DEEP DIVE: ENDOMETRIOSIS

Written By April Woodroffe

PART 1 - Understanding Endometriosis

Endometriosis occurs when tissue similar to the lining of the uterus grows outside of it — on the ovaries, fallopian tubes, bladder, bowel, and in some cases beyond the pelvis entirely.

Unlike the endometrial lining which sheds during menstruation, this tissue has nowhere to go. It bleeds, becomes inflamed, and over time forms adhesions and scar tissue that distort the surrounding anatomy.

What makes endometriosis particularly complex is that it is driven by immune dysfunction, chronic inflammation, and hormonal imbalance — which is why managing it requires far more than addressing the lesions alone.

Endometriosis is far more than painful periods.

The symptom picture is wide ranging and varies significantly between individuals — which is one reason it is so frequently missed.

SYMPTOMS

Neurological and Musculokeletal

  • Leg pain, numbness, or weakness worsening cyclically

  • Referred pain to the lower back, hips, shoulder or tailbone

  • Pelvic floor dysfunction

  • Burning or shooting pain in the pelvis or legs

  • Cyclical headaches and migraines

  • Widespread pain sensitivity

Menstrual

  • Severe cramping and pain before and/or during menstruation

  • Heavy or prolonged bleeding

  • Large clots

  • Spotting between periods

  • Nausea, vomiting, or diarrhoea

  • Fainting

  • Cycles becoming progressively more painful

Bladder

  • Painful urination

  • Urinary urgency and frequency

  • Incomplete bladder emptying

  • Recurrent UTIs not resolving with antibiotics

  • Bladder pain worsening in the luteal phase

  • Interstitial cystitis diagnosis without resolution

Bowel

  • Painful bowel movements

  • Cyclical constipation, diarrhoea, or both

  • Severe cyclical bloating

  • Rectal bleeding cyclically

  • Nausea after eating

  • Incomplete bowel emptying

  • IBS diagnosis without resolution

Pelvic and Sexual

  • Deep pelvic pain during or after intercourse

  • Chronic pelvic pain throughout the month

  • Pelvic heaviness or pressure

  • Painful ovulation

  • Painful internal examinations

  • Pain radiating to the lower back, hips, buttocks, or legs

Systemic

  • Fatigue disproportionate to sleep

  • Brain fog

  • Low mood, depression, and anxiety

  • Increased rates of autoimmune conditions

  • Increased susceptibility to infections

  • Food sensitivities and intolerances

THE DIAGNOSIS GAP

Endometriosis affects approximately 1 in 9 women and those assigned female at birth — yet average time to diagnosis remains 7–10 years.

This happens for several reasons:

Normalisation of pain — menstrual pain is so frequently dismissed as normal that many people do not seek help, or are turned away when they do. Pain that interferes with daily life is never normal.

Symptom overlap — endometriosis symptoms can mimic IBS, bladder conditions, pelvic inflammatory disease, and anxiety — leading to misdiagnosis and misdirected treatment.

No non-invasive diagnostic test — endometriosis was previously only diagnosed via laparoscopy, meaning many practitioners have been reluctant to investigate without significant symptom burden.

Lack of awareness — among both the general population and within parts of the medical community.

If you have been told your pain is normal, that your results are fine, or that you just need to manage it — you deserve a second opinion.

DIAGNOSIS

A definitive diagnosis of endometriosis requires direct visualisation of lesions during laparoscopic surgery, with confirmation through tissue biopsy.

However, a strong clinical (suspected) diagnosis can often be made based on:

  • A detailed history of symptoms and presentation.

  • Imaging studies such as MRI or specialist ultrasound (including deep infiltrating endometriosis ultrasound)

Imaging cannot rule endometriosis out.

Recent research suggests that specific biomarkers detectable in blood samples may be associated with the presence of endometriosis. However, these findings have not yet been incorporated into formal diagnostic protocols.

STAGING

Endometriosis is classified into four stages based on the extent and location of lesions found during laparoscopy — but staging is frequently misunderstood.

Symptom severity does not correlate with disease stage.

Some people with minimal disease have debilitating symptoms. Others with extensive disease have none.

Stage 1

“Minimal” presence of disease tissue

  • Few superficial implants (might be located on ovarian peritoneum)

Stage 2

“Mild” presence of disease tissue

  • More and deeper implants (might be located on ovarian peritoneum)

Stage 3

“Moderate” presence of disease tissue

  • Many deep implants

  • Small cysts on one or both ovaries

  • Presence of filmy adhesions

Stage 4

“Severe” presence of disease tissue

  • Many deep implants

  • Large cysts on one or both ovaries

  • Many dense adhesions

DIFFERENT TYPES

Endometriosis can also be classified according to how deeply it infiltrates tissues outside the reproductive organs.

The peritoneum — a thin membrane that lines the abdominal cavity and covers the abdominal organs — is one of the most commonly affected areas.

Depending on the type and depth of invasion, some lesions may be detected using specialised transvaginal ultrasound imaging.

Category 1

Superficial peritoneal disease (SUP)

Endometriosis lesions adhered to the peritoneum

Category 2

Ovarian endometrioma (OMA)

Involving cysts within the ovaries (chocolate cysts)

Category 3

Deep infiltrating endometriosis (DIE)

Endometriotic lesions invading >5 mm beyond the surface of the peritoneum

THE CONVENTIONAL APPROACH

Conventional approaches to endometriosis typically focus on suppressing symptoms with medications or surgery, rather than addressing the underlying imbalances that contribute to the condition.

Pain Management (Symptom Relief)

  • NSAIDs (e.g., ibuprofen, naproxen) for pain and inflammation

  • Analgesics for general “symptom control”

Hormonal Therapies

  • Combined Oral Contraceptives – induce cyclical withdrawal bleeds and slow lesion growth stimulated by endogenous estrogen

  • Progestins (pills, injections, or IUDs) – suppress endometrial growth

  • GnRH Agonists/Antagonists – induce temporary menopause-like state

  • Danazol – rare, limits estrogen production

Surgical Interventions

  • Laparoscopy – removal or ablation of lesions (please don’t get ablation)

  • Hysterectomy – considered in severe cases, although it is NOT a reproductive tract disease, so removing this often doesn’t solve anything and can make symptoms worse

So, how does endometriosis actually develop? Let’s uncover what’s happening behind the scenes ⟶ Pt. 2

April Woodroffe
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HERB SPOTLIGHT