Severe period pain is common enough that many women are told to simply endure it. But period pain that repeatedly stops you from going to work or school, disrupts sleep, makes sex painful, causes pain during bowel movements or is accompanied by difficulty becoming pregnant deserves proper medical attention.
One possible cause is endometriosis.
Endometriosis is a chronic condition in which tissue similar to the lining inside the uterus grows outside the uterus. This can trigger inflammation, pain and scar tissue.
It most commonly affects structures within the pelvis, including the ovaries and tissues surrounding the uterus, although endometriosis can occur elsewhere in the body.
The World Health Organization estimates that endometriosis affects about 10% of women of reproductive age worldwide, equivalent to approximately 190 million people.
But having painful periods does not automatically mean you have endometriosis, and the severity of pain does not always tell doctors how extensive the disease is.
The important question is therefore not simply:
“Do I have painful periods?”
It is:
“Are my symptoms severe, persistent or disruptive enough that they need medical investigation?”
What Does Endometriosis Pain Feel Like?
There is no single symptom pattern that identifies endometriosis.
For some women, the main problem is extremely painful menstruation. Others experience pelvic pain throughout the month, painful sex or difficulty becoming pregnant.
Some people have relatively extensive endometriosis with few symptoms, while others experience severe pain with less extensive disease.
Symptoms may include:
Severe menstrual cramps
Pelvic pain before or during menstruation
Chronic pelvic pain
Lower abdominal or lower back pain
Pain during or after sexual intercourse
Pain during bowel movements, particularly around menstruation
Pain when urinating during menstruation
Heavy menstrual bleeding
Bleeding between periods
Abdominal bloating
Nausea
Fatigue
Difficulty becoming pregnant
Some women also experience constipation, diarrhoea or other bowel symptoms that become worse around their menstrual period.
This is one reason endometriosis can sometimes be confused with gastrointestinal or urinary conditions.
When Is Period Pain No Longer “Normal”?
Some discomfort during menstruation is common.
But severe pain should not automatically be dismissed simply because it occurs during a period.
Consider seeking medical assessment when menstrual pain:
Regularly prevents you from working or attending school
Makes normal daily activities difficult
Causes vomiting, faintness or severe physical distress
Is becoming progressively worse
Does not respond adequately to ordinary pain relief
Occurs during sex
Occurs during bowel movements or urination
Continues outside your menstrual period
Is associated with difficulty becoming pregnant
A useful practical question is:
“Is my period controlling my life?”
If the answer is repeatedly yes, it deserves investigation.
What Actually Happens in Endometriosis?
The inside of the uterus is lined by tissue called the endometrium.
In endometriosis, tissue similar to this lining develops outside the uterus.
Endometriosis may affect areas such as:
The ovaries
Fallopian tubes
Pelvic lining
Tissue around the uterus
Bowel
Bladder
Endometriosis involving an ovary can sometimes form a cyst called an endometrioma.
Inflammation associated with endometriosis can also contribute to adhesions, where tissues or organs that would normally move independently become stuck together by bands of scar-like tissue.
Less commonly, endometriosis can occur outside the pelvis.
What Causes Endometriosis?
The exact cause of endometriosis remains unknown.
Several biological mechanisms have been proposed, including movement of menstrual tissue through the fallopian tubes into the pelvis, immune-system factors, genetic susceptibility and transformation of certain cells into endometrium-like cells.
None of these explanations alone completely explains the disease.
One thing is important:
Endometriosis is not caused by poor hygiene, sexual activity or a sexually transmitted infection.
It is also not something a woman develops because she failed to take proper care of herself.
Who Is More Likely to Develop Endometriosis?
Endometriosis can affect people who menstruate from adolescence through adulthood.
Having a close family member with endometriosis may increase the likelihood of developing the condition.
Other factors have been associated with endometriosis, including menstrual characteristics such as shorter cycles or prolonged/heavy menstruation.
However, risk factors cannot diagnose endometriosis.
Someone without obvious risk factors can still develop the condition.
How Is Endometriosis Diagnosed?
This is where understanding of endometriosis has changed considerably.
Historically, many women were told that endometriosis could only be definitively diagnosed through laparoscopy, a surgical procedure in which a camera is inserted into the abdomen.
Surgery remains important in selected cases, but it is not always necessary before treatment can begin.
Evaluation may involve several steps.
1. Your Symptoms and Menstrual History
A detailed history is extremely important.
A healthcare professional may ask:
When does the pain occur?
Does it worsen during menstruation?
How severe is it?
Does it interfere with work or school?
Is sex painful?
Are bowel movements painful during your period?
Do you experience urinary pain?
How heavy are your periods?
How long have you been trying to become pregnant?
Does anyone in your family have endometriosis?
Keeping a menstrual and symptom diary can therefore be useful before an appointment.
Record when pain occurs, how severe it becomes, associated bleeding, bowel or bladder symptoms and whether it interferes with normal activities.
2. Physical Examination
A clinician may perform an abdominal or pelvic examination depending on your symptoms and circumstances.
An examination may identify tenderness, masses or other abnormalities.
However, a normal examination does not automatically exclude endometriosis.
3. Ultrasound
Ultrasound is commonly used when endometriosis is suspected.
It can help identify ovarian endometriomas and some forms of deeper endometriosis.
But another important point is:
A normal ultrasound does not necessarily mean that you do not have endometriosis.
Some endometriosis lesions are too small or located in places that are difficult to detect using routine ultrasound.
4. MRI
Magnetic resonance imaging may be useful in selected patients, particularly when doctors need more detailed information about suspected deep endometriosis or are planning treatment.
MRI is not required for everyone with suspected endometriosis.
5. Laparoscopy
Laparoscopy allows a surgeon to look directly inside the pelvis using a small camera inserted through the abdomen.
Endometriosis lesions may be identified and sometimes treated during the procedure.
Tissue may also be removed for laboratory examination.
However, current approaches increasingly recognise that symptoms, examination and appropriate imaging can sometimes provide enough information to begin treatment without requiring diagnostic surgery first.
Is There a Blood Test for Endometriosis?
At present, there is no routine blood test that can reliably confirm or rule out endometriosis on its own.
Research continues into blood, saliva, menstrual-fluid and other biomarkers that could make diagnosis easier and less invasive.
Until sufficiently accurate tests become established in routine clinical practice, diagnosis continues to depend primarily on symptoms, clinical assessment, imaging and, in selected cases, surgery.
Why Can Endometriosis Take So Long to Diagnose?
Endometriosis can be difficult to recognise because its symptoms overlap with many other conditions.
Pelvic pain, for example, may also occur with:
Adenomyosis
Fibroids
Pelvic inflammatory disease
Ovarian cysts
Urinary disorders
Gastrointestinal conditions
Another major problem is the normalisation of menstrual pain.
Girls and women may spend years believing severe pain is simply something they are expected to tolerate.
Healthcare providers may also initially attribute symptoms to other conditions.
The World Health Organization reports that the average time to diagnosis internationally can range from approximately 4 to 12 years.
That delay matters because years of untreated symptoms can affect education, employment, relationships, mental health and quality of life.
How Is Endometriosis Treated?
There is currently no treatment that guarantees a permanent cure for endometriosis.
Instead, treatment aims to:
Reduce pain
Control other symptoms
Improve quality of life
Address fertility problems where relevant
Manage complications
Reduce recurrence where possible
The best treatment depends heavily on the individual.
A 22-year-old with severe pain who does not currently want pregnancy may need a very different treatment plan from a 36-year-old who has been trying to conceive.
Treatment decisions should therefore consider:
Age
Symptoms
Severity of symptoms
Location and extent of disease where known
Previous treatments
Side effects
Other medical conditions
Cost and availability
Whether pregnancy is currently desired
Pain Relief
Medicines such as non-steroidal anti-inflammatory drugs may be used to help manage endometriosis-associated pain.
Examples include ibuprofen and naproxen.
These medicines do not remove endometriosis lesions. Their purpose is symptom relief.
They are also not appropriate for everyone. People with certain kidney, stomach, cardiovascular or other medical conditions may need alternatives.
Regular or prolonged use should therefore be discussed with an appropriate healthcare professional.
Hormonal Treatment
Hormonal treatment can reduce endometriosis-associated pain in many women.
Options may include:
Combined hormonal contraceptives
Progestogen-based treatments
Hormonal intrauterine systems
Gonadotropin-releasing hormone treatments in selected patients
Other specialist hormonal therapies
These treatments work in different ways to suppress or modify hormonal stimulation associated with endometriosis.
The important limitation is that many hormonal treatments prevent pregnancy while they are being used.
That means treatment decisions must consider whether someone is currently trying to conceive.
Hormonal treatment may control symptoms, but it does not necessarily permanently eliminate endometriosis.
Symptoms can return after treatment is stopped.
Surgery
Surgery may be considered when:
Pain remains severe despite appropriate medical treatment
Endometriosis significantly affects organs
An endometrioma requires assessment or treatment
Deep endometriosis is suspected
Fertility circumstances make surgery potentially appropriate
Diagnosis remains uncertain in selected cases
During laparoscopic surgery, visible endometriosis lesions and adhesions may be removed or treated.
Surgery can improve symptoms for some people.
However:
Surgery does not guarantee that endometriosis will never return.
Symptoms and lesions can recur.
The benefits and risks of surgery should therefore be discussed carefully, particularly when fertility is an important consideration.
Does Hysterectomy Cure Endometriosis?
Not necessarily.
A hysterectomy removes the uterus.
But endometriosis is defined by endometrium-like tissue outside the uterus. Removing the uterus therefore does not automatically remove every endometriosis lesion.
Hysterectomy may be considered for selected patients who have severe symptoms, have completed childbearing and have not responded adequately to more conservative treatment.
It should not be presented as a guaranteed cure.
Endometriosis and Fertility
One of the biggest fears following an endometriosis diagnosis is:
“Will I still be able to have children?”
The answer is often yes.
Endometriosis can make conception more difficult for some women, but having endometriosis does not automatically mean you are infertile.
WHO reports that among women experiencing infertility, approximately 25% to 50% may have endometriosis.
Endometriosis may affect fertility through several mechanisms, including inflammation, adhesions, ovarian involvement and changes affecting the normal interaction between the ovaries, fallopian tubes and reproductive environment.
But fertility depends on much more than endometriosis alone.
Age, ovarian reserve, whether the fallopian tubes are open, sperm quality and other reproductive conditions also matter.
When Should Someone With Endometriosis Seek Fertility Help?
In general, infertility is defined as not achieving pregnancy after 12 months of regular unprotected intercourse.
However, earlier assessment may be appropriate when there is a known condition that could affect fertility, including significant endometriosis, or when age or other reproductive factors make delay undesirable.
Fertility assessment should also involve both partners where applicable.
It should not automatically be assumed that difficulty conceiving is entirely caused by the woman's endometriosis.
Fertility Treatment and Endometriosis
Treatment depends on individual circumstances.
Options may include:
Trying naturally for a defined period
Surgery in selected cases
Ovulation stimulation
Intrauterine insemination (IUI)
In vitro fertilisation (IVF)
There is no single fertility pathway appropriate for every woman with endometriosis.
Age, ovarian reserve, severity of disease, previous surgery, duration of infertility, tubal function and semen analysis can all influence the decision.
Women who want future pregnancy should therefore discuss fertility goals before major ovarian surgery whenever possible, particularly when ovarian endometriomas are involved.
Endometriosis in Nigeria
Endometriosis presents particular challenges in Nigeria and similar health systems.
Severe menstrual pain may be normalised within families and communities, meaning girls and women sometimes delay seeking care.
Others may repeatedly use pain medicines without investigating why menstruation is consistently disabling.
Access to specialist gynaecological assessment, appropriate imaging, laparoscopy and fertility treatment can also vary substantially according to location and ability to pay.
Fertility carries additional social significance in many Nigerian communities.
When pregnancy does not occur quickly, women may experience considerable family and social pressure, even though infertility can involve female factors, male factors, both partners or remain unexplained.
This makes responsible endometriosis care particularly important.
A woman experiencing infertility should not automatically be blamed, and an endometriosis diagnosis should not be interpreted as proof that pregnancy is impossible.
What Should You Do If You Think You Have Endometriosis?
The practical pathway is straightforward.
First, track your symptoms.
Record when pain occurs, how severe it becomes, whether it relates to menstruation, whether sex or bowel movements are painful and how symptoms affect normal activities.
Second, seek proper assessment.
Persistent disabling menstrual or pelvic pain deserves medical evaluation rather than years of repeated self-treatment.
Third, explain the impact, not just the pain.
Tell the healthcare professional if symptoms cause you to miss work, school, sleep, exercise or sexual activity.
That information helps demonstrate the true severity of the problem.
Fourth, discuss fertility goals early.
If you want pregnancy now or in the future, tell your clinician before treatment decisions are made.
Fifth, ask what the treatment is trying to achieve.
Is the objective pain control?
Improved fertility?
Treatment of an endometrioma?
Investigation of another possible condition?
Understanding the goal makes it easier to weigh the benefits and limitations of different options.
What Endometriosis Is NOT
Several misconceptions deserve correction.
Endometriosis is not a sexually transmitted infection.
It is not caused by having sex.
It is not caused by poor hygiene.
Pregnancy is not a guaranteed cure.
Hysterectomy is not automatically a cure.
A normal ultrasound does not always exclude endometriosis.
Having endometriosis does not automatically mean you cannot become pregnant.
And perhaps most importantly:
Severe menstrual pain should not automatically be dismissed as normal.
When Should You Seek Urgent Medical Care?
Most endometriosis symptoms are managed through planned medical care rather than emergency treatment.
However, urgent assessment is appropriate for:
Sudden severe or rapidly worsening pelvic or abdominal pain
Fainting or collapse
Very heavy bleeding accompanied by dizziness, weakness or shortness of breath
Persistent vomiting with severe abdominal pain
Severe pain during a known or possible pregnancy
Symptoms suggesting another acute abdominal or gynaecological emergency
Not every episode of severe pelvic pain in someone with endometriosis is necessarily caused by endometriosis.
Other urgent conditions, including ectopic pregnancy, ovarian torsion, ruptured ovarian cysts and acute infections, can produce similar symptoms.
Questions to Ask at Your Appointment
If endometriosis is suspected, useful questions include:
Could my symptoms be caused by endometriosis?
What other conditions could explain them?
Would an ultrasound be useful?
If my ultrasound is normal, what happens next?
What treatment options are available for my pain?
What are the possible side effects?
Will this treatment prevent pregnancy while I use it?
Could endometriosis affect my fertility?
Should I see a fertility specialist?
When would surgery be appropriate?
What should make me return for urgent medical care?
Good healthcare decisions should involve understanding your options rather than simply receiving a prescription.
Frequently Asked Questions
Can you have endometriosis without knowing?
Yes.
Symptoms vary considerably. Some people have relatively mild symptoms and only discover endometriosis during investigation for infertility or another condition.
Can an ultrasound rule out endometriosis?
No.
Ultrasound can identify certain forms of endometriosis, particularly ovarian endometriomas and some deep lesions, but a normal scan does not necessarily exclude the disease.
Can endometriosis become cancer?
Endometriosis is not cancer.
Some research has identified associations between endometriosis and increased risk of certain uncommon ovarian cancers, but the absolute risk for an individual remains low.
An endometriosis diagnosis should therefore not be interpreted as a cancer diagnosis.
Can endometriosis cause infertility?
Yes, endometriosis can contribute to infertility.
But many women with endometriosis become pregnant, including some without fertility treatment.
Does endometriosis disappear after pregnancy?
Pregnancy may temporarily change symptoms in some women because of hormonal changes, but pregnancy is not a treatment or cure for endometriosis.
Symptoms may return.
Does menopause cure endometriosis?
Symptoms often improve after natural menopause because oestrogen levels fall substantially.
However, endometriosis symptoms can persist in some people after menopause, particularly under certain circumstances.
Is there a cure for endometriosis?
There is currently no guaranteed cure.
Treatment focuses on controlling symptoms, protecting quality of life, addressing fertility concerns and managing complications.
The Bottom Line
Endometriosis is more than simply “bad period pain.”
It is a chronic condition that can affect menstruation, pelvic health, sexual health, bowel and bladder function, mental wellbeing, work, education and fertility.
But an endometriosis diagnosis does not automatically mean infertility, surgery or lifelong severe pain.
Modern management is increasingly individualised.
Some women primarily need effective pain management. Others need hormonal treatment. Some require specialist imaging or surgery. Others first come to medical attention because they are trying to become pregnant.
The most important first step is recognising when symptoms deserve investigation.
If menstrual pain repeatedly disrupts your normal life, if pelvic pain persists outside your period, if sex or bowel movements are painful, or if you are having difficulty becoming pregnant, seek assessment from an appropriately qualified healthcare professional.
You do not need to wait until the pain becomes unbearable before asking why it is happening.
References and Further Reading
World Health Organization. Endometriosis
https://www.who.int/news-room/fact-sheets/detail/endometriosis
American College of Obstetricians and Gynecologists. Diagnosis of Endometriosis: Clinical Practice Guideline No. 11, 2026
https://www.acog.org/clinical/clinical-guidance/clinical-practice-guideline/articles/2026/03/diagnosis-of-endometriosis
European Society of Human Reproduction and Embryology. ESHRE Guideline: Endometriosis
https://www.eshre.eu/Guidelines-and-Legal/Guidelines/Endometriosis-guideline.aspx
World Health Organization. Infertility
https://www.who.int/news-room/fact-sheets/detail/infertility
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