Endometriosis

Have you experienced period pain is severe enough that over-the-counter medication barely touches it?

Have you been  rearranging your schedule around your cycle for years?

Perhaps your doctor has told you that the pain is normal, that it's "just stress", or that it will get better after pregnancy.

Is sex is painful, changing the way you feel about intimacy and worrying about the connection you have with your partner?

Do you have bowel symptoms, bloating, or bladder issues that flare around your period, and have you been worked up for irritable bowel syndrome without a clear answer?

Are you exhausted in a way that does not improve with sleep, and has no one connected that fatigue to anything else going on in your body?

Have you been trying to conceive without success, with no clear cause?

Did you have a normal ultrasound and have been told nothing is wrong, even though your symptoms have not changed?

Endometriosis is a chronic inflammatory condition in which tissue resembling the uterine lining grows outside the uterus, most commonly on the pelvic peritoneum, ovaries, and structures behind the uterus. It affects roughly one in ten women of reproductive age. The tissue responds to hormonal signals, and the resulting inflammation, bleeding, and scarring can produce pain, adhesions, and, in some cases, difficulty conceiving. Importantly, the severity of symptoms does not always match the extent of visible disease. Some patients have significant pain with minimal findings on imaging, and others have advanced disease with relatively few symptoms.

The condition is also more than a pelvic problem. Research increasingly recognizes endometriosis as a systemic inflammatory and immune-mediated condition. It has been found to co-occur with autoimmune conditions, and the chronic inflammation it generates affects the gut, the nervous system, energy, mood, and immune function.

For decades, a definitive diagnosis required surgery, which contributed to diagnostic delays that averaged seven to ten years. That standard has changed. European guidance published in 2022 moved away from requiring laparoscopy for diagnosis, and in February 2026, the American College of Obstetricians and Gynecologists published clinical guidance supporting a presumptive diagnosis based on symptoms, examination, and imaging. A normal ultrasound does not rule the condition out. Treatment can now begin based on clinical findings without waiting for a surgical answer.

That shift is significant, because the quality of the initial clinical conversation now carries real diagnostic weight. A rushed visit that checks a box and moves on is not enough. A careful, detailed intake that asks the right questions and looks for the right patterns is the foundation the rest of the evaluation is built on.

A normal ultrasound does not mean nothing is wrong. Routine imaging frequently misses superficial endometriosis, and the absence of findings on a standard scan has historically been used to close conversations that should have stayed open.

Normal lab results do not mean nothing is wrong either, particularly when the labs that were ordered were not comprehensive enough to evaluate the hormonal, inflammatory, nutritional, and metabolic factors that influence endometriosis symptoms.

Being told that pain is normal, that it is stress, that it will improve with pregnancy, or that there is nothing more to do is a common experience for women with endometriosis. It is not a clinical conclusion. It is often the result of a care model that does not have the time, the framework, or the training to look deeper.

At Compassion Primary Care, a thorough evaluation takes the time the condition requires. Patients are assessed across multiple systems, not dismissed because one test came back within range. Symptoms are taken seriously, investigated carefully, and treated based on what the full clinical picture reveals.

Most conventional care for endometriosis focuses on two things: hormonal suppression of the menstrual cycle and surgery to remove visible lesions. Both can be valuable, however they address the condition at the tissue level without asking what else is contributing to the inflammation, the pain, or the hormonal environment that allows the disease to progress.

Endometriosis is driven by chronic inflammation and influenced by estrogen. The way a patient's body produces, metabolizes, and eliminates estrogen directly affects how the condition behaves. So does her gut health, her nutrient status, stress physiology, sleep, and her blood sugar stability impact the progression. Addressing those factors is not an alternative to medical treatment. It is the clinical layer that determines whether medical treatment works well or only works halfway.

This is the difference between managing a single diagnosis and evaluating the whole patient.

Endometriosis tissue is estrogen-dependent. When estrogen levels are elevated or when the body struggles to clear estrogen efficiently, the inflammatory environment worsens.

Estrogen is metabolized in two steps. The first takes place in the liver, where estrogen is broken down and prepared for elimination. That process requires adequate levels of specific nutrients, including magnesium, B vitamins, and the compounds found in cruciferous vegetables. When those nutrients are depleted, or when liver function is burdened by other demands, estrogen clearance slows down.

The second step takes place in the gut, where metabolized estrogen is packaged and eliminated through the stool. Gut bacteria play a direct role in this process. When the microbiome is imbalanced, certain bacteria can cause estrogen to be reabsorbed into circulation rather than eliminated, contributing to higher circulating estrogen levels. Research has also found that a significant percentage of women with endometriosis have concurrent small intestinal bacterial overgrowth (SIBO), and that the health of the intestinal microbiome plays a role in the progression of the condition.

This means that gut health is not a side topic in endometriosis care. It is part of the hormonal picture.

In a balanced hormonal system, progesterone counterbalances the effects of estrogen. In endometriosis, that balance is often disrupted. Research suggests that endometriosis tissue can develop resistance to progesterone, meaning the body's natural progesterone is less effective at keeping estrogen's influence in check. Chronic stress compounds this problem, because sustained cortisol production can divert the raw materials the body uses to produce progesterone, shifting the hormonal balance further toward estrogen.

Progesterone evaluation and, when clinically appropriate, progesterone support are part of the integrative approach at Compassion Primary Care. This is not a matter of prescribing a single hormone in isolation. It is a clinical decision made after reviewing labs, symptoms, stress load, cycle history, and the broader hormonal picture.

Pain in endometriosis is not generated solely by the lesions. Over time, the chronic inflammatory environment can sensitize the nervous system, meaning pain signals are amplified independently of how much disease is present. This is called central sensitization, and it helps explain why some patients have severe symptoms with minimal visible disease and why hormonal therapy alone sometimes provides less relief than expected.

Several factors outside the lesions themselves influence how much inflammation the body generates and how sensitized the nervous system becomes.

Magnesium affects muscle tension (including pelvic floor tension, which is common in endometriosis), inflammation, estrogen metabolism, sleep quality, and the nervous system's ability to regulate pain signals. Studies have found magnesium supplementation associated with reductions in menstrual and endometriosis-related pain. Nearly half of Americans are estimated to have insufficient magnesium intake, and stress, caffeine, and alcohol deplete magnesium stores further.

Vitamin D plays a role in immune regulation and inflammatory modulation. Even in sun-rich areas, a significant portion of the population is deficient, and research has linked vitamin D status to pain intensity in women with endometriosis.

Omega-3 fatty acids have well-documented anti-inflammatory properties, and systematic reviews have associated omega-3 intake with reductions in pain and improved quality of life in women with endometriosis.

Blood sugar stability matters because chronic blood sugar swings contribute to systemic inflammation. When blood sugar is consistently unstable, it drives inflammatory signaling, disrupts energy and mood, and can worsen pain over time.

Sleep affects inflammation, cortisol regulation, immune function, and pain perception. Poor sleep worsens every other factor on this list, and endometriosis symptoms frequently disrupt sleep, creating a cycle that is difficult to break without addressing sleep directly.

Chronic stress raises cortisol, which promotes inflammation, suppresses progesterone production, disrupts gut motility, destabilizes blood sugar, and impairs immune regulation. For many women with endometriosis, the physiological cost of long-term stress is a significant and unaddressed contributor to their symptoms.

The most valuable diagnostic tool for endometriosis is a detailed clinical history. At Compassion Primary Care, the first visit is built around that history, not around a quick review and a prescription.

Expect thorough questions about when pain occurs relative to the menstrual cycle, how it has changed over time, whether it involves bowel movements or urination, whether intercourse is painful and where, what medications and hormonal treatments have already been tried, fertility history and goals, and any family history of endometriosis or chronic pelvic pain.

A pelvic examination is used to evaluate for tenderness, nodularity, restricted organ mobility, and pelvic floor muscle tension. Imaging typically begins with transvaginal ultrasound performed by someone experienced in evaluating specifically for endometriosis, because a routine scan frequently misses superficial disease. MRI may be added when deep disease is suspected or surgical planning is being considered.

Lab work is used to evaluate the broader clinical picture rather than to diagnose the condition itself. Testing may include a hormone panel, thyroid function, inflammatory markers, nutrient status (vitamin D, magnesium, B12, ferritin, iron), blood sugar and metabolic markers, and gut health markers when indicated. The purpose is to understand the environment in which the endometriosis is operating, because that environment determines how the patient feels and how effectively treatment works.

Because endometriosis frequently coexists with other conditions, the evaluation also considers adenomyosis, pelvic floor dysfunction, interstitial cystitis, irritable bowel syndrome, SIBO, and histamine sensitivity. Treating endometriosis while leaving a coexisting pain generator unaddressed is a common reason patients feel only partially better after treatment.

Treatment is layered, individualized, and built around what the evaluation reveals.

When hormonal therapy is indicated, options include progesterone-based treatments, combined hormonal therapy, and other agents that reduce cyclical stimulation of the endometriosis tissue. The choice depends on the patient's age, fertility goals, lab results, cardiovascular risk profile, and response to any previous treatments. Nonsteroidal anti-inflammatory medication is often used alongside hormonal therapy for pain management.

Surgery is not performed at Compassion Primary Care, but referral to a skilled excision surgeon is coordinated when medical management is insufficient, when deep disease is affecting the bowel or urinary structures, or when fertility goals make surgical intervention appropriate. Surgery can reduce pain and improve fertility outcomes in some situations. It is not curative, and recurrence is common, which is why a plan for what happens after surgery is discussed before surgery rather than after.

Based on what the evaluation reveals, the treatment plan may include progesterone support to address hormonal imbalance, magnesium and targeted nutrient repletion based on documented deficiencies, gut health evaluation and support (including addressing SIBO, dysbiosis, or intestinal permeability when present), anti-inflammatory nutritional support tailored to the individual patient rather than a one-size-fits-all elimination diet, sleep support to address cortisol rhythm disruption and the sleep-pain cycle, stress physiology support to address the hormonal and inflammatory consequences of chronic stress, and pelvic floor physical therapy referral when pelvic floor tension or overactivity is contributing to pain.

Every patient is evaluated across hormones and thyroid, gut health, sleep, stress, whole-body health, and nutrition, because endometriosis does not exist in isolation from the rest of the body. The six-pillar framework prevents the mistake of treating a single diagnosis while leaving the contributing factors untouched.

For patients who are actively trying to conceive, the treatment approach is sequenced differently, because most hormonal therapies prevent pregnancy. Coordination with a reproductive endocrinologist is typically part of the plan from the beginning when fertility is a priority.

If you have spent years being told your symptoms are normal, the next step is an evaluation that takes them seriously. Book a free discovery call to review your history, discuss what the workup would involve, and determine whether Compassion Primary Care is the right fit.

Treatments for endometriosis have side effects that are worth knowing about in advance. Nonsteroidal anti-inflammatory medications can cause stomach upset, reflux, and, with prolonged use, gastrointestinal bleeding or kidney effects. Hormonal therapies commonly cause irregular bleeding or spotting during the first few months, along with breast tenderness, mood changes, headache, nausea, or reduced libido. Gonadotropin-releasing hormone medications can produce hot flashes, vaginal dryness, sleep disruption, and bone density loss with longer use, which is why add-back therapy and monitoring are often part of the plan. Pelvic floor physical therapy frequently causes temporary soreness or a brief increase in symptoms after early sessions. Dietary changes and new supplements may cause bloating, nausea, or changes in bowel habits, and supplements can interact with prescribed medications.

Contact the clinic if bleeding becomes heavier or more prolonged than usual, if side effects from a new medication persist beyond three months, if pain is escalating rather than improving on your current plan, if you develop new bowel or bladder symptoms, or if you are considering stopping a medication. Contact us as well if you become pregnant or are planning to conceive, since most treatments need to be changed. Seek urgent care immediately for severe sudden pelvic or abdominal pain, fever with pelvic pain, heavy bleeding that soaks through a pad or tampon hourly for more than two hours, fainting or lightheadedness, inability to urinate or pass stool, chest pain, shortness of breath, or swelling and pain in one leg.

Not necessarily, and this has changed recently. Current guidance from both European and United States professional bodies supports making a presumptive diagnosis based on symptoms, examination, and imaging, and beginning treatment on that basis. Surgery is reserved for situations where imaging is inconclusive and initial treatment has not worked, or where surgery is being considered for treatment anyway.

No. Negative imaging does not rule out endometriosis. Superficial peritoneal disease often does not appear on ultrasound or MRI at all. A normal scan means the imaging did not find endometriomas or deep nodules, which is useful information, but it does not close the question.

No treatment currently eliminates the condition permanently. It is a chronic condition that is managed, and symptoms can recur after both medical treatment and surgery. That said, many people achieve substantial and durable improvement in pain and function with an appropriate plan, and the goal of care is exactly that.

Many people with endometriosis conceive without assistance. The condition is associated with reduced fertility, and roughly four in ten people evaluated for infertility have endometriosis, but the relationship varies considerably by individual. If conception is a goal, that should shape the treatment plan from the start, since most hormonal therapies prevent pregnancy while you are taking them.

Hormonal therapy suppresses the cyclical stimulation that drives inflammation and pain, so it treats a genuine mechanism rather than only dulling symptoms. It does not remove existing lesions. Whether it is the right choice depends on your symptoms, your fertility plans, and how you tolerate it.

This is common and usually means more than one pain mechanism is involved. Pelvic floor muscle overactivity, central sensitization, adenomyosis, interstitial cystitis, or irritable bowel syndrome can all persist after the endometriosis itself is being treated. Identifying which of these is contributing is a specific part of the evaluation.

There is no diet with strong enough trial evidence to be called a treatment. Some people identify individual foods that reliably worsen their symptoms, and addressing documented nutritional deficiencies is worthwhile. Any dietary recommendation should be framed as supportive rather than curative.

Hormonal therapy is typically given three months before judging whether it is working, since irregular bleeding and side effects are most common early on. Pelvic floor physical therapy usually requires several weeks before change is noticeable. Your clinician should give you a specific timeline and a plan for what happens if that timeline passes without improvement.

• American College of Obstetricians and Gynecologists. Endometriosis. ACOG Patient Education FAQ.
• American College of Obstetricians and Gynecologists, Committee on Clinical Practice Guidelines-Gynecology. Diagnosis of Endometriosis: ACOG Clinical Practice Guideline 2026.
• Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, guideline: endometriosis. Human Reproduction Open. 2022.
• Zondervan KT, Becker CM, Missmer SA. Endometriosis. New England Journal of Medicine. 2020
• Can G, Pinto Amorim das Virgens I, Feher B, Orban EP Physiotherapy for endometriosis-associated pelvic pain: a systematic review 2026

You may also want to read about Advanced Lab Testing, Perimenopause and Menopause, Gut Health, and Integrative Medicine, since these areas often overlap with endometriosis and the pelvic, digestive, and hormonal symptoms that accompany it.