1. What is endometriosis?
Endometriosis (say quot;en-doh-mee-tree-OH-susquot;) is a problem many women have during their
childbearing years. It means that a type of tissue that lines your uterus is also growing outside
your uterus. This does not always cause symptoms, and it usually is not dangerous. But it can
cause pain and other problems.
The clumps of tissue that grow outside your uterus are called implants. They usually grow on the
ovaries, the fallopian tubes, the outer wall of the uterus, the intestines, or other organs in the
belly. In rare cases, they spread to areas beyond the belly.
How does endometriosis cause problems?
Your uterus is lined with a type of tissue called endometrium (say quot;en-doh-MEE-tree-umquot;). It is
like a soft nest where a fertilized egg can grow. Each month, your body releases hormones that
cause the endometrium to thicken and get ready for an egg. If you get pregnant, the fertilized egg
attaches to the endometrium and starts to grow. If you do not get pregnant, the endometrium
breaks down, and your body sheds it as blood. This is your menstrual period.
When you have endometriosis, the implants of tissue outside your uterus act just like the tissue
lining your uterus. During your menstrual cycle, they get thicker, then break down and bleed.
But the implants are outside your uterus, so the blood cannot flow out of your body. The
implants can get irritated and painful. Sometimes they form scar tissue or fluid-filled sacs (cysts).
Scar tissue may make it hard to get pregnant.
What causes endometriosis?
Experts do not know what causes endometrial tissue to grow outside your uterus. But they do
know that the female hormone estrogen makes the problem worse. Women have high levels of
estrogen during their childbearing years. It is during these years-usually from their teens into
their 40s-that women have endometriosis. Estrogen levels drop when menstrual periods stop
(menopause). Symptoms usually go away then.
What are the symptoms?
The most common symptoms are:
Pain. Where it hurts depends on where the implants are growing. You may have pain in
your lower belly, your rectum or vagina, or your lower back. You may have pain only
before and during your periods or all the time. Some women have more pain during sex,
when they have a bowel movement, or when their ovaries release an egg (ovulation).
Abnormal bleeding. Some women have heavy periods, spotting or bleeding between
periods, bleeding after sex, or blood in their urine or stool.
Trouble getting pregnant (infertility). This is the only symptom some women have.

2. Endometriosis varies from woman to woman. Some women do not know that they have it until
they go to see a doctor because they cannot get pregnant. Some have mild cramping that they
think is normal for them. In other women, the pain and bleeding are so bad that they are not able
to work or go to school.
How is endometriosis diagnosed?
Many different problems can cause painful or heavy periods. To find out if you have
endometriosis, your doctor will:
Ask questions about your symptoms, your periods, your past health, and your family
history. Endometriosis sometimes runs in families.
Do a pelvic exam. This may include checking both your vagina and rectum.
If it seems like you have endometriosis, your doctor may suggest that you try medicine for a few
months. If you get better using medicine, you probably have endometriosis.
To find out if you have a cyst on an ovary, you might have an imaging test like an ultrasound, an
MRI, or a CT scan. These tests show pictures of what is inside your belly.
The only way to be sure you have endometriosis is to have a type of surgery called laparoscopy
(say quot;lap-uh-ROS-cuh-peequot;). During this surgery, the doctor puts a thin, lighted tube through a
small cut in your belly. This lets the doctor see what is inside your belly. If the doctor finds
implants, scar tissue, or cysts, he or she can remove them during the same surgery.
How is it treated?
There is no cure for endometriosis, but there are good treatments. You may need to try several
treatments to find what works best for you. With any treatment, there is a chance that your
symptoms could come back.
Treatment choices depend on whether you want to control pain or you want to get pregnant. For
pain and bleeding, you can try medicines or surgery. If you want to get pregnant, you may need
surgery to remove the implants.
Treatments for endometriosis include:
Over-the-counter pain medicines like ibuprofen (such as Advil or Motrin) or naproxen
(such as Aleve). These medicines are called anti-inflammatory drugs, or NSAIDs. They
can reduce bleeding and pain.
Birth control pills. They are the best treatment to control pain and shrink implants. Most
women can use them safely for years. But you cannot use them if you want to get
pregnant.
Hormone therapy. This stops your periods and shrinks implants. But it can cause side
effects, and pain may come back after treatment ends. Like birth control pills, hormone
therapy will keep you from getting pregnant.

3. Laparoscopy to remove implants and scar tissue. This may reduce pain, and it may also
help you get pregnant.
As a last resort for severe pain, some women have their uterus and ovaries removed
(hysterectomy and oophorectomy). If you have your ovaries taken out, your estrogen level will
drop and your symptoms will probably go away. But you may have symptoms of menopause,
and you will not be able to get pregnant.
If you are getting close to menopause, you may want to try to manage your symptoms with
medicines rather than surgery. Endometriosis usually stops causing problems when you stop
having periods.
What else should you think about?
If you are thinking about using medicines for pain, keep the following in mind:
NSAIDs are not a good choice if there is a chance that you are or could soon become
pregnant. They may increase the chance that you will have a miscarriage. Check with
your doctor before using any over-the-counter medicine for more than a few days at a
time.
Hormone therapy can cause a range of side effects. Some are unpleasant, like those
caused by menopause. Others are serious, like bone thinning (osteoporosis). To limit
these problems, hormone therapy is only used for a few months at a time. Be sure to find
out the side effects of any therapy you are thinking about.
Endometriosis - Treatment Overview
Although there is no cure for endometriosis, treatment can help with pain and infertility.
Treatment depends on how severe your symptoms are and whether you have future pregnancy
plans. For pain only, any hormone therapy that lowers your body's estrogen levels will shrink
endometriosis implants and may reduce pain. To become pregnant, surgery, infertility treatment,
or both may help.
Endometriosis symptoms, no pregnancy plans
If you have endometrial pain or bleeding and no immediate plans to become pregnant, birth
control hormones (patch, pills, or ring) or anti-inflammatories (NSAIDs) may be all that you
need to control pain. Birth control hormones help shrink endometrial tissue and reduce pain for
most women. They are also likely to keep endometriosis from getting worse.7 Anti-
inflammatories reduce bleeding, inflammation, and pain. Most women can use these medicines
safely for the long term with few side effects.
If you have more severe symptoms or if birth control hormones and NSAIDs do not work, you
might try a stronger hormone therapy such as therapy with a gonadotropin-releasing hormone
agonist (GnRH-a), progestin, a progestin intrauterine device (Mirena), danazol, or aromatase
inhibitors. Some doctors will first do a laparoscopy to look for signs of endometriosis in the

4. pelvis. But many think this is not needed unless there is a chance that you have another
problem.8
Should I use hormone therapy to treat endometriosis?
If hormone therapy does not work or if growths are affecting other organs, surgery to remove
endometrial growths and scar tissue is the next step. This can usually be done through one or
more small incisions, using laparoscopy. Some studies suggest that using hormone therapy after
surgery can make the pain-free period longer by preventing the growth of new or returning
endometriosis.7 Surgery relieves pain for a year or two in most women, although about 20% of
women report no improvement after surgery.9
In severe cases, removing the uterus and ovaries (hysterectomy and oophorectomy) is an option.
This surgery causes early menopause. It is reserved for women with no pregnancy plans who
have had little relief with other treatments. But up to 15% of women continue to have pain after
this major surgery.10
Should I have a hysterectomy and oophorectomy to treat endometriosis?
Infertility treatment
If you are having trouble becoming pregnant, treatment decisions for endometriosis may be more
complex. The treatment you and your doctor choose may depend on how bad your endometriosis
is, your age, your health in general, and other factors. Options to improve your chances of
pregnancy include:
Intercourse during the most fertile days of each menstrual cycle. If your endometriosis is
not very bad, this may be all you need to try.
Laparoscopic surgery. Surgical removal of endometriosis and scar tissue can improve
pain and your chance for pregnancy. This is especially true for women with mild to
moderate endometriosis.11
Superovulation medicine (clomiphene or gonadotropins) and intrauterine insemination.
These are often used to treat infertility in women.
In vitro fertilization. If surgery does not lead to pregnancy, in vitro fertilization can help
improve your chances.
Using hormone therapy for endometriosis will not help with infertility. Hormone therapy
for endometriosis prevents pregnancy. But some studies of women with severe
endometriosis have found that 6 months of GnRH-a treatment before in vitro fertilization
improves the chances of conceiving a successful pregnancy.11
What To Think About
Not all women with endometriosis have pain, and endometriosis does not always get
worse over time. During pregnancy, endometriosis usually improves, as it does after
menopause. If you have mild pain, have no plans for a future pregnancy, or are near
menopause (around age 50), you may not feel a need for treatment. The decision is up to
you.

5. Pain recurrence after hormone therapy
After treatment with any hormone therapy, endometriosis pain can, but does not always,
return. Pain is more likely to return with more severe endometriosis.