Endometriosis: Symptoms, Diagnosis & Treatment Options

What Is Endometriosis?

Endometriosis is a chronic, inflammatory condition in which tissue similar to the uterine lining (the endometrium) grows outside the uterus. These lesions — found most commonly on the ovaries, fallopian tubes, bladder, bowel, and pelvic peritoneum — respond to hormonal cycles the same way the lining inside the uterus does. They build up, break down, and bleed. But because the blood has nowhere to exit the body, it triggers inflammation, scar tissue, and pain.

When endometrial tissue forms a cyst on the ovary, it fills with old blood and is sometimes called a chocolate cyst (endometrioma) because of its dark, tar-like appearance on ultrasound. These cysts can impair ovarian reserve and are a leading cause of endometriosis-associated infertility.

Endometriosis Symptoms: What to Look For

Symptoms vary widely in type and severity and do not always correlate with the extent of disease. A woman with minimal lesions may experience debilitating pain, while someone with extensive adhesions may have almost none.

Common Endometriosis Symptoms

When Endometriosis Symptoms Are "Silent"

Some women have no pain at all and only discover endometriosis during investigations for infertility. This is why symptom screening alone is insufficient — clinical assessment by a specialist matters.

How Endometriosis Is Diagnosed

The Diagnostic Challenge

Because endometriosis symptoms overlap with conditions such as irritable bowel syndrome, pelvic inflammatory disease, and adenomyosis, misdiagnosis is common. A 2011 global study found that women see an average of five physicians before receiving a correct diagnosis.¹

Diagnostic Approaches

1. Clinical history and symptom mapping A detailed menstrual and pain history is the first step. Specialist gynaecologists use validated tools such as the Biberoglu & Behrman score and the EHP-30 quality-of-life questionnaire to quantify symptom burden.

2. Pelvic ultrasound Transvaginal ultrasound (TVUS) is the first-line imaging tool. It has high sensitivity for ovarian endometriomas (chocolate cysts) and deep infiltrating lesions involving the bladder or bowel, but can miss superficial peritoneal disease.²

3. MRI Magnetic resonance imaging provides superior soft-tissue contrast and is particularly useful for mapping deep infiltrating endometriosis (DIE) involving the rectovaginal septum, bowel, and ureters — critical information before surgical planning.

4. Diagnostic laparoscopy (gold standard) The definitive diagnosis of endometriosis requires direct visualisation during laparoscopy, ideally with histological confirmation of excised lesions. Current guidelines from ESHRE and ACOG recommend not delaying empirical treatment while awaiting surgery if clinical suspicion is high.²³

Stages of endometriosis (ASRM classification):

• Stage I (Minimal): Few superficial implants
• Stage II (Mild): More implants, shallow endometriomas
• Stage III (Moderate): Many deep implants, small endometriomas, adhesions
• Stage IV (Severe): Many deep implants, large endometriomas, dense adhesions

Endometriosis Treatment Options

There is currently no cure for endometriosis, but effective treatment can significantly reduce pain, slow disease progression, and preserve fertility. Treatment is individualised based on symptoms, disease stage, desire for pregnancy, and patient preference.

1. Hormonal Medical Therapy

Hormonal treatment suppresses oestrogen production or the effects of oestrogen on lesions, reducing inflammation and pain.

• Combined oral contraceptives (COCs): Continuous or extended cycling reduces the frequency of menstruation and associated pain flares. Often the first-line treatment for pain management.
• Progestins (e.g., dienogest, norethisterone): Dienogest has robust evidence specifically for endometriosis and is approved in Singapore for this indication. It reduces endometrioma size and relieves dysmenorrhoea.⁶
• Levonorgestrel-releasing IUD (LNG-IUD): Reduces menstrual blood loss and pelvic pain with a localised hormone effect.
• GnRH agonists (e.g., leuprorelin, goserelin): Induces temporary medical menopause. Highly effective for pain but limited to 6-month courses due to bone density loss unless add-back HRT is used.
• GnRH antagonists (e.g., elagolix, relugolix): Newer agents with faster onset; dose-adjustable to balance efficacy and side effects.

2. Surgical Treatment

Surgery aims to excise or ablate (destroy) endometriotic lesions and restore pelvic anatomy.

• Laparoscopic excision of lesions is preferred over ablation — studies show lower recurrence rates when disease is cut out rather than destroyed.
• Cystectomy (removal of endometrioma wall) is recommended over drainage alone, as drainage has very high recurrence rates.
• Deep infiltrating endometriosis surgery is complex, often requiring a multidisciplinary team including colorectal surgeons. Best performed at an accredited endometriosis centre.

Recurrence after surgery is common — estimated at 21.5% within 2 years and 40–50% within 5 years without postoperative medical suppression.⁴ Hormonal therapy after surgery significantly reduces this risk.

3. Endometriosis and Fertility

For women trying to conceive:

• Natural conception may be possible with mild-to-moderate disease; surgical removal of endometriomas can improve egg quality in some cases.
• IVF (In Vitro Fertilisation) is recommended when surgery has failed, when disease is severe, or when tubal damage is present. IVF outcomes in endometriosis vary by ovarian reserve and severity.
• Ovarian reserve testing (AMH, antral follicle count) is essential before any treatment that may further reduce reserve.

4. Integrative and Lifestyle Approaches

While not curative, the following can support overall wellbeing alongside medical treatment:

• Anti-inflammatory diet (Mediterranean-style)
• Regular moderate exercise (reduces prostaglandin-driven pain)
• Pelvic physiotherapy for myofascial pain and dyspareunia
• Psychological support — endometriosis has significant mental health impacts; CBT and specialist counselling are evidence-based adjuncts⁵

Living With Endometriosis: Key Takeaways

• Endometriosis is a medical condition, not "bad periods." Severe period pain that disrupts daily life warrants specialist evaluation.
• Earlier diagnosis leads to better outcomes — advocate for yourself if symptoms are dismissed.
• Treatment is not one-size-fits-all: the right plan depends on your symptoms, fertility goals, and disease extent.
• Post-surgical hormonal suppression is critical to reducing recurrence.
• A multidisciplinary care team — gynaecologist, radiologist, physiotherapist, and mental health professional — gives the best results.

Frequently Asked Questions (AEO / Featured Snippet)

What are the first signs of endometriosis? The most common early signs are period pain that is severe enough to disrupt daily activities, pain during or after sex, heavy menstrual bleeding, and fatigue. Some women also experience pain when using the toilet during their period. Symptoms often begin in the teenage years but may go undiagnosed for a decade or more.

Can endometriosis be cured? There is currently no cure for endometriosis. However, symptoms can be effectively managed with hormonal therapy, surgery, or a combination of both. After surgical removal of lesions, ongoing hormonal treatment significantly reduces the risk of disease returning.

Does endometriosis always cause infertility? No. While endometriosis is found in up to 50% of women investigated for infertility, many women with the condition conceive naturally — especially with mild-to-moderate disease. For those who do struggle, fertility treatments including IVF can be effective.

What is a chocolate cyst (endometrioma)? A chocolate cyst is a type of endometriotic cyst that forms on the ovary. It fills with old, dark menstrual blood — hence the name. These cysts can damage healthy ovarian tissue and reduce egg reserve, making early diagnosis and appropriate management important for women planning a family.

How is endometriosis diagnosed? Diagnosis combines clinical history, transvaginal ultrasound, and sometimes MRI. Definitive diagnosis requires laparoscopy (keyhole surgery) with visual inspection and ideally biopsy of lesions. Many guidelines now recommend starting treatment based on clinical suspicion without waiting for surgical confirmation.