It is often difficult to evaluate the extent of endometriosis by physical examination and clinical history review. The most common symptoms for women who have endometriosis are pelvic pain, infertility and abdominal bloating which adversely affect the quality of life.

Other symptoms may include:

  • Pain during intercourse
  • Painful periods – pain is usually severe
  • Heavy or irregular periods
  • Fatigue

Unfortunately it can take up to 10 years to reach a diagnosis of endometriosis, with many misdiagnoses in the way.

Pelvic pain

Women with endometriosis sometimes feel that pain controls their lives, and they have to arrange everyday life and social events to avoid times when the pain can be severe. The experience of this has been described as the pain as intense and disabling and ‘taking away their life’.

Pain results from:

  • cyclic recurrent micro-bleeding within the lesions and the consequent inflammation
  • adhesions and compression or infiltration of nerves in the pelvic space


Infertility is another common outcome of women with endometriosis. Furthermore, studies on IVF have shown that women with endometriosis have higher rates of pregnancy loss, complication of preterm delivery, pre-eclampsia and infants small for gestational age.

The underlying causes of endometriosis-induced infertility remain unclear and are likely multifactorial. In women with endometriosis, the microenvironment of the endometrium becomes proinflammatory, oestrogen-dominant, and progesterone-resistant, and thereby impairs receptivity for establishment of pregnancy. The endometrium first becomes hyper-responsive to oestrogen and then resistant to progesterone. The loss of normal endometrial function becomes more evident with progression of disease. The disruption of these signalling processes in endometrial epithelial and stromal cells appears to be a consequence of growth of lesions, which might be orchestrated by progressive deregulated interactions among PGE2, oestrogen, and progesterone.

Dr Jeffrey Braverman suggests that the ovaries are bathed in very high levels of reactive oxygen species (ROS) – by-products of oxidative stress produced by the lesions – which affects egg quality and egg division and leads to poor embryo quality. Hence excision of the lesions can lead to better outcomes for pregnancy.

Additionally women with endometriosis often have extremely high resistance to the blood flow through all the pelvic vessels, both to the uterus and the ovaries, caused by pelvic inflammation.

Gastrointestinal – The Endo Belly

Endometriosis causes gastrointestinal symptoms for many women. Endo belly is the pronounced bloating or swelling of the abdomen, which can often be uncomfortable or painful, often accompanied by a feeling of ‘fullness’ in the abdomen. This bloating may occur at certain points of the menstrual cycle or randomly at other points of the month.

A bowel movement is when your stool passes through and out of your body after the food eaten has gone through the digestive tract. One of the common symptoms of endometriosis is painful bowel movements specially during the menstrual cycle. But the bowel symptoms are not only limited to painful defecation, but it can include the following:

  • Constipation
  • Diarrhea
  • Bloating
  • Rectal bleeding
  • Nausea and vomiting

The severe level of pain due to irregular bowel movements is sometimes described by patients as “feels like cutting with razor blades” “I sit on commode for hours with pain but can’t empty it completely” “I pass blood when I poop” “I fear going to loo” and so many more descriptions of painful bowel movements and bowel related symptoms.

Painful bowel movements and constipation are significant signs that endometriosis is located in and around bowel. If its cyclical in nature, do mention these symptoms to your doctor which helps in differentiating it from other gastro disorders.

How does endometriosis cause abdominal pain?

The lesions – specially during menstruation – are highly inflamed and tender and when stool passes through the rectum, these lesions, by putting pressure on the outside of the intestine or by stiffening of the rectum can cause severe pain.

When the peritoneum and cul-de-sac are involved, this can give symptoms like bowel endometriosis. This causes rectal and bowel inflammation and rectal pulling towards vagina and torus uterinus. It causes constipation, painful defecation. Women may also have painful sex when cul-de-sac is involved.

Endometriosis directly involving the rectum may cause rectal bleeding along with pain and constipation.

Endo often involves the colon and may be missed on colonoscopy as the lesions are outside the lumen and can be picked up when laparoscopy is performed by endometriosis excision surgeons.

The appendix is a common organ for endo lesions.

There may not be any lesions on bowel but when uterosacrals are involved by endometriotic nodules it can cause painful bowel movements as the stool passes through rectum the inflamed lesions at the uterosacrals hurt badly.