Endometriosis: symptoms, modern diagnostics & treatment

At a glance

FrequencyOne of the most common gynaecological diseases; affects women of reproductive age; the diagnosis is often only made after years
What happensTissue similar to the uterine lining grows outside the uterus and causes chronic inflammation, pain and adhesions
Curable?According to current knowledge not curable at the root — but usually treatable well, with the aim of the longest possible freedom from symptoms
TreatmentPain therapy, hormonal therapy and/or surgical therapy — individual according to symptoms, life situation and the wish to have children
GuidelineS2k guideline DGGG (AWMF 015-045, version 5.0, April 2025)
ICD-10N80 (endometriosis)

Table of contents

  1. What is endometriosis?
  2. Symptoms
  3. Causes
  4. Diagnosis
  5. Treatment: medications and hormones
  6. Treatment: surgery
  7. The wish to have children and endometriosis
  8. Everyday life with endometriosis
  9. How brite helps you
  10. FAQ
  11. Related topics

1. What is endometriosis?

In endometriosis, tissue similar to the uterine lining grows outside the uterus — for example on the ovaries, on the peritoneum, on the fallopian tubes, on the bowel, on the bladder or, in rare cases, also at other places in the body. This tissue responds to the hormonal fluctuations of the menstrual cycle and can cause chronic inflammation, pain, adhesions and organ damage.¹

Endometriosis is one of the most common gynaecological diseases. Nevertheless, by estimates it takes several years on average from the first symptoms to the diagnosis — because the symptoms are often dismissed or misinterpreted as normal period pain.¹

Treatment rather than cure — but good prospects According to current knowledge, the disease is not curable at the root. The aim of treatment is the longest possible freedom from symptoms, the prevention of organ damage and the adjustment of the therapy to the individual life situation.¹

2. Symptoms

The symptoms of endometriosis are extremely variable — they depend on where the endometriosis lesions are located and how pronounced they are. The extent of the symptoms does not always correlate with the extent of the disease.¹

Common symptoms

  • Severe period pain (dysmenorrhoea) — the key symptom; often stronger than normal menstrual cramps and increasing over time
  • Chronic lower abdominal pain — also outside menstruation
  • Pain during sexual intercourse (dyspareunia) — especially with deep penetration
  • Pain during bowel movements or urination — especially during menstruation; can indicate bowel or bladder endometriosis
  • Heavy and/or prolonged monthly bleeding
  • Tiredness and exhaustion (fatigue) — often underestimated
  • Involuntary childlessness — endometriosis is one of the most common causes of infertility

Other possible complaints

  • Bloating, nausea, diarrhoea or constipation — especially cycle-dependent; can be misdiagnosed as irritable bowel syndrome
  • Back pain — especially during menstruation
  • Blood in the stool or urine — during menstruation
  • Psychological strain — anxiety, depression, frustration from chronic pain and the delay in diagnosis
Severe period pain is not "normal" Not every woman with severe period pain has endometriosis — but severe period pain that impairs everyday life should usually be medically assessed. When painkillers no longer help sufficiently, that is a signal.

3. Causes

The exact cause of endometriosis is, according to current knowledge, not fully clarified. Several theories are discussed.¹

  • Retrograde menstruation: menstrual blood flows back through the fallopian tubes into the abdominal cavity — the most widely held theory. It does not, however, explain all forms of endometriosis.
  • Metaplasia: the body's own cells transform into endometrium-like tissue.
  • Immune system: a misdirected immune response could prevent scattered endometrium tissue from being broken down.
  • Genetics: a familial clustering is known. First-degree relatives have an increased risk.
  • Adenomyosis: a special form in which endometrium tissue grows into the muscle layer of the uterus. Often leads to heavy bleeding and pain.

4. Diagnosis

The diagnosis of endometriosis usually requires a combination of medical history, gynaecological examination and imaging.¹

  • Medical history: the targeted questioning about period pain, pain during sexual intercourse, bowel complaints and the wish to have children is decisive. A structured pain questionnaire can be helpful.
  • Gynaecological examination: the palpation findings can give clues but are not always abnormal.
  • Transvaginal ultrasound: according to the current guideline, the primary diagnostic tool. It can show endometriosis cysts on the ovaries (endometriomas), adenomyosis and deep endometriosis lesions.¹
  • MRI: can be used additionally when deep endometriosis is suspected (e.g. bowel, bladder, ureter).
  • Laparoscopy: was previously regarded as the gold standard for the diagnosis. According to the current guideline, a diagnostic laparoscopy is not strictly necessary when the imaging is clear and a medication-based therapy is planned. Before a surgical therapy, it usually remains the standard.¹

More: Preparing for a doctor's appointment.

Use an endometriosis centre The guideline recommends that especially complex cases (deep endometriosis, the wish to have children, repeated operations) be treated at a certified endometriosis centre. A list of such centres can be found, among others, via the Endometriose-Vereinigung Deutschland (German Endometriosis Association).

5. Treatment: medications and hormones

The therapy depends on the individual symptoms, the wish to have children and the life situation. The decision is usually made by the treating gynaecology — ideally at a certified endometriosis centre.¹

Pain Pain therapy
NSAIDs — ibuprofen, diclofenac and others
Ibuprofen and diclofenac are often used for period pain. They do not act at the root of the endometriosis but can relieve pain.
Escalation of pain therapy
When NSAIDs do not work sufficiently, the pain therapy can be escalated individually — usually in consultation with pain medicine.
First line Hormonal therapy — progestogens

Hormonal medications can inhibit the growth of the endometriosis lesions and reduce the pain. They are usually a long-term therapy.

Dienogest
Usually regarded as the first-line hormonal therapy for endometriosis. It can suppress menstruation and shrink the endometriosis lesions. Used as a continuous therapy.¹
Alternative Combined oral contraceptives
The pill in a long cycle
As a continuous use (without a break), they can reduce period pain and endometriosis symptoms.
Reserve GnRH analogues
GnRH analogues ("artificial menopause")
Put the body into a kind of hormonal resting phase. They are usually used only for a limited time, because side effects can occur in the long term (including bone density loss). Mostly combined with an add-back therapy.

More: Drug interactions.

6. Treatment: surgery

A surgical therapy can be useful when the medication-based treatment does not work sufficiently, organ damage is imminent or there is a wish to have children. The standard procedure is the laparoscopy (keyhole surgery).¹

  • Endometriosis lesions are specifically removed or destroyed
  • Adhesions are released
  • Endometriosis cysts on the ovaries (endometriomas) can be shelled out — care is usually taken to preserve as much healthy ovarian tissue as possible
  • With deep infiltrating endometriosis (e.g. bowel, bladder), an extended operation can be necessary — usually at a certified endometriosis centre
Relapses are common — hormones after surgery recommended After an operation, relapses are common. A hormonal follow-up treatment (e.g. with dienogest) is usually recommended to lower the relapse risk.

7. The wish to have children and endometriosis

Endometriosis is one of the most common causes of involuntary childlessness. The treatment when there is a wish to have children requires an individual approach.¹

  • The hormonal endometriosis therapy (e.g. dienogest) usually has to be stopped before attempting a natural conception, because it suppresses ovulation
  • A surgical removal of endometriosis lesions can improve the natural pregnancy rate — especially with mild to moderate endometriosis
  • If success does not follow, a reproductive medicine treatment (IVF/ICSI) can be useful
  • The treatment should usually be interdisciplinary — gynaecology, reproductive medicine and an endometriosis centre

8. Everyday life with endometriosis

  • Pain management: individual pain coping (medications, warmth, exercise, relaxation). More: Taking medications correctly.
  • Exercise: regular physical activity is recommended in the guideline and can improve pain and wellbeing.¹
  • Psychological strain: chronic pain, the delay in diagnosis, the issue of the wish to have children and a lack of understanding can be a considerable burden. Psychological support, self-help groups (Endometriose-Vereinigung Deutschland e. V., the German Endometriosis Association) and multimodal therapy approaches can help.
  • Diet: according to current knowledge, there is no specific endometriosis diet. A balanced, anti-inflammatory diet is often recommended. Individual intolerances can play a role.
  • Rehabilitation: rehabilitation measures are a recognized service for endometriosis and can help to cope better with everyday life.¹

How brite helps you with endometriosis

Dienogest on time every day, ibuprofen as needed, more during flare-ups — and with it the wish to one day recognize when a flare is actually coming. Endometriosis treatment is long-term work. brite holds the line.

  • Medication reminder — dienogest, the pill or other hormone preparations: taking them on time every day is especially important with continuous hormonal therapy, because fluctuations can reduce the effect. Set up a reminder
  • Interaction check — dienogest plus an antibiotic? The pill plus St John's wort? brite shows when the hormonal effect can be impaired — and which alternatives would make sense. Check now
  • Health history — document pain days, your cycle, symptoms and quality of life over time. That way, at your next appointment in gynaecology, you can show what is really happening — instead of having to reconstruct it from memory. Track your history
  • Digital medication plan — all your medications clearly laid out for gynaecology, pain medicine, reproductive medicine and your family doctor. Helpful precisely when the treatment runs across disciplines. Go to medication plan
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FAQ: Common questions about endometriosis

Usually through a combination of a targeted medical history, a gynaecological examination and transvaginal ultrasound. A laparoscopy is not strictly necessary in every case — the current guideline emphasizes the role of imaging as the primary diagnostic tool.¹
According to current knowledge, not curable at the root. The aim of the therapy is the longest possible freedom from symptoms. With the menopause, the symptoms usually improve, because the hormone levels fall — but that is not a guarantee.
In many cases yes — even though endometriosis is a common cause of infertility. The treatment when there is a wish to have children requires an individual approach. A surgical removal of endometriosis lesions can improve the chances. If success does not follow, a reproductive medicine treatment (IVF/ICSI) can be useful.¹
A progestogen that is usually used as the first-line hormonal therapy for endometriosis. It inhibits the growth of the endometriosis lesions and can reduce the pain. It is mostly taken as a continuous therapy.¹
A certified facility that specializes in the diagnosis and treatment of endometriosis. The guideline recommends that especially complex cases (deep endometriosis, the wish to have children, repeated operations) be treated at a certified centre.¹
According to current knowledge, there is no specific endometriosis diet. A balanced, anti-inflammatory diet is often recommended but usually cannot replace the medication-based or surgical therapy.
Because the symptoms are extremely variable and are often misinterpreted as normal period pain or as other diseases. In addition, there was for a long time no simple screening. The current guideline emphasizes the importance of a targeted medical history and of transvaginal ultrasound as the primary diagnostic tool.¹
After a surgical removal of endometriosis lesions, a hormonal follow-up treatment (e.g. with dienogest) is usually recommended to lower the relapse risk. The decision is made by the treating gynaecology.¹

11. Related topics

Irritable bowel syndrome Depression Iron deficiency anaemia Taking medications correctly Drug interactions Stopping medications

Sources

  1. S2k-Leitlinie Diagnostik und Therapie der Endometriose (DGGG, AWMF Reg-Nr. 015-045, Version 5.0, April 2025). awmf.org
  2. gesundheitsinformation.de (IQWiG): Endometriose. gesundheitsinformation.de
  3. Endometriose-Vereinigung Deutschland e. V. endometriose-vereinigung.de
  4. Deutsche Gesellschaft für Gynäkologie und Geburtshilfe (DGGG). dggg.de
Medical disclaimer: This article is for general information and does not replace medical advice, diagnosis or treatment. Endometriosis usually requires individual treatment planning. With severe period pain or suspected endometriosis, a gynaecological assessment should take place. The choice and dosing of medication is always determined individually by the treating gynaecology. Last updated: April 2026.