jun, which are proto-oncogenes that are associated with high-grade lesions.<ref name=":3" />
• Microbiome: Some studies have reported differences in gut microbial composition in individuals with endometriosis compared to healthy controls. These findings have led to suggestions that alterations in the gut microbiome may contribute to the pathophysiology of endometriosis, though further research is needed to clarify this relationship.<ref>Template:Cite journal</ref>

Pain

There are multiple causes of pain. Endometriosis lesions react to hormonal stimulation and may "bleed" during menstruation. The blood accumulates locally if not cleared shortly by the immune, circulatory, and lymphatic systems. This accumulation can lead to swelling, which triggers inflammation via cytokines, resulting in pain. Another source of pain is organ dislocation that arises from adhesion binding internal organs together. The ovaries, the uterus, the oviducts, the peritoneum, and the bladder can all be bound together. Pain triggered in this way can last throughout the menstrual cycle, not just during menstrual periods.<ref>Template:Page neededTemplate:Cite book</ref>

Additionally, endometriotic lesions can develop an independent nerve supply, creating a direct and two-way interaction between lesions and the central nervous system. This interaction can produce a variety of individual differences in pain that, in some cases, become independent of the disease itself.<ref name="Stratton2011" /> Nerve fibers and blood vessels are thought to grow into endometriosis lesions by a process known as neuroangiogenesis.<ref>Template:Cite journal</ref>

Diagnosis

A health history and a physical examination can lead the health care practitioner to suspect endometriosis. Symptoms in combination with ultrasound or MRI imaging can lead to a presumed diagnosis of endometriosis. The gold standard for definite diagnosis is via surgery and a biopsy, but there is a shift away from requiring surgical confirmation before starting treatment to prevent delays.<ref name=":7" /> Patients in the UK have an average delay in diagnosis of 8 years and in Norway of 6.7 years.<ref name="ReferenceA">Template:Cite journal</ref> A third of women had consulted their GP six or more times before being diagnosed.<ref name="ReferenceA" />

Endometriosis can be classified into four different stages. The American Society of Reproductive Medicine's scale, revised in 1996, gives higher scores to deep, thick lesions or intrusions on the ovaries and dense, enveloping adhesions on the ovaries or fallopian tubes.<ref name="pmid9130884">Template:Cite journal</ref>

As for deep infiltrating endometriosis, TVUS, TRUS, and MRI are the techniques of choice for non-invasive diagnosis with a high sensitivity and specificity.<ref name="Zhang He Shen 2020 p.">Template:Cite journal</ref>

Physical examination

A trauma-informed framework is recommended for a physical examination, where the health practioner validates pain and fosters trust. The examination focuses on assessing both general symptoms and those linked to deep endometriosis or endometriosis outside the pelvis. Risk factors are also reviewed. The physical examination can include an abdominal exam, a single digit exam of the vagina and pelvic floor, a bimanual exam and examination with a speculum.<ref name=":7" />

Ultrasound

Transvaginal ultrasonography showing a 67 x 40 mm endometrioma as distinguished from other types of ovarian cysts by a somewhat grainy and not completely anechoic content

Vaginal ultrasound can be used to diagnose endometriosis or to localize an endometrioma before surgery.<ref name=":0">Template:Cite web</ref> This can be used to identify the spread of disease in individuals with well-established clinical suspicion of endometriosis.<ref name=":0" /> Vaginal ultrasound is inexpensive, easily accessible, has no contraindications, and requires no preparation.<ref name=":0" /> By extending the ultrasound assessment into the posterior and anterior pelvic compartments, a sonographer can evaluate structural mobility and look for deep infiltrating endometriotic nodules.<ref name=":2">Template:Cite journal</ref> Better sonographic detection of deep infiltrating endometriosis could reduce the number of diagnostic laparoscopies, as well as guide disease management and enhance patient quality of life.<ref name=":2" />

Ultrasounds cannot be used to exclude a diagnosis of endometriosis.Template:Sfn If a transvaginal ultrasound is not suitable or declined, an alternative is an ultrasound via the lower abdomen.Template:Sfn

Magnetic resonance imaging

Trichromatic color MRI of ovarian cysts. The bottom right cyst is endometriosis (a chocolate cyst).

MRI is another means of detecting lesions in a non-invasive manner.<ref name="Imaging">Template:Cite journal</ref> MRI is not widely used due to its cost and limited availability.<ref name="Imaging" /> It can reliably detect endometriomas and deep infiltrating endemetriosis. It is sometimes used for planning surgery, for instance if an ultrasound is unclear, or for diagnosis if a transvaginal ultrasound is not appropriate or is declined. The field of view is larger in an MRI compared to an ultrasound, which allows a larger part of the bowel to be assessed.<ref>Template:Cite journal</ref>

Laparoscopy

Laparoscopic image of endometriotic lesions at the peritoneum of the pelvic wall

Laparoscopy (keyhole surgery) is a surgical procedure where a camera is used to look inside the abdominal cavity. Laparoscopy with a biopsy is the most accurate way to diagnose endometriosis.<ref name=":7" /> It can be used when endometriosis is suspected, but not visible via medical imaging.<ref name=":12" /> An alternative after negative imaging is to try out treatment and give a presumed diagnosis if that improves symptoms ('empirical treatment').Template:Sfn

Surgery for diagnosis also allows for surgical treatment of endometriosis at the same time.Template:Sfn In nearly 40% of cases, no cause for pelvic pain is discovered during laparoscopy.<ref name=":12" />

The lesions of superficial endometriosis often appear dark blue or black. In the earlier stages of disease, they may be white, red or yellow-brown. Ovarian cysts are typically dark brown. Adhesions are made up of fibrous scar tissue. Deep endometriosis looks like multiple distinct nodules.<ref name=":12" />

A biopsy may be negative even when endometriosis is present, particularly in younger women. As such, it cannot be used to exclude a diagnosis of endometriosis.<ref name=":12" /> For confirmation, biopsy samples should show at least two of the following features:<ref>Template:Cite web</ref>

• Endometrial type stroma
• Endometrial epithelium with glands
• Evidence of chronic hemorrhage, such as hemosiderin deposits

• 
  Endometriosis, abdominal wall
• 
  Micrograph showing endometriosis (right) and ovarian stroma (left)
• 
  Micrograph of the wall of an endometrioma. All features of endometriosis are present (endometrial glands, endometrial stroma and hemosiderin-laden macrophages).

Stages

There are three staging or classification systems commonly used. Fertility is assessed with the Endometriosis Fertility Index (EFI).<ref name=":12">Template:Cite journal</ref> Endometriosis can be classified as stage I–IV by the revised American Society of Reproductive Medicine (rASRM) staging system. The stages range from minimal (stage I) to severe (stage IV).<ref name="Crump2024">Template:Cite journal</ref> The scale uses a point system that assesses lesions and adhesions during surgery. The ENZIAN system focuses more on deep endometriosis compared to rASRM. The rASRM and ENZIAN systems correlate poorly with how much pain women have.<ref name=":12" />

The American Association of Gynecologic Laparoscopists (AAGL) endometriosis staging system, introduced in 2021, correlates well with complexity of surgery, and captures pain better than rASRM. Like rASRM, it divides endometriosis into four stages.<ref>Template:Cite journal</ref>

Prevention

The US Office of Women's Health states that the chance of developing endometriosis can be reduced by lowering the levels of the hormone estrogen in the body.<ref name="WH2025" /> According to the World Health Organization, there is no known way to prevent endometriosis.<ref name="WHO Fact Sheet" />

Management

While there is no cure for endometriosis, there are treatments for pain and endometriosis-associated infertility. Pain can be treated with hormones, painkillers, or, in severe cases, surgery.<ref>Template:Cite web</ref> The goal of management is to provide pain relief, to restrict the progression of the process, and to restore or preserve fertility where needed.<ref name="zondervan32212520" />

Treatment with medication for pain management can be initiated based on the presence of symptoms, examination, and ultrasound findings that rule out other potential causes.<ref name="Women's Healthcare 2020">Template:Cite web</ref> The UK National Institute for Health and Care Excellence recommends starting initial medication for those with suspected endometriosis, at the same time as referral for investigations such as ultrasound.Template:Sfn

In general, the diagnosis of endometriosis is confirmed during surgery, at whih time removal can be performed. Further steps depend on circumstances: someone without infertility can manage symptoms with pain medication and hormonal medication that suppresses the natural cycle, while an infertile individual may be treated expectantly after surgery, with fertility medication, or with in vitro fertilisation (IVF).

A 2020 Cochrane systematic review found that for all types of endometriosis, "it is uncertain whether laparoscopic surgery improves overall pain compared to diagnostic laparoscopy".<ref name="Bafort Beebeejaun Tomassetti Bosteels p.">Template:Cite journal</ref>

Hormonal medications

• Hormonal birth control pills: combined estrogren-progestin birth control pills are a first-line treatment. The recommendation is to use the pills continuously to stop periods.<ref name=":7">Template:Cite journal</ref> A 2018 Cochrane systematic review found that there is insufficient evidence to make a judgement on the effectiveness of the combined oral contraceptive pill compared with placebo or other medical treatment for managing pain associated with endometriosis partly because of lack of included studies for data analysis (only two for COCP vs placebo).<ref name="Brown Crawford Datta Prentice p.">Template:Cite journal</ref>
• Progestin-only hormonal suppression (progestogen) is another first-line therapy. It come in different forms and includes the hormonal coil (intrauterine device), the oral dienogest, an injection of medroxyprogesterone acetate every three months or an implant under the skin.<ref name=":7" /> Dienogest, which may better than injections,<ref name=":10">Template:Cite journal</ref> is not available on its own in the US.<ref name=":7" /> Oral progestins likely reduce overall pain and period pain compared to placebo, and may also help with pelvic pain. It is unclear how well they work compared to other hormonal therapies.<ref name=":10" />
• Gonadotropin-releasing hormone (GnRH) modulators are second-line treatments: These drugs include GnRH agonists such as leuprorelin, and GnRH antagonists such as elagolix and decrease estrogen levels.<ref name=":7" /> GnRH agonists mimic the effects of menopause, and seem more effective than placebo or oral progestin at reducing pain.<ref name=":11">Template:Cite journal</ref> They come with side effects of hot flashes and decreased bone density. GnRHs can be prescribed with hormonal 'add-back' therapy or with calcium-regulating agents to reduce the amount of bone loss.<ref name=":7" /><ref name=":11" />
• Aromatase inhibitors are third-line treatments and block estrogen production throughout the body. Examples of aromatase inhibitors include anastrozole and letrozole. Common side effects are hot flashes, night sweats and functional cysts.<ref name=":7" /><ref name="Garzon Laganà Barra Casarin 2020 pp. 1377–1388">Template:Cite journal</ref> In premenopausal women, these should be taken with other hormones (such as the combined pill) to prevent ovarian stimulation and to prevent menopause symptoms. They can be a option for post-menopausal women who still have endometriosis symptoms, as their action is not limited to suppressing estrogen from ovaries. Evidence is limited.<ref name=":7" />
• Progesterone receptor modulators like mifepristone and gestrinone have the potential (based on only one randomized controlled trial each) to be used as a treatment to manage pain caused by endometriosis.<ref name="Fu Song Zhou Zhu p.">Template:Cite journal</ref>

Other medicines

• Pentoxifylline, an immunomodulating agent, has been theorized to improve pain as well as improve pregnancy rates in individuals with endometriosis. There is not enough evidence to support the effectiveness or safety of either of these uses.<ref>Template:Cite journal</ref>
• NSAIDs are anti-inflammatory medications commonly used for endometriosis patients despite unproven efficacy and unintended adverse effects.<ref>Template:Cite journal</ref>

Surgery

Clinical guidelines recommend surgery when medical treatment does not work sufficiently, has unacceptable side effects or is contraindicated. Large endometriomas can only effectively be treated with surgery. Surgery is also recommended when deep endometriosis causes problems in the bowels or urinary tract, such as obstruction. It is unclear what the effect of surgery is for pain relief in cases of superficial periteneal endometriosis.<ref name=":7" />

Laparoscopy (keyhole surgery) is the standard surgical approach. Treatment consists of the removal of endometriosis and the restoration of pelvic anatomy via the division of adhesions.Template:Sfn The removal takes place via excision (cutting out) or electrosurgery (coagulation or ablation/vaporisation).Template:SfnTemplate:Sfn When laparoscopic surgery is used, small instruments are inserted through the incisions to remove the endometriosis tissue and adhesions. Because the incisions are tiny, there will only be small scars on the skin after the procedure, and most individuals recover from surgery quickly and have a reduced risk of adhesions.<ref>Template:Cite web</ref> A 2017 literature review found that excision improved some outcomes over ablation.<ref>Template:Cite journal</ref> In the United States, some specialists trained in excision for endometriosis do not accept health insurance because insurance companies do not reimburse the higher costs of this procedure over ablation.<ref>Template:Cite news</ref>

Endometriomas are usually excised (removed completely). Compared to drainage and coagulation of the cyst, excision makes it less likely the cysts and pain symptoms come back. However, excision may damage fertility, as it can affect the ovarian reserve, the amount of egg cells that can be fertilised.<ref name=":12" /><ref name=":7" />

For deep endometriosis, surgery improves quality of life and pain symptoms.Template:Sfn However, the procedure can be complicated, especially if the lesions are in or near the bowel, ureter of the urinary system or the chest, and requires a interdisciplinary surgical team in those cases. For instance, for rectovaginal endometriosis, 7% of surgeries had complications.<ref name=":7" /> Sometimes, a part of the bowel is removed.Template:Sfn

Historically, a hysterectomy (removal of the uterus) was thought to be a cure for endometriosis in individuals who do not wish to conceive. Removal of the uterus may be beneficial as part of the treatment if the uterus itself is affected by adenomyosis. However, this should only be done in combination with the removal of the endometriosis by excision. If endometriosis is not also removed at the time of hysterectomy, pain may persist.<ref name="John2013">Template:Cite journal</ref>

Presacral neurectomy may be performed where the nerves to the uterus are cut. However, this technique is not usually used due to the high incidence of associated complications, including presacral hematoma and irreversible problems with urination and constipation.<ref name="John2013" />

Recurrence

The underlying process that causes endometriosis may not cease after a surgical or medical intervention. Even though surgery can improve symptoms, the resurgence of pain is common.<ref name=":9">Template:Cite journal</ref> A study has shown that dysmenorrhea recurs at a rate of 30 percent within a year following laparoscopic surgery. Resurgence of lesions tends to appear in the same location if the lesions were not completely removed during surgery. It has been shown that laser ablation resulted in higher and earlier recurrence rates when compared with endometrioma cystectomy, and recurrence after repetitive laparoscopy was similar to that after the first surgery. Endometriosis has a 10% recurrence rate after hysterectomy and bilateral salpingo-oophorectomy.<ref name="updateonrecur">Template:Cite journal</ref>

Endometriosis recurrence following conservative surgery is estimated as 21.5% at 2 years and 40–50% at 5 years.<ref>Template:Cite journal</ref>

Comparison of interventions

A 2021 meta-analysis found that GnRH analogs and combined hormonal contraceptives were the best treatment for reducing dyspareunia and menstrual and non-menstrual pelvic pain.<ref name="Samy Taher Sileem Abdelhakim 2021 p=101798">Template:Cite journal</ref> A 2018 Swedish systematic review found several studies but a general lack of scientific evidence for most treatments.<ref name=":0" /> There was only one study of sufficient quality and relevance comparing the effect of surgery and non-surgery.<ref name=":1">Template:Cite web</ref> Cohort studies indicate that surgery is effective in decreasing pain.<ref name=":1" /> Most complications occurred in cases of low intestinal anastomosis, while the risk of fistula occurred in cases of combined abdominal or vaginal surgery, and urinary tract problems were common in intestinal surgery.<ref name=":1" /> The evidence was found to be insufficient regarding surgical intervention.<ref name=":1" />

The advantages of physical therapy techniques are decreased cost, absence of major side effects, it does not interfere with fertility, and a near-universal increase in sexual function.<ref name="JOEPPD">Template:Primary source inline Template:Cite journal</ref> Disadvantages are that there are no large or long-term studies of its use for treating pain or infertility related to endometriosis.<ref name="JOEPPD"/>

Treatment of infertility

Assistive reproductive technology like IVF can help with fertility in endometriosis.

Infertility can be treated with assistive reproductive technology (ART) such as in vitro fertilization (IVF) or surgery.Template:Sfn IVF procedures are effective in improving fertility in many individuals with endometriosis. IVF is increasingly recommended over surgery for older women or for those where there might be multiple reasons why they struggle to conceive.Template:Sfn It does not increase recurrence of endometriosis.Template:Sfn The Endometriosis Fertility Index can help guide decisions on treatment of infertility.Template:Sfn Surgery is typically not recommended before starting ART.Template:Sfn

In terms of surgery, endometriomas can be cut out (a cystectomy), or drained and destroyed (ablation). The ablation technique may be better able to preserve the number of remaining viable eggs (the ovarian reserve), compared to cutting out the endometrioma.Template:Sfn On the other hand, cutting out the endometrioma may help more with pain.Template:Sfn Surgery likely also helps with infertility in the case of superficial peritoneal endometriosis.<ref name=":7" /> Receiving hormonal suppression therapy after surgery might be help with endometriosis recurrence and pregnancy.<ref>Template:Cite journal</ref> but evidence for pregancy outcomes is mixedTemplate:Sfn and the both NICE and the European Society of Human Reproduction and Embryology recommend against hormonal suppression to improve fertility.Template:SfnTemplate:Sfn

Epidemiology

Determining how many people have endometriosis is challenging because a definitive diagnosis requires surgical visualization through laparoscopic surgery.<ref name="Risk">Template:Cite journal</ref> Criteria that are commonly used to establish a diagnosis include pelvic pain, infertility, surgical assessment, and in some cases, magnetic resonance imaging. An ultrasound can identify large clumps of tissue as potential endometriosis lesions and ovarian cysts, but it is not effective for all patients, especially in cases with smaller, superficial lesions.<ref>Template:Cite web</ref>

Ethnic differences in endometriosis have been observed. The condition is more common in women of East Asian and Southeast Asian descent than in White women.<ref name=zondervan32212520/>

Estimates of prevalance vary. One source estimates that between 6 and 10% of the general female population have endometriosis.<ref name="Bulletti2010" /> Another estimates that between 2 and 11% of asymptomatic women are affected.<ref name="zondervan32212520" /> In addition, 11% of women in a general population have undiagnosed endometriosis that can be seen on magnetic resonance imaging (MRI).<ref name="bucklewis21719000">Template:Cite journal</ref><ref name="Risk" /> Globally, around 176 girls and women are effected, with roughly 22 million having a diagnosis confirmed surgically as of 2021.<ref>Template:Cite journal</ref>

Endometriosis is most common in those in their thirties and forties; however, it can begin in girls as early as eight years old.<ref name="WH2014" /><ref name="Mc2013" /> It results in few deaths with unadjusted and age-standardized death rates of 0.1 and 0.0 per 100,000.<ref name="GBD2015Pre" /> Endometriosis was first determined to be a separate condition in the 1920s.<ref name="Bro2012">Template:Cite book</ref> Before that time, endometriosis and adenomyosis were considered together.<ref name="Bro2012" />

It chiefly affects adults from premenarche to postmenopause, regardless of race or ethnicity or whether or not they have had children, and is estimated to affect over 190 million women in their reproductive years.<ref name="Nothnick">Template:Cite journal</ref> Incidences of endometriosis have occurred in postmenopausal individuals,<ref name="Medscape">Template:Cite journal</ref> and in less common cases, individuals may have had endometriosis symptoms before they even reach menarche.<ref>Template:Cite journal</ref><ref name="Marsh EE 2004">Template:Cite journal</ref>

The rate of recurrence of endometriosis is estimated to be 40-50% for adults over five years.<ref name=":4">Template:Cite journal</ref> The rate of recurrence has been shown to increase with time from surgery and is not associated with the stage of the disease, initial site, surgical method used, or post-surgical treatment.<ref name=":4" />

History

Endometriosis was first discovered microscopically by Karl von Rokitansky in 1860,<ref name="batt">Template:Cite book</ref> although the earliest antecedents may have stemmed from concepts published almost 4,000 years ago.<ref name="nezhat">Template:Cite journal</ref> The Hippocratic Corpus outlines symptoms similar to endometriosis, including uterine ulcers, adhesions, and infertility.<ref name=nezhat/> Historically, women with these symptoms were treated with leeches, straitjackets, bloodletting, chemical douches, genital mutilation, pregnancy (as a form of treatment), hanging upside down, surgical intervention, and even killing due to suspicion of demonic possession.<ref name=nezhat/> Hippocratic doctors recognized and treated chronic pelvic pain as a true organic disorder 2,500 years ago, but during the Middle Ages, there was a shift into believing that women with pelvic pain were mad, immoral, imagining the pain, or simply misbehaving.<ref name=nezhat/> The symptoms of inexplicable chronic pelvic pain were often attributed to imagined madness, female weakness, promiscuity, or hysteria.<ref name=nezhat/> The historical diagnosis of hysteria, which was thought to be a psychological disease, may have indeed been endometriosis in many cases.<ref name=nezhat/> The idea that chronic pelvic pain was related to mental illness influenced modern attitudes regarding individuals with endometriosis, leading to delays in correct diagnosis and indifference to the patients' true pain throughout the 20th and into the 21st century.<ref name=nezhat/>

Hippocratic doctors believed that delaying childbearing could trigger diseases of the uterus, which caused endometriosis-like symptoms. Women with dysmenorrhea were encouraged to marry and have children at a young age.<ref name=nezhat/> The fact that Hippocratics were recommending changes in marriage practices due to an endometriosis-like illness implies that this disease was likely common.<ref name=nezhat/>

The theory of retrograde menstruation as a cause of endometriosis was first proposed by John A. Sampson.<ref name="vanderLinden1996" /><ref name="sampson27ajppmcid">Template:Cite journal</ref>

The early treatment of endometriosis was surgical and included oophorectomy (removal of the ovaries) and hysterectomy (removal of the uterus).<ref name="pmid17857917">Template:Cite journal</ref> In the 1940s, the only available hormonal therapies for endometriosis were high-dose testosterone and high-dose estrogen therapy.<ref name=barbieri1992>Template:Cite journal</ref> High-dose estrogen therapy with diethylstilbestrol for endometriosis was first reported by Karnaky in 1948 and was the main pharmacological treatment for the condition in the early 1950s.<ref name="Aiman2012">Template:Cite book</ref><ref name="Josimovich2013">Template:Cite book</ref><ref name="Kistner1995">Template:Cite book</ref> Pseudopregnancy (high-dose estrogen–progestogen therapy) for endometriosis was first described by Kistner in the late 1950s.<ref name="Aiman2012" /><ref name="Josimovich2013" /> Pseudopregnancy, as well as progestogen monotherapy, dominated the treatment of endometriosis in the 1960s and 1970s.<ref name="Kistner1995" /> These agents, although efficacious, were associated with intolerable side effects. Danazol was first described for endometriosis in 1971 and became the main therapy in the 1970s and 1980s.<ref name="Aiman2012" /><ref name="Josimovich2013" /><ref name="Kistner1995" /> In the 1980s, GnRH agonists gained prominence for the treatment of endometriosis and by the 1990s had become the most widely used therapy.<ref name="Josimovich2013" /><ref name="Kistner1995" /> Oral GnRH antagonists such as elagolix were introduced for the treatment of endometriosis in 2018.<ref name="pmid30763525">Template:Cite journal</ref>

Society and culture

Public figures

Several public figures have spoken about their experience with endometriosis, including: Template:Div col

• RuthAnne<ref>Template:Cite web</ref>
• Emma Barnett<ref>Template:Cite web</ref>
• Emma Bunton<ref>Template:Cite web</ref>
• Alexa Chung<ref>Template:Cite web</ref>
• Danielle Collins<ref>Template:Cite news</ref>
• Olivia Culpo<ref>Template:Cite magazine</ref>
• Lena Dunham<ref>Template:Cite web</ref>
• Diana Falzone
• Abby Finkenauer<ref>Template:Cite web</ref>
• Bethenny Frankel<ref>Template:Cite web</ref>
• Whoopi Goldberg<ref>Template:Cite web</ref>
• Mel Greig<ref>Template:Cite news</ref>
• Halsey<ref>Template:Cite magazine</ref>
• Emma Hayes<ref>Template:Cite web</ref>
• Julianne Hough<ref>Template:Cite web</ref><ref>Template:Cite web</ref><ref>Template:Cite web</ref>
• Bridget Hustwaite<ref>Template:Cite web</ref>
• Bindi Irwin<ref>Template:Cite news</ref>
• Jaime King<ref>Template:Cite web</ref>
• Padma Lakshmi<ref>Template:Cite web</ref>
• Cyndi Lauper<ref>Template:Cite news</ref>
• Jillian Michaels<ref>Template:Cite web</ref>
• Monica<ref>Template:Cite web</ref>
• Marilyn Monroe<ref>Template:Cite web</ref>
• Tia Mowry<ref>Template:Cite web</ref>
• Sinéad O'Connor<ref>Template:Cite web</ref>
• Dolly Parton<ref>Template:Cite web</ref>
• Florence Pugh<ref>Template:Cite web</ref>
• Daisy Ridley<ref>Template:Cite web</ref>
• Emma Roberts<ref>Template:Cite web</ref>
• Susan Sarandon<ref>Template:Cite web</ref>
• Amy Schumer<ref>Template:Cite web</ref>
• Kirsten Storms<ref>Template:Cite web</ref>
• Gabrielle Union<ref>Template:Cite web</ref>
• Lacey Schwimmer<ref>Template:Cite web</ref><ref>Template:Cite web</ref><ref>Template:Cite web</ref>
• Chrissy Teigen<ref>Template:Cite web</ref>
• Emma Watkins<ref>Template:Cite web</ref>
• Mae Whitman<ref>Template:Cite web</ref>
• Jessica Williams<ref>Template:Cite web</ref>
• Leah Williamson<ref>Template:Cite web</ref>

Economic burden

The economic burden of endometriosis is widespread and multifaceted.<ref name=":5">Template:Cite journal</ref> Endometriosis is a chronic disease that has direct and indirect costs, which include loss of work days, direct costs of treatment, symptom management, and treatment of other associated conditions such as depression or chronic pain.<ref name=":5" /> One factor that seems to be associated with especially high costs is the delay between the onset of symptoms and diagnosis.

Costs vary greatly between countries.<ref>Template:Cite journal</ref> Two factors that contribute to the economic burden include healthcare costs and losses in productivity. A Swedish study of 400 endometriosis patients found "Absence from work was reported by 32% of the women, while 36% reported reduced time at work because of endometriosis".<ref>Template:Cite journal</ref> An additional cross sectional study with Puerto Rican women, "found that endometriosis-related and coexisting symptoms disrupted all aspects of women's daily lives, including physical limitations that affected doing household chores and paid employment. The majority of women (85%) experienced a decrease in the quality of their work; 20% reported being unable to work because of pain, and over two-thirds of the sample continued to work despite their pain."<ref>Template:Cite journal</ref> A study published in the UK in 2025 found that after women received a diagnosis of endometriosis in an English NHS hospital their earnings were on average £56 per month less in the four to five years after diagnosis than they were in the two years before. There was also a reduction in the proportion of women in employment.<ref>Template:Cite news</ref>

Medical culture

There are many barriers that those affected face in receiving a diagnosis and treatment for endometriosis. Some of these include outdated standards for laparoscopic evaluation, stigma about discussing menstruation and sex, lack of understanding of the disease, primary-care physicians' lack of knowledge, and assumptions about typical menstrual pain.<ref>Template:Cite journal</ref> On average, those later diagnosed with endometriosis waited 2.3 years after the onset of symptoms before seeking treatment, and nearly three-quarters of women receive a misdiagnosis before endometriosis.<ref>Template:Cite journal</ref> Self-help groups say practitioners delay making the diagnosis, often because they do not consider it a possibility. There is a typical delay of 7–12 years from symptom onset in affected individuals to professional diagnosis.<ref>Template:Cite journal</ref> There is a general lack of knowledge about endometriosis among primary care physicians. Half of the general health care providers surveyed in a 2013 study could not name three symptoms of endometriosis.<ref>Template:Cite journal</ref> Healthcare providers are also likely to dismiss described symptoms as normal menstruation.<ref name="Time elapsed from onset of symptoms">Template:Cite journal</ref> Younger patients may also feel uncomfortable discussing symptoms with a physician.<ref name="Time elapsed from onset of symptoms"/>

Race and ethnicity

Race and ethnicity may impact how endometriosis affects one's life. Endometriosis is less thoroughly studied among Black people, and the research that has been done is outdated.<ref>Template:Cite journal</ref><ref name=":6">Template:Cite journal</ref> Cultural differences among ethnic groups also contribute to attitudes toward and treatment of endometriosis, especially in Hispanic or Latino communities. A study done in Puerto Rico in 2020 found that health care and interactions with friends and family related to discussing endometriosis were affected by stigma.<ref name=":8">Template:Cite journal</ref> The most common finding was a referral to those expressing pain related to endometriosis as "changuería" or "changas", terms used in Puerto Rico to describe pointless whining and complaining, often directed at children.<ref name=":8" />

Stigma

The existing stigma surrounding women's health, specifically endometriosis, can lead to patients not seeking diagnoses, lower quality of healthcare, increased barriers to care and treatment, and negative reception from members of society.<ref name="Stigma and Endometriosis: A Brief O">Template:Cite journal</ref> Additionally, menstrual stigma significantly contributes to the broader issue of endometriosis stigma, creating an interconnected challenge that extends beyond reproductive health.<ref>Template:Cite journal</ref><ref>Template:Cite web</ref> Widespread awareness campaigns, developments, and implementations aimed at multilevel anti-stigma organizational and structural changes, as well as more qualitative studies of the endometriosis stigma, help to overcome the harm of the phenomenon.<ref name="Stigma and Endometriosis: A Brief O"/>

Research

A priority area of research is the search for endometriosis biomarkers, which can help with earlier diagnoses.<ref>Template:Cite journal</ref> Studies have examined potential biomarkers such as microRNAs, glycoproteins, and immune markers in blood, menstrual and urine samples, but none have shown the high accurarcy needed for clinical use yet. CA-125, a tumor marker, has been studied extensively. It is elevated in endometriosis, but also in many other conditions, and cannot be used on its own. MicroRNAs might be most promosing, but the high diversity in expression makes them a challenging target.<ref>Template:Cite journal</ref>

Preliminary research on mouse models showed that monoclonal antibodies, as well as inhibitors of MyD88 downstream signaling pathway, can reduce lesion volume. Thanks to that, clinical trials are being done on using a monoclonal antibody directed against IL-33 and using anakinra, an IL-1 receptor antagonist.<ref name="Saunders Horne 2021 pp. 2807–2824">Template:Cite journal</ref>

Taking contraceptive pills or getting long-acting progestogen injections seems to be equally effective for preventing recurring pain after endometriosis surgery. Compared to taking the pill, progestogen might result in a reduced risk of needing further treatments or surgery.<ref name=":9" /><ref>Template:Cite journal</ref>

Clinical trials are exploring the potential benefits of cannabinoid extracts, dichloroacetic acid, and curcuma capsules.<ref name="Saunders Horne 2021 pp. 2807–2824" />

References

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Cited sources

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