Endometriosis:
Symptoms, Modern Diagnosis & Treatment

1. What is endometriosis?

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

Endometriosis is one of the most common gynaecological conditions. Despite this, it takes on average several years from the first symptoms to diagnosis — because complaints are often dismissed as normal period pain or misinterpreted.^¹

2. Symptoms

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

Common symptoms

• Severe period pain (dysmenorrhoea) — the leading symptom; often more severe than normal menstrual cramps and progressive over time
• Chronic pelvic pain — also outside menstruation
• Pain during intercourse (dyspareunia) — particularly with deep penetration
• Pain on bowel movements or urination — particularly during menstruation; may indicate bowel or bladder endometriosis
• Heavy and/or prolonged menstrual bleeding
• Fatigue and exhaustion — often underestimated
• Infertility — endometriosis is one of the most common causes of difficulty conceiving

Other possible symptoms

• Bloating, nausea, diarrhoea or constipation — particularly cycle-related; can be misdiagnosed as irritable bowel syndrome
• Back pain — particularly during menstruation
• Blood in stool or urine — during menstruation
• Mental health impact — anxiety, depression, frustration from chronic pain and diagnostic delay

3. Causes

The exact cause of endometriosis is currently not fully understood. Several theories are discussed.^¹

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

4. Diagnosis

Diagnosing endometriosis typically requires a combination of history, gynaecological examination and imaging.^¹

• History: targeted questioning about period pain, pain during intercourse, bowel symptoms and fertility plans is crucial. A structured pain questionnaire can be helpful.
• Gynaecological examination: physical findings can give clues but are not always abnormal.
• Transvaginal ultrasound: according to current guidelines, the primary diagnostic tool. Can detect endometriotic cysts on the ovaries (endometriomas), adenomyosis and deep endometriotic lesions.^¹
• MRI: can be used in addition when deep endometriosis (e.g. bowel, bladder, ureter) is suspected.
• Laparoscopy: previously considered the gold standard for diagnosis. According to current guidelines, a diagnostic laparoscopy is not strictly necessary when imaging is conclusive and medical therapy is planned. Before surgical therapy, it generally remains the standard.^¹

5. Treatment: medications and hormones

Treatment depends on individual symptoms, fertility plans and life situation. The decision is typically made by the treating gynaecology team — ideally at a certified endometriosis centre.^¹

6. Treatment: surgery

Surgical treatment can be useful when medical therapy does not provide sufficient relief, organ damage is impending or there is a desire to conceive. The standard procedure is laparoscopy (keyhole surgery).^¹

• Endometriotic lesions are removed or destroyed
• Adhesions are released
• Ovarian endometriotic cysts (endometriomas) can be cyst-stripped — care is generally taken to preserve as much healthy ovarian tissue as possible
• For deep infiltrating endometriosis (e.g. bowel, bladder), more extensive surgery may be necessary — typically at a certified endometriosis centre

7. Fertility and endometriosis

Endometriosis is one of the most common causes of difficulty conceiving. Treatment when planning pregnancy requires an individual approach.^¹

• Hormonal endometriosis therapy (e.g. dienogest) typically needs to be stopped before attempting natural conception, as it suppresses ovulation
• Surgical removal of endometriotic lesions can improve natural conception rates — particularly for mild to moderate endometriosis
• If conception does not occur, assisted reproductive technology (IVF/ICSI) may be an option
• Treatment should typically be multidisciplinary — gynaecology, reproductive medicine and endometriosis centre

8. Daily life with endometriosis

• Pain management: individual pain coping (medication, heat, exercise, relaxation).
• Exercise: regular physical activity is recommended in guidelines and can improve pain and well-being.^¹
• Mental health impact: chronic pain, diagnostic delay, fertility concerns and lack of understanding can be very burdensome. Psychological support, peer support groups and multimodal treatment approaches can help.
• Nutrition: there is no specific endometriosis diet supported by current evidence. A balanced, anti-inflammatory diet is often recommended. Individual food intolerances may play a role.
• Rehabilitation: rehab measures are an established component of endometriosis care and can help manage daily life.^¹

How brite helps you with endometriosis

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

• Intake reminder — dienogest, the pill or other hormonal preparations: punctual daily intake is particularly important for hormonal long-term therapy because fluctuations can reduce effectiveness.
• Drug interaction check — dienogest plus an antibiotic? The pill plus St John's wort? brite shows when hormonal effects may be affected — and what alternatives could be sensible.
• Health journal — track pain days, cycle, symptoms and quality of life over time. So at the next gynaecology appointment, what's actually happening can be shown — instead of having to reconstruct it from memory.
• Digital medication plan — all medications clearly organised for gynaecology, pain medicine, reproductive medicine and GP. Particularly helpful when treatment is multidisciplinary.

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