What Are the Signs and Symptoms of Endometriosis?

The symptoms of endometriosis may vary from person to person, however, some of the most common symptoms are listed below.

Period pain

Period pain that occurs regularly and is not associated with another underlying condition is called primary dysmenorrhea. Unlike primary dysmenorrhea, secondary dysmenorrhea is period pain that is the result of another underlying condition. Examples of conditions that can lead to secondary dysmenorrhea include endometriosis, uterine fibroids, infections, pelvic inflammatory disease, and adenomyosis (where endometrial tissue grows into the wall of the uterus), among other conditions.1,2

In the case of endometriosis, it is thought that this pain is a result of endometrial lesions elsewhere in the pelvis growing and breaking down where they shouldn’t be. This process, along with the trapped blood and tissue it creates, may affect period pain. Additionally, endometrial lesions may affect the inflammatory and cell growth processes of the area surrounding them. These changes in inflammation and cell composition may affect pain levels during a woman’s period. Finally, some theories suggest that endometriosis lesions may grow and irritate or infiltrate nerves within the pelvis. If these nerves are negatively impacted by endometriosis lesions, severe secondary dysmenorrhea may occur.3

Chronic pelvic pain (non-menstrual pain)

Chronic pelvic pain is described as pain lasting at least three to six months that is centralized below the bellybutton and between the hips. Chronic pelvic pain is thought to be a neuropathic condition, meaning it’s related to the nerves. Chronic pelvic pain may be a symptom of another underlying condition, such as endometriosis, irritable bowel syndrome, or fibromyalgia, however, it can also occur on its own without an identifiable cause. In the case of endometriosis, chronic pelvic pain may be caused by the active building, breaking down, and bleeding of endometriosis lesions, changes in the local cellular environment around endometriosis lesions (including a potential increase in inflammation of amount of certain immune system-related chemicals), and infiltration or irritation of nerves within the pelvis by endometriosis lesions.4,5

Pain during sex

Many women and some men will experience pain with intercourse at some point in their lifetime. The clinical term for pain during sex is dyspareunia, and its characteristics can vary greatly from person to person. Pain during sex may have larger implications if not addressed, such as impacting an individual’s intimate relationships, self-esteem, self-perception, or mental health. Women with endometriosis often experience dyspareunia, most commonly deep dyspareunia.5-7

It has been theorized that the incidence and severity of this type of pain may be associated with irritation or invasion of the pelvic floor nerves, or infiltration of the uterosacral ligaments. The uterosacral ligaments support the uterus and attach to the sacrum (the bone at the base of the spine right above the tailbone). Other issues that may contribute to dyspareunia are internal scarring, especially from a surgical procedure like a hysterectomy or other pelvic surgery, as well as conditions like uterine prolapse, pelvic inflammatory disease, uterine fibroids, cystitis (inflammation in the bladder), hemorrhoids, ovarian cysts, irritable bowel syndrome, or retroverted uterus (uterus is tilted back toward the rectum).5-7

Abnormal menstrual bleeding

The average menstrual cycle lasts roughly 28 days; however, many experts agree that a cycle that lasts anywhere between 21 and 35 days is still considered typical. In contrast, cycles that occur in less than 21 day intervals or longer than 35 day intervals are considered abnormal. Menstrual bleeding may also be considered abnormal if it is significantly lighter or heavier than normal, or if a woman experiences bleeding between periods or post-menopause. Periods with bleeding that lasts longer than seven days are also considered examples of abnormal menstrual bleeding, as well as bleeding following sex. Women with endometriosis may experience varying menstrual cycle lengths and abnormal menstrual bleeding.8,9

Infertility and pregnancy complications

Infertility is the inability to become pregnant or carry a baby to term, however, endometriosis does not always cause complete infertility. In addition to having an association with infertility though, research suggests that women with endometriosis may also have a higher risk of developing pregnancy-related complications. Since endometriosis commonly affects the female reproductive system and structures surrounding the uterus, it makes sense that fertility and pregnancy may be affected. Common theories as to why fertility and pregnancy may be affected by endometriosis include scarring that blocks the fallopian tubes or that has impacted the structure of key reproductive organs, immune system-related issues that cause the body to mistakenly attack a developing fetus, and developmental anomalies or malformations of the uterus or other structures in the female reproductive system (such as developing an abnormally shaped uterus).10-11

Fatigue

Fatigue is an unrelenting feeling of exhaustion or inner weariness. Fatigue can get stronger over time, and does not go away after resting. Fatigue may eventually impact an individual’s ability to perform their daily routine or hobbies they once enjoyed. This, in turn, can affect an individual’s mental and emotional well-being. Fatigue that is constant and has no obvious underlying cause is often diagnosed as chronic fatigue syndrome (CFS). In relation to endometriosis, the reason for fatigue is not completely understood. Many experts speculate that fatigue is the body’s long-term response to constantly battling the chronic inflammation and chronic pain that those with endometriosis often experience. Additionally, psychological stress and mental health issues that can accompany endometriosis and managing its related symptoms, such as pain during sex or infertility, may also contribute to physical fatigue.12-15

Bladder and bowel problems

Bladder and bowel issues may be the result of an underlying condition, such as irritable bowel syndrome, arise as a result of treatment regimen such as radiation to destroy cancer cells in the pelvic area, occur naturally with age, or come on suddenly after a major physical event such as a trauma or childbirth. The relationship between endometriosis and bladder and bowel symptoms is one that is still being actively investigated. Some experts believe that bladder and bowel symptoms may be the result of endometriosis lesions that are growing and breaking down directly on the surface of the bladder or bowel. These lesions may infiltrate deeper than the surface, and may lead to trapped blood within these organs. Another common theory is that the constant state of inflammation that endometriosis can cause in certain areas of the pelvis may eventually affect the bladder or bowel and cause issues in these organs.16-18

Back and leg pain

It’s also possible for women with endometriosis to experience pain in other parts of their body as a result of their endometriosis, specifically pain in the lower back or legs. This pain may be the result of endometriosis lesions that infiltrate and irritate the nerves responsible for perceiving pain in these areas, or in response to the constant inflammation that accompanies endometriosis.5

Written by: Casey Hribar | Last reviewed: June 2018
View References
  1. Dysmenorrhea. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/4148-dysmenorrhea. Published July 13, 2014. April 1, 2018.
  2. Dysmenorrhea: Painful Periods. Frequently Asked Questions: The American College of Obstetricians and Gynecologists. https://www.acog.org/-/media/For-Patients/faq046.pdf. Published January 2015. Accessed April 1, 2018.
  3. The Practice Committee of the American Society for Reproductive Medicine. Treatment of pelvic pain associated with endometriosis: A committee opinion. Fertility and Sterility. Apr 2014; 101(4), 927-935. Available from: http://www.fertstert.org/article/S0015-0282(14)00150-2/pdf. Accessed April 1, 2018.
  4. Barbieri RL. Patient Education: Chronic Pelvic Pain in Women (Beyond the Basics). UpToDate. https://www.uptodate.com/contents/chronic-pelvic-pain-in-women-beyond-the-basics. Published December 8, 2018. Accessed April 4, 2018.
  5. The Practice Committee of the American Society for Reproductive Medicine. Treatment of pelvic pain associated with endometriosis: A committee opinion. Fertility and Sterility. Apr 2014; 101(4), 927-935. Available from: http://www.fertstert.org/article/S0015-0282(14)00150-2/pdf. Accessed April 4, 2018.
  6. Painful Intercourse (Dyspareunia). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/painful-intercourse/symptoms-causes/syc-20375967. Published Jan 12, 2018. Accessed April 4, 2018.
  7. Ferrero S, Abbamonte LH, Giordano M, Ragni N, Remorgida V. Deep dyspareunia and sex life after laparoscopic excision of endometriosis. Human Reproduction. 1 Apr 2007; 22(4), 1142-8. Available from: https://academic.oup.com/humrep/article/22/4/1142/695457. Accessed April 4, 2018.
  8. Abnormal Menstruation (Periods). Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/14633-abnormal-menstruation-periods. Published January 16, 2015. Accessed April 4, 2018.
  9. Abnormal Uterine Bleeding. The American College of Obstetricians and Gynecologists. https://www.acog.org/Patients/FAQs/Abnormal-Uterine-Bleeding. Published March 2017. Accessed April 4, 2018.
  10. Practice Committee of the American Society for Reproductive Medicine. Endometriosis and infertility: A committee opinion. Fertil Steril. Sep 2012; 98(3), 591-8.
  11. Petresin J, Wolf J, Emir S, Muller A, and Boosz AS. Endometriosis-associated maternal pregnancy complications-Case report and literature review. Geburtshilfe Frauenheilkd (English Print). Aug 2016; 76(8), 902-5. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4999325/. Accessed March 29, 2018.
  12. Fatigue. Mayo Clinic. https://www.mayoclinic.org/symptoms/fatigue/basics/causes/sym-20050894. Published January 11, 2018. Accessed April 4, 2018.
  13. Chronic Fatigue Syndrome. U.S. National Library of Medicine: MedlinePlus. https://medlineplus.gov/chronicfatiguesyndrome.html. Accessed April 4, 2018.
  14. Endometriosis Symptoms: Fatigue and Personality Changes. Endometriosis Foundation of America. https://www.endofound.org/fatigue-personality-changes. Accessed April 4, 2018.
  15. Sinaii N, Cleary SD, Ballweg ML, Nieman LK, Stratton P. High rates of autoimmune and endocrine disorders, fibromyalgia, chronic fatigue syndrome and atopic disease among women with endometriosis: A survey analysis. Human Reproduction. 1 Oct 2002; 17(10), 2715-24. Available from: https://academic.oup.com/humrep/article/17/10/2715/607769. Accessed April 4, 2018.
  16. Endometriosis and the Bladder. Endometriosis UK. https://www.endometriosis-uk.org/endometriosis-and-bladder. Accessed April 4, 2018.
  17. When IBS is Really Endometriosis on the Bowel-Ken Sinervo, MD. Endometriosis Foundation of America. https://www.endofound.org/when-ibs-is-really-endometriosis-on-the-bowel-ken-sinervo-md. Published 2013. Accessed April 4, 2018.
  18. Wynn-Williams M. Endometriosis and the Bowel. Endometriosis Australia. https://www.endometriosisaustralia.org/single-post/2016/10/07/Endometriosis-and-the-Bowel. Published October 7, 2016. Accessed April 4, 2018.