Endometriosis

Last updated

Endometriosis
Blausen 0349 Endometriosis.png
Specialty Gynecology
Symptoms Pelvic pain, infertility [1]
Usual onsetUnknown. The first symptoms appear before the age of 20–30 years old. [2] [3] [4]
DurationLong term [1]
Causes Unknown [1]
Risk factors Family history [3]
Diagnostic method Based on symptoms, medical imaging, tissue biopsy [3]
Differential diagnosis Pelvic inflammatory disease, irritable bowel syndrome, interstitial cystitis, fibromyalgia [1]
PreventionNone [5]
Treatment NSAIDs, continuous birth control pills, intrauterine device with progestogen, surgery [3]
Frequency10–15% of all women of reproductive age [6]
Deaths≈100 (0.0 to 0.1 per 100,000, 2015) [7] [8]

Endometriosis is a disease in which tissue similar to the lining of the uterus grows elsewhere in the body. [9] It occurs in humans and a limited number of other mammals that have a menstruation cycle, notably primates. [10] The tissue most often grows on or around the ovaries and fallopian tubes, on the outside surface of the uterus, or the tissues surrounding the uterus and the ovaries. [3] It can also grow on other organs in the pelvic region like the bowels, stomach or bladder. [11] Rarely, it can also occur in other parts of the body. [3]

Contents

Symptoms can be very different from person to person, varying in range and intensity. About 25% of individuals have no symptoms, [1] while for some it can be a debilitating disease. [12] Common symptoms include pelvic pain, heavy and painful periods, pain with bowel movements, painful urination, pain during sexual intercourse, and infertility. [1] [13] Nearly half of those affected have chronic pelvic pain, while 70% feel pain during menstruation. [1] Up to half of affected individuals are infertile. [1] Besides physical symptoms, endometriosis can affect a person's mental health and social life. [14]

Diagnosis is usually based on symptoms and medical imaging; [3] however, a definitive diagnosis is made through laparoscopy (keyhole surgery). [3] Other causes of similar symptoms include pelvic inflammatory disease, irritable bowel syndrome, interstitial cystitis, and fibromyalgia. [1] Endometriosis is often misdiagnosed and many patients report being incorrectly told their symptoms are trivial or normal. [14] Patients with endometriosis see an average of seven physicians before receiving a correct diagnosis. [15]

Worldwide, around 10% of the female population of reproductive age (190 million women) are affected by endometriosis. [5] Asian women are more likely than White women to be diagnosed with endometriosis. [16] [17] The exact cause of endometriosis is not known. Possible causes include problems with menstrual period flow, genetic factors, hormones, and problems with the immune system. [3]

While there is no cure for endometriosis, several treatments may improve symptoms. [1] This includes pain medication, hormonal treatments or surgery. The recommended pain medication is usually a non-steroidal anti-inflammatory drug (NSAID), such as naproxen. Taking the birth control pill continuously or using a hormonal IUD (coil) is another first-line treatment. Other types of hormonal treatment can be tried if the pill or IUD are not effective. [18] Surgical removal of endometriosis may be used to treat those whose symptoms are not manageable with other treatments, or to treat infertility. [19]

Subtypes

Endoscopic image of a ruptured endometrioma (chocolate cyst) in left ovary Perforierte Endometriosezyste.jpg
Endoscopic image of a ruptured endometrioma (chocolate cyst) in left ovary

Endometriosis can be subdivided into four categories: [20]

Superficial peritoneal endometriosis

Small spots of endometriosis grow on the surface layer that covers the organs inside the abdomen or pelvis (the peritoneum)

Deep infiltrating endometriosis

Lesions grow into the tissue beneath the lining of the pelvis or into the muscle layers of pelvic organs like the bowel, bladder, or ureter

Endometriomas (ovarian)

Cysts that grow in the ovaries

Extrapelvic endometriosis

Lesions outside of the pelvic regions, such as in the lungs or diaphragm

Health care providers may call areas of endometriosis by different names, such as implants, lesions, or nodules. Larger lesions may be seen within the ovaries as endometriomas or "chocolate cysts"; "chocolate" because they contain a thick brownish fluid, mostly old blood. [21]

Endometriosis most commonly affects the ovaries, the fallopian tubes between the ovaries and the womb, the outer surface of the womb and the tissues that hold the womb in place. Less common pelvic sites are the rectum, bladder, bowel, vulva, vagina and cervix [19] Deep infiltrating endometriosis occurs when endometriosis grows more than 5 mm beneath the peritoneal surface. [22] It can infiltrate the muscles around organs. [20] The prevalence of deep infiltrating endometriosis is estimated to be 1–2% in women of reproductive age. [22] Deep endometriosis often looks like nodules, and can include fibrosis and adhesions. [20]

Rarely, endometriosis appears in outside of the pelvis, such as the lungs, brain, and skin. [19] Diaphragmatic endometriosis is rare, almost always on the right hemidiaphragm, and may cause the cyclic pain of the right shoulder or neck during a menstrual period. [23] Scar endometriosis can rarely form on the abdominal wall as a complication of surgery, most often following a ceasarean section or other pelvic surgery. [24]

Signs and symptoms

Pain and infertility are common symptoms, although 20–25% of affected women are asymptomatic. [1] The presence of pain symptoms is associated with the type of endometrial lesions, as 50% of women with typical (peritoneal) lesions, 10% of women with cystic ovarian lesions, and 5% of women with deep endometriosis do not have pain. [25]

Pelvic pain

A major symptom of endometriosis is recurring pelvic pain. The pain can range from mild to severe cramping or stabbing pain that occurs on both sides of the pelvis, in the lower back and rectal area, and even down the legs. The amount of pain a person feels correlates weakly with the extent or stage (1 through 4) of endometriosis, with some individuals having little or no pain despite having extensive endometriosis or endometriosis with scarring, while others may have severe pain even though they have only a few small areas of endometriosis. [26] The most severe pain is typically associated with menstruation. Pain can also start a week before a menstrual period, during, and even a week after a menstrual period, or it can be constant. The pain can be debilitating and result in emotional stress. [27] Symptoms of endometriosis-related pain may include:

Compared with patients with superficial endometriosis, those with deep disease appear to be more likely to report shooting rectal pain and a sense of their insides being pulled down. [31] Individual pain areas and intensity appear to be unrelated to the surgical diagnosis, and the area of pain is unrelated to the area of endometriosis. [31]

Infertility

About a third of women with infertility have endometriosis. [1] Among those with endometriosis, about 40% are infertile. [1]

Other

Bowel endometriosis may include symptoms like diarrhea, constipation, tenesmus, dyschezia, and, rarely, rectal bleeding. Other symptoms include chronic fatigue, nausea and vomiting, migraines, low-grade fevers, heavy (44%) and/or irregular periods (60%), and hypoglycemia. [28] [32] [29] Endometriosis may also affect the nearby colon, which in rare situations may progress to partial obstruction, requiring emergency surgery. [33]

Thoracic endometriosis occurs when endometrium-like tissue implants in the lungs or pleura around the lungs. When it occurs in the lungs, common signs and symptoms are blood discharge from the lungs during menstruation and nodules which become bigger during menstruation. When it is found in the pleura, symptoms may be a collapsed lung during or outside of menstruation and bleeding into the pleural space. Further symptoms are a cyclical cough and cyclical shoulder pain. Most often, the endometriosis is found in the right lung. [34]

Stress may be a contributing factor or a consequence of endometriosis. [35]

Complications

Physical health

Ovarian endometriosis may complicate pregnancy through decidualization, abscess formation, and/or rupture. [36] Women with endometriosis also face a significantly increased risk of experiencing ante- and postpartum hemorrhage [37] as well as a 170% increased risk of severe pre-eclampsia [38] during pregnancy. Endometriosis can also impact a woman's fetus or neonate, increasing the risks for congenital malformations, preterm delivery, and higher neonatal death rates. [38]

Sciatic endometriosis, also called catamenial or cyclical sciatica, is a rare form where endometriosis affects the sciatic nerve. Diagnosis is usually confirmed through MRI or CT-myelography. [39]

A 20-year study involving 12,000 women with endometriosis found that individuals under 40 are three times more likely to develop heart problems compared to their healthy peers. [40]

Endometriosis increases the risk of developing ovarian and thyroid cancers compared to women without the condition, and slightly increases the risk of breast cancer. [41]

The mortality rates associated with endometriosis are low, with unadjusted and age-standardized death rates of 0.1 and 0.0 per 100,000, respectively. [7]

Mental health

"Endometriosis is associated with an elevated risk of developing depression and anxiety disorders". [42] Studies suggest this is partially due to the pelvic pain experienced by endometriosis patients.

"It has been demonstrated that pelvic pain has significant negative effects on women's mental health and quality of life; in particular, women who suffer from pelvic pain report high levels of anxiety and depression, loss of working ability, limitations in social activities and a poor quality of life" [43]

Mental health concerns like depression and anxiety can also result due to poor diagnostic procedures related to cultural norms where women's concerns are devalued or ignored, especially by medical professionals. [44] [45]

Risk factors

Genetics

Endometriosis is a heritable condition influenced by both genetic and environmental factors, [46] a genetic disorder of polygenic/multifactorial inheritance [47] acquired via affected genes from either a person's father or mother. For example, children or siblings of women with endometriosis are at higher risk of developing endometriosis themselves; low progesterone levels may be genetic, and may contribute to a hormone imbalance. [48] Individuals with an affected first-degree relative have an approximate six-fold increase incidence of endometriosis. [49]

Inheritance is significant but not the sole risk factor for endometriosis. Studies attribute 50% of the risk to genetics, the other 50% to environmental factors. [50] It has been proposed that endometriosis may result from multiple mutations within target genes, in a mechanism similar to the development of cancer. [46] In this case, the mutations may be either somatic or heritable. [46]

A 2019 genome-wide association study (GWAS) review enumerated 36 genes with mutations associated with endometriosis development. [51] Nine chromosome loci were robustly replicated: [52] [53] [54] [55]

ChromosomeGene/cytobandGene ProductFunction
1 WNT4 /1p36.12Wingless-type MMTV integration site family member 4Vital for the development of the female reproductive organs
2 GREB1 /2p25.1Growth regulation by estrogen in breast cancer 1/Fibronectin 1Early response gene in the estrogen regulation pathway/Cell adhesion and migration processes
2ETAA1/2p14(ETAA1 Activator Of ATR Kinase) is a protein-coding gene.Diseases associated with ETAA1 include Adult Lymphoma and Restless Legs Syndrome
2IL1A/2q13 Interleukin 1 alpha (IL-1α) is encoded by the IL1A gene.Interleukin 1 alpha (IL-1α) is encoded by the IL1A gene.
4KDR/4q12KDR is the human gene encoding kinase insert domain receptor, also known as vascular endothelial growth factor receptor 2 (VEGFR-2)Primary mediator of VEGF-induced endothelial proliferation, survival, migration, tubular morphogenesis and sprouting [56]
6 ID4 /6p22.3Inhibitor of DNA binding 4Ovarian oncogene, biological function unknown
77p15.2 Transcription factors Influence transcriptional regulation of uterine development
9 CDKN2BAS /9p21.3Cyclin-dependent kinase inhibitor 2B antisense RNARegulation of tumour suppressor genes
12 VEZT /12q22Vezatin, an adherens junction transmembrane proteinTumor suppressor gene

There are many findings of altered gene expression and epigenetics, but both of these can also be a secondary result of, for example, environmental factors and altered metabolism. Examples of altered gene expression include that of miRNAs. [46]

Environmental toxins

Some factors associated with endometriosis include:

Potential toxins:

Autoimmune and autoinflammatory conditions

Endometriosis patients show a significantly increased risk of autoimmune, autoinflammatory, and mixed-pattern psoriatic diseases, with two studies in 2025 pointing to the connection. One of the studies suggested that the chances of receiving a diagnosis of at least one of the autoimmune conditions for those with endometriosis was around twice that of a control cohort. The linked conditions include rheumatoid arthritis, multiple sclerosis, coeliac disease, osteoarthritis, and psoriasis. This reinforces the view that there is a genetic correlation between endometriosis and osteoarthritis, rheumatoid arthritis, and multiple sclerosis (MS), and a potential causal link to rheumatoid arthritis. The work suggests a shared biological basis between endometriosis on one side, and autoimmune and autoinflammatory diseases, on the other. This suggests that certain autoimmunne treatment pathways could be repurposed to provided alternative therapy options for those with endometriosis. [65] [66] [67]

Mechanism

Six characteristics of endometriosis: estrogen dependency, retrograde menstruation, angiogenesis, local inflammation, oxidative stress and stem cells Characteristics of endometriosis.webp
Six characteristics of endometriosis: estrogen dependency, retrograde menstruation, angiogenesis, local inflammation, oxidative stress and stem cells

While the exact cause of endometriosis remains unknown, many theories have been presented to understand and explain its development. These concepts do not necessarily exclude each other. The pathophysiology of endometriosis is likely to be multifactorial and to involve an interplay between several factors. [46]

Formation

The main theories for the formation of the ectopic endometrium-like tissue include retrograde menstruation, Müllerianosis, coelomic metaplasia, vascular dissemination of stem cells, and surgical transplantation, which were postulated as early as 1870. Each is further described below. [16] [68] [69]

Retrograde menstruation theory

During menstruation, some menstrual blood, tissue, and fluid can flow backward through the fallopian tubes into the pelvic area (the peritoneal cavity). This backward flow (called retrograde menstruation) is thought to be the main reason why endometriosis develops inside the pelvic cavity. However, this explanation alone is not enough, because almost all women have some backward flow of menstrual fluid, but only some of them develop endometriosis. [2]

Evidence in support of the theory are based on retrospective epidemiological studies that an association with endometrial implants attached to the peritoneal cavity, which would develop into endometrial lesions and retrograde menstruation; and the fact that animals like rodents and non-human primates whose endometrium is not shed during the estrous cycle don't produce naturally endometriosis contrary to animals that have a natural menstrual cycle like rhesus monkeys and baboons. [70]

Endometriosis has shown up in people who have never experienced menstruation including men, female fetuses, and prepubescent girls. [71] Further theoretical additions are needed to complement the retrograde menstruation theory to explain why cases of endometriosis show up in the brain [72] and lungs. [73]

Researchers are investigating the possibility that the immune system may be unable to cope with the cyclic onslaught of retrograde menstrual fluid. In this context there is interest in studying the relationship of endometriosis to autoimmune disease, allergic reactions, and the impact of toxic materials. [74] [75]

Endometriotic lesions differ in their biochemistry, hormonal response, immunology, and inflammatory response compared to the endometrium. [16] [76] This is likely because the cells that give rise to endometriosis are a side population of cells. [46] Similarly, there are changes in, for example, the mesothelium of the peritoneum in people with endometriosis, such as loss of tight junctions. It is unknown if these are causes or effects of the disorder. [77]

In rare cases, when an imperforate hymen persists to menarche, menstrual outflow can be obstructed, leading to retention of blood within the vagina and uterus (hematocolpos/hematometra) and, in some cases, into the Fallopian tubes. Symptoms (e.g., pelvic or abdominal pain) may be nonspecific, contributing to delayed recognition. Prolonged obstruction can produce retrograde menstruation, a mechanism widely discussed in reviews of endometriosis pathogenesis. [78] [79] [80]

Other theories

  • Stem cells: Endometriosis may arise from stem cells from bone marrow and potentially other sources. In particular, this theory explains endometriosis found in areas remote from the pelvis, such as the brain or lungs. [69] Stem cells may be from local cells such as the peritoneum (see coelomic metaplasia below) or cells disseminated in the bloodstream (see vascular dissemination below) such as those from the bone marrow. [68] [69] [81]
  • Vascular dissemination: Vascular dissemination is a 1927 theory that has been revived with new studies of bone marrow stem cells involved in pathogenesis. [69] [81]
  • Müllerianosis: A theory supported by foetal autopsy is that cells with the potential to become endometrial, which are laid down in tracts during embryonic development called the female reproductive (Müllerian) tract, as it migrates downward at 8–10 weeks of embryonic life, could become dislocated from the migrating uterus and act like seeds or stem cells. [68] [82]
  • Coelomic metaplasia: Coelomic cells which are the common ancestor of endometrial and peritoneal cells may undergo metaplasia (transformation) from one type of cell to the other, perhaps triggered by inflammation. [68] [83]
  • Vasculogenesis: Up to 37% of the microvascular endothelium of ectopic endometrial tissue originates from endothelial progenitor cells, which result in de novo formation of microvessels by the process of vasculogenesis rather than the conventional process of angiogenesis. [84] [ clarification needed ]
  • Neural growth: An increased expression of new nerve fibres is found in endometriosis, but does not fully explain the formation of ectopic endometriotic tissue and is not definitely correlated with the amount of perceived pain. [85] [ clarification needed ]

Disease processes

Pain

There are multiple causes of pain. Endometriosis lesions react to hormonal stimulation and may "bleed" during menstruation. The blood accumulates locally if not cleared shortly by the immune, circulatory, and lymphatic systems. This accumulation can lead to swelling, which triggers inflammation via cytokines, resulting in pain. Another source of pain is organ dislocation that arises from adhesion binding internal organs together. The ovaries, the uterus, the oviducts, the peritoneum, and the bladder can all be bound together. Pain triggered in this way can last throughout the menstrual cycle, not just during menstrual periods. [90]

Additionally, endometriotic lesions can develop an independent nerve supply, creating a direct and two-way interaction between lesions and the central nervous system. This interaction can produce a variety of individual differences in pain that, in some cases, become independent of the disease itself. [26] Nerve fibers and blood vessels are thought to grow into endometriosis lesions by a process known as neuroangiogenesis. [91]

Infertility

The infertility associated with endometriosis likely has multiple causes. Inflammation and hormonal dysfunction explain some instances. The ovarian reserve, the amount of viable egg cells in the ovaries, is typically lower in those with endometriosis. In particular, endometriomas may reduce ovarian reserve in affected ovaries. [92] There is contradictory evidence on whether endometriosis causes reduced ovulation. Anatomical distortions, for instance from adhesions, can explain further instances of infertility. Sometimes with severe endometriosis, sperm or egg cells are fully blocked. Pain during sex may lead couples to avoid it, leading to fewer opportunities for natural conception. [93]

Diagnosis

A health history and a physical examination can lead the health care practitioner to suspect endometriosis. Symptoms in combination with ultrasound or MRI imaging can lead to a presumed diagnosis of endometriosis. The gold standard for definite diagnosis is via surgery and a biopsy, but there is a shift away from requiring surgical confirmation before starting treatment to prevent delays. [20] Patients in the UK have an average delay in diagnosis of 8 years and in Norway of 6.7 years. [94] A third of women had consulted their GP six or more times before being diagnosed. [94]

Endometriosis can be classified into four different stages. The American Society of Reproductive Medicine's scale, revised in 1996, gives higher scores to deep, thick lesions or intrusions on the ovaries and dense, enveloping adhesions on the ovaries or fallopian tubes. [95]

As for deep infiltrating endometriosis, TVUS, TRUS, and MRI are the techniques of choice for non-invasive diagnosis with a high sensitivity and specificity. [96]

Physical examination

A trauma-informed framework is recommended for a physical examination, where the health practioner validates pain and fosters trust. The examination focuses on assessing both general symptoms and those linked to deep endometriosis or endometriosis outside the pelvis. Risk factors are also reviewed. The physical examination can include an abdominal exam, a single digit exam of the vagina and pelvic floor, a bimanual exam and examination with a speculum. [20]

Ultrasound

Transvaginal ultrasonography showing a 67 x 40 mm endometrioma as distinguished from other types of ovarian cysts by a somewhat grainy and not completely anechoic content Endometrioma.jpg
Transvaginal ultrasonography showing a 67 x 40 mm endometrioma as distinguished from other types of ovarian cysts by a somewhat grainy and not completely anechoic content

Vaginal ultrasound can be used to diagnose endometriosis or to localize an endometrioma before surgery. [97] This can be used to identify the spread of disease in individuals with well-established clinical suspicion of endometriosis. [97] Vaginal ultrasound is inexpensive, easily accessible, has no contraindications, and requires no preparation. [97] By extending the ultrasound assessment into the posterior and anterior pelvic compartments, a sonographer can evaluate structural mobility and look for deep infiltrating endometriotic nodules. [98] Better sonographic detection of deep infiltrating endometriosis could reduce the number of diagnostic laparoscopies, as well as guide disease management and enhance patient quality of life. [98]

Ultrasounds cannot be used to exclude a diagnosis of endometriosis. [99] If a transvaginal ultrasound is not suitable or declined, an alternative is an ultrasound via the lower abdomen. [100]

Magnetic resonance imaging

Trichromatic color MRI of ovarian cysts. The bottom right cyst is endometriosis (a chocolate cyst). Trichromatic Color MRI of ovarian cysts.jpg
Trichromatic color MRI of ovarian cysts. The bottom right cyst is endometriosis (a chocolate cyst).

MRI is another means of detecting lesions in a non-invasive manner. [101] MRI is not widely used due to its cost and limited availability. [101] It can reliably detect endometriomas and deep infiltrating endemetriosis. It is sometimes used for planning surgery, for instance if an ultrasound is unclear, or for diagnosis if a transvaginal ultrasound is not appropriate or is declined. The field of view is larger in an MRI compared to an ultrasound, which allows a larger part of the bowel to be assessed. [102]

Laparoscopy

Laparoscopic image of endometriotic lesions at the peritoneum of the pelvic wall Peritoneal endometriosis.jpg
Laparoscopic image of endometriotic lesions at the peritoneum of the pelvic wall

Laparoscopy (keyhole surgery) is a surgical procedure where a camera is used to look inside the abdominal cavity. Laparoscopy with a biopsy is the most accurate way to diagnose endometriosis. [20] It can be used when endometriosis is suspected, but not visible via medical imaging. [92] An alternative after negative imaging is to try out treatment and give a presumed diagnosis if that improves symptoms ('empirical treatment'). [103]

Surgery for diagnosis also allows for surgical treatment of endometriosis at the same time. [104] In nearly 40% of cases, no cause for pelvic pain is discovered during laparoscopy. [92]

The lesions of superficial endometriosis often appear dark blue or black. In the earlier stages of disease, they may be white, red or yellow-brown. Ovarian cysts are typically dark brown. Adhesions are made up of fibrous scar tissue. Deep endometriosis looks like multiple distinct nodules. [92]

A biopsy may be negative even when endometriosis is present, particularly in younger women. As such, it cannot be used to exclude a diagnosis of endometriosis. [92] For confirmation, biopsy samples should show at least two of the following features: [105]

Stages

There are three staging or classification systems commonly used. Fertility is assessed with the Endometriosis Fertility Index (EFI). [92] Endometriosis can be classified as stage I–IV by the revised American Society of Reproductive Medicine (rASRM) staging system. The stages range from minimal (stage I) to severe (stage IV). [106] The scale uses a point system that assesses lesions and adhesions during surgery. The ENZIAN system focuses more on deep endometriosis compared to rASRM. The rASRM and ENZIAN systems correlate poorly with how much pain women have. [92]

The American Association of Gynecologic Laparoscopists (AAGL) endometriosis staging system, introduced in 2021, correlates well with complexity of surgery, and captures pain better than rASRM. Like rASRM, it divides endometriosis into four stages. [107]

Prevention

The US Office of Women's Health states that the chance of developing endometriosis can be reduced by lowering the levels of the hormone estrogen in the body. [19] According to the World Health Organization, there is no known way to prevent endometriosis. [5]

Management

While there is no cure for endometriosis, there are treatments for pain and endometriosis-associated infertility. Pain can be treated with hormones, painkillers, or, in severe cases, surgery. [108] The goal of management is to provide pain relief, to restrict the progression of the process, and to restore or preserve fertility where needed. [16]

Treatment with medication for pain management can be initiated based on the presence of symptoms, examination, and ultrasound findings that rule out other potential causes. [109] The UK National Institute for Health and Care Excellence recommends starting initial medication for those with suspected endometriosis, at the same time as referral for investigations such as ultrasound. [110]

In general, the diagnosis of endometriosis is confirmed during surgery, at which time removal can be performed. Further steps depend on circumstances: someone without infertility can manage symptoms with pain medication and hormonal medication that suppresses the natural cycle, while an infertile individual may be treated expectantly after surgery, with fertility medication, or with in vitro fertilisation (IVF).

Hormonal medications

The hormonal coil (Mirena) is one of the treatment options for endometriosis Mirena IntraUterine System.jpg
The hormonal coil (Mirena) is one of the treatment options for endometriosis

Progestin-only hormonal suppression (progestogen) is another first-line therapy. It come in different forms and includes the hormonal coil (intrauterine device), the oral dienogest, an injection of medroxyprogesterone acetate every three months or an implant under the skin. [20] Dienogest, which may better than injections, [111] is not available on its own in the US. [20] Oral progestins likely reduce overall pain and period pain compared to placebo, and may also help with pelvic pain. It is unclear how well they work compared to other hormonal therapies. [111]

Hormonal birth control pills: combined estrogren-progestin birth control pills are a first-line treatment. The recommendation is to use the pills continuously to stop periods. [20] A 2018 Cochrane systematic review found that there is insufficient evidence to make a judgement on the effectiveness of the combined oral contraceptive pill compared with placebo or other medical treatment for managing pain associated with endometriosis partly because of lack of included studies for data analysis (only two for COCP vs placebo). [112]

Gonadotropin-releasing hormone (GnRH) modulators are second-line treatments: These drugs include GnRH agonists such as leuprorelin, and GnRH antagonists such as elagolix and decrease estrogen levels. [20] GnRH agonists mimic the effects of menopause, and seem more effective than placebo or oral progestin at reducing pain. [113] They come with side effects of hot flashes and decreased bone density. GnRHs can be prescribed with hormonal 'add-back' therapy or with calcium-regulating agents to reduce the amount of bone loss. [20] [113]

Aromatase inhibitors are third-line treatments and block estrogen production throughout the body. Examples of aromatase inhibitors include anastrozole and letrozole. Common side effects are hot flashes, night sweats and functional cysts. [20] [114] In premenopausal women, these should be taken with other hormones (such as the combined pill) to prevent ovarian stimulation and to prevent menopause symptoms. They can be a option for post-menopausal women who still have endometriosis symptoms, as their action is not limited to suppressing estrogen from ovaries. Evidence is limited. [20]

Progesterone receptor modulators like mifepristone and gestrinone have the potential (based on only one randomized controlled trial each) to be used as a treatment to manage pain caused by endometriosis. [115]

Other medicines

NSAIDs like naproxen are anti-inflammatory medications commonly used for endometriosis pain. [116] Only a single small study has been done on it, so it has unclear effectiveness. NSAIDs can have side effects, predominantly gastrointestinal, but they are generally safe to try. [117]

Surgery

Laparoscopy of the uterus and fallopian tubes. The abdomen is filled with gas so that the surgeon can see better and have space for instruments. Blausen 0602 Laparoscopy 02.png
Laparoscopy of the uterus and fallopian tubes. The abdomen is filled with gas so that the surgeon can see better and have space for instruments.

Clinical guidelines recommend surgery when medical treatment does not work sufficiently, has unacceptable side effects or is contraindicated. Large endometriomas can only effectively be treated with surgery. Surgery is also recommended when deep endometriosis causes problems in the bowels or urinary tract, such as obstruction. It is unclear what the effect of surgery is for pain relief in cases of superficial periteneal endometriosis. [20]

Laparoscopy (keyhole surgery) is the standard surgical approach. Treatment consists of the removal of endometriosis and the restoration of pelvic anatomy via the division of adhesions. [118] The removal takes place via excision (cutting out) or electrosurgery (coagulation or ablation/vaporisation). [119] [120] With laparoscopic surgery, small instruments are inserted through incisions to remove the endometriosis tissue and adhesions. After surgery, people can usually return home the same day. [121]

Two literature reviews have compared excision to ablation. A 2017 literature review found that excision improved some outcomes over ablation for endometriosis in general. A 2021 literature review on minimal to mild endometriosis found no difference. For deep endometriosis, excision is the standard therapy, as ablation does not allow the surgeon to see if all endometriosis is removed. [122] In the United States, some specialists trained in excision for endometriosis do not accept health insurance because insurance companies do not reimburse the higher costs of this procedure over ablation. [123]

Endometriomas are usually excised (removed completely). Compared to drainage and coagulation of the cyst, excision makes it less likely the cysts and pain symptoms come back. However, excision may damage fertility, as it can affect the ovarian reserve, the amount of egg cells that can be fertilised. [92] [20]

For deep endometriosis, surgery improves quality of life and pain symptoms. [124] However, the procedure can be complicated, especially if the lesions are in or near the bowel, ureter of the urinary system or the chest, and requires a interdisciplinary surgical team in those cases. For instance, for rectovaginal endometriosis, 7% of surgeries had complications. [20] Sometimes, a part of the bowel or bladder is removed. [125] [126]

For women who still have significant pain after hormonal treatment and other surgery, and do not want to become pregnant, a hysterectomy (removal of the womb) can be offered. This is done in combination with removal of endometriosis lesions. Removal of the womb may be beneficial if the uterus itself is affected by adenomyosis. When the ovaries are removed too, women will experience early menopause and may need hormone replacement therapy. Removal of the ovaries comes with cardiovascular, metabolic and mental health risks. [127] [20]

Recurrence and postoperative hormonal suppression

In an analysis with a medium follow-up of 24 months pain after surgery recurred in about 16% of women. [20] Endometriosis recurrence following surgery is estimated as 21.5% at 2 years and 40–50% at 5 years. Hormonal therapy before surgery has little effect on recurrence, but treatment afterwards reduces the risk. [92] At a median follow-up of 18 months, endometriosis recurred in 26% of women without postoperative hormonal suppression, compared with 10% of women who received it. [20] The risk of recurrence is higher in younger women and in those with a less aggressive surgery. [120]

Comparison of interventions

A 2021 meta-analysis found that GnRH analogs and combined hormonal contraceptives were the best treatment for reducing dyspareunia and menstrual and non-menstrual pelvic pain. [128] A 2018 Swedish systematic review found several studies but a general lack of scientific evidence for most treatments. [97] There was only one study of sufficient quality and relevance comparing the effect of surgery and non-surgery. [129] Cohort studies indicate that surgery is effective in decreasing pain. [129] Most complications occurred in cases of low intestinal anastomosis, while the risk of fistula occurred in cases of combined abdominal or vaginal surgery, and urinary tract problems were common in intestinal surgery. [129] The evidence was found to be insufficient regarding surgical intervention. [129]

The advantages of physical therapy techniques are decreased cost, absence of major side effects, it does not interfere with fertility, and a near-universal increase in sexual function. [130] Disadvantages are that there are no large or long-term studies of its use for treating pain or infertility related to endometriosis. [130]

Treatment of infertility

Assistive reproductive technology like IVF can help with fertility in endometriosis. InVitroFertilization.jpg
Assistive reproductive technology like IVF can help with fertility in endometriosis.

Infertility can be treated with assistive reproductive technology (ART) such as in vitro fertilization (IVF) or surgery. [131] IVF procedures are effective in improving fertility in many individuals with endometriosis. IVF is increasingly recommended over surgery for older women or for those where there might be multiple reasons why they struggle to conceive. [132] It does not increase recurrence of endometriosis. [133] The Endometriosis Fertility Index can help guide decisions on treatment of infertility. [134] Surgery is typically not recommended before starting ART. [135]

In terms of surgery, endometriomas can be cut out (a cystectomy), or drained and destroyed (ablation). The ablation technique may be better able to preserve the number of remaining viable eggs (the ovarian reserve), compared to cutting out the endometrioma. [136] On the other hand, cutting out the endometrioma may help more with pain. [132] Surgery likely also helps with infertility in the case of superficial peritoneal endometriosis. [20] Receiving hormonal suppression therapy after surgery might be help with endometriosis recurrence and pregnancy. [137] but evidence for pregancy outcomes is mixed [138] and the both NICE and the European Society of Human Reproduction and Embryology recommend against hormonal suppression to improve fertility. [138] [139]

Epidemiology

Determining how many people have endometriosis is challenging because a definitive diagnosis requires surgical visualization through laparoscopic surgery. [140] Criteria that are commonly used to establish a diagnosis include pelvic pain, infertility, surgical assessment, and in some cases, magnetic resonance imaging. An ultrasound can identify large clumps of tissue as potential endometriosis lesions and ovarian cysts, but it is not effective for all patients, especially in cases with smaller, superficial lesions. [141]

Ethnic differences in endometriosis have been observed. The condition is more common in women of East Asian and Southeast Asian descent than in White women. [16]

Estimates of prevalance vary. One source estimates that between 6 and 10% of the general female population have endometriosis. [1] Another estimates that between 2 and 11% of asymptomatic women are affected. [16] In addition, 11% of women in a general population have undiagnosed endometriosis that can be seen on magnetic resonance imaging (MRI). [142] [140] Globally, around 176 million girls and women are effected, with roughly 22 million having a diagnosis confirmed surgically as of 2021. [143]

Endometriosis is most common in those in their thirties and forties; however, it can begin in girls as early as eight years old. [3] [4] It results in few deaths with unadjusted and age-standardized death rates of 0.1 and 0.0 per 100,000. [7] Endometriosis was first determined to be a separate condition in the 1920s. [144] Before that time, endometriosis and adenomyosis were considered together. [144]

It chiefly affects adults from premenarche to postmenopause, regardless of race or ethnicity or whether or not they have had children, and is estimated to affect over 190 million women in their reproductive years. [145] Incidences of endometriosis have occurred in postmenopausal individuals, [146] and in less common cases, individuals may have had endometriosis symptoms before they even reach menarche. [147] [148]

The rate of recurrence of endometriosis is estimated to be 40-50% for adults over five years. [149] The rate of recurrence has been shown to increase with time from surgery and is not associated with the stage of the disease, initial site, surgical method used, or post-surgical treatment. [149]

History

Endometriosis was first discovered microscopically by Karl von Rokitansky in 1860, [150] although the earliest antecedents may have stemmed from concepts published almost 4,000 years ago. [151] The Hippocratic Corpus outlines symptoms similar to endometriosis, including uterine ulcers, adhesions, and infertility. [151] Historically, women with these symptoms were treated with leeches, straitjackets, bloodletting, chemical douches, genital mutilation, pregnancy (as a form of treatment), hanging upside down, surgical intervention, and even killing due to suspicion of demonic possession. [151] Hippocratic doctors recognized and treated chronic pelvic pain as a true organic disorder 2,500 years ago, but during the Middle Ages, there was a shift into believing that women with pelvic pain were mad, immoral, imagining the pain, or simply misbehaving. [151] The symptoms of inexplicable chronic pelvic pain were often attributed to imagined madness, female weakness, promiscuity, or hysteria. [151] The historical diagnosis of hysteria, which was thought to be a psychological disease, may have indeed been endometriosis in many cases. [151] The idea that chronic pelvic pain was related to mental illness influenced modern attitudes regarding individuals with endometriosis, leading to delays in correct diagnosis and indifference to the patients' true pain throughout the 20th and into the 21st century. [151]

Hippocratic doctors believed that delaying childbearing could trigger diseases of the uterus, which caused endometriosis-like symptoms. Women with dysmenorrhea were encouraged to marry and have children at a young age. [151] The fact that Hippocratics were recommending changes in marriage practices due to an endometriosis-like illness implies that this disease was likely common. [151]

The theory of retrograde menstruation as a cause of endometriosis was first proposed by John A. Sampson. [68] [152]

The early treatment of endometriosis was surgical and included oophorectomy (removal of the ovaries) and hysterectomy (removal of the uterus). [153] In the 1940s, the only available hormonal therapies for endometriosis were high-dose testosterone and high-dose estrogen therapy. [154] High-dose estrogen therapy with diethylstilbestrol for endometriosis was first reported by Karnaky in 1948 and was the main pharmacological treatment for the condition in the early 1950s. [155] [156] [157] Pseudopregnancy (high-dose estrogen–progestogen therapy) for endometriosis was first described by Kistner in the late 1950s. [155] [156] Pseudopregnancy, as well as progestogen monotherapy, dominated the treatment of endometriosis in the 1960s and 1970s. [157] These agents, although efficacious, were associated with intolerable side effects. Danazol was first described for endometriosis in 1971 and became the main therapy in the 1970s and 1980s. [155] [156] [157] In the 1980s, GnRH agonists gained prominence for the treatment of endometriosis and by the 1990s had become the most widely used therapy. [156] [157] Oral GnRH antagonists such as elagolix were introduced for the treatment of endometriosis in 2018. [158]

Society and culture

Public figures

Several public figures have spoken about their experience with endometriosis, including:

Economic burden

The economic burden of endometriosis is widespread and multifaceted. [201] Endometriosis is a chronic disease that has direct and indirect costs, which include loss of work days, direct costs of treatment, symptom management, and treatment of other associated conditions such as depression or chronic pain. [201] One factor that seems to be associated with especially high costs is the delay between the onset of symptoms and diagnosis.

Costs vary greatly between countries. [202] Two factors that contribute to the economic burden include healthcare costs and losses in productivity. A Swedish study of 400 endometriosis patients found "Absence from work was reported by 32% of the women, while 36% reported reduced time at work because of endometriosis". [203] An additional cross sectional study with Puerto Rican women, "found that endometriosis-related and coexisting symptoms disrupted all aspects of women's daily lives, including physical limitations that affected doing household chores and paid employment. The majority of women (85%) experienced a decrease in the quality of their work; 20% reported being unable to work because of pain, and over two-thirds of the sample continued to work despite their pain." [204] A study published in the UK in 2025 found that after women received a diagnosis of endometriosis in an English NHS hospital their earnings were on average £56 per month less in the four to five years after diagnosis than they were in the two years before. There was also a reduction in the proportion of women in employment. [205]

Medical culture

There are many barriers that those affected face in receiving a diagnosis and treatment for endometriosis. Some of these include outdated standards for laparoscopic evaluation, stigma about discussing menstruation and sex, lack of understanding of the disease, primary-care physicians' lack of knowledge, and assumptions about typical menstrual pain. [206] On average, those later diagnosed with endometriosis waited 2.3 years after the onset of symptoms before seeking treatment, and nearly three-quarters of women receive a misdiagnosis before endometriosis. [207] Self-help groups say practitioners delay making the diagnosis, often because they do not consider it a possibility. There is a typical delay of 7–12 years from symptom onset in affected individuals to professional diagnosis. [208] There is a general lack of knowledge about endometriosis among primary care physicians. Half of the general health care providers surveyed in a 2013 study could not name three symptoms of endometriosis. [209] Healthcare providers are also likely to dismiss described symptoms as normal menstruation. [210] Younger patients may also feel uncomfortable discussing symptoms with a physician. Patients are made to categorise their pain using the pain scale. However, this is not representative of endometriosis specific pain levels which impacts diagnosis and treatment. [211]

Race and ethnicity

Race and ethnicity may impact how endometriosis affects one's life. Endometriosis is less thoroughly studied among Black people, and the research that has been done is outdated. [212] [213] Cultural differences among ethnic groups also contribute to attitudes toward and treatment of endometriosis, especially in Hispanic or Latino communities. A study done in Puerto Rico in 2020 found that health care and interactions with friends and family related to discussing endometriosis were affected by stigma. [214] The most common finding was a referral to those expressing pain related to endometriosis as "changuería" or "changas", terms used in Puerto Rico to describe pointless whining and complaining, often directed at children. [214]

Stigma

The existing stigma surrounding women's health, specifically endometriosis, can lead to patients not seeking diagnoses, lower quality of healthcare, increased barriers to care and treatment, and negative reception from members of society. [215] Additionally, menstrual stigma significantly contributes to the broader issue of endometriosis stigma, creating an interconnected challenge that extends beyond reproductive health. [216] [217] Widespread awareness campaigns, developments, and implementations aimed at multilevel anti-stigma organizational and structural changes, as well as more qualitative studies of the endometriosis stigma, help to overcome the harm of the phenomenon. [215]

Research directions

A priority area of research is the search for endometriosis biomarkers, which can help with earlier diagnoses. [218] Studies have examined potential biomarkers such as microRNAs, glycoproteins, and immune markers in blood, menstrual and urine samples, but none have shown the high accurarcy needed for clinical use yet. CA-125, a tumor marker, has been studied extensively. It is elevated in endometriosis, but also in many other conditions, and cannot be used on its own. MicroRNAs might be most promosing, but the high diversity in expression makes them a challenging target. [219]

Hormonal treatment is the standard way to manage endometriosis with drugs. These treatment can have undesirable side effects, and there is a search for alternative medications. Pentoxifylline, an immunomodulating agent, has been theorized to improve pain as well as improve pregnancy rates in individuals with endometriosis. There is not enough evidence to support the effectiveness or safety of either of these uses. [220]

Preliminary research on mouse models showed that monoclonal antibodies, as well as inhibitors of MyD88 downstream signaling pathway, can reduce lesion volume. Thanks to that, clinical trials are being done on using a monoclonal antibody directed against IL-33 and using anakinra, an IL-1 receptor antagonist. [221]

Clinical trials are exploring the potential benefits of cannabinoid extracts, dichloroacetic acid, and curcuma capsules. [221]

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Bulletti C, Coccia ME, Battistoni S, Borini A (August 2010). "Endometriosis and infertility". Journal of Assisted Reproduction and Genetics. 27 (8): 441–7. doi:10.1007/s10815-010-9436-1. PMC   2941592 . PMID   20574791.
  2. 1 2 Horne AW, Missmer SA (November 2022). "Pathophysiology, diagnosis, and management of endometriosis". BMJ. 379 e070750. doi:10.1136/bmj-2022-070750. hdl: 20.500.11820/a2c07717-cf08-4119-b0f4-b7f8aa50193e . PMID   36375827.
  3. 1 2 3 4 5 6 7 8 9 10 "Endometriosis". Office on Women's Health. 13 February 2017. Archived from the original on 13 May 2017. Retrieved 20 May 2017.
  4. 1 2 McGrath PJ, Stevens BJ, Walker SM, Zempsky WT (2013). Oxford Textbook of Paediatric Pain. OUP Oxford. p. 300. ISBN   978-0-19-964265-6. Archived from the original on 10 September 2017.
  5. 1 2 3 "Endometriosis". World Health Organization (WHO). Retrieved 11 January 2025.
  6. ↑ Parasar P, Ozcan P, Terry KL (2017). "Endometriosis: Epidemiology, Diagnosis and Clinical Management". Curr Obstet Gynecol Rep. 6 (1): 34–41. doi:10.1007/s13669-017-0187-1. PMC   5737931 . PMID   29276652.
  7. 1 2 3 Vos T, Allen C, Arora M, Barber RM, Bhutta ZA, Brown A, et al. (October 2016). "Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015". Lancet. 388 (10053): 1545–1602. doi: 10.1016/S0140-6736(16)31678-6 . PMC   5055577 . PMID   27733282.
  8. ↑ Wang H, Naghavi M, Allen C, Barber RM, Bhutta ZA, Carter A, et al. (GBD 2015 Mortality and Causes of Death Collaborators) (October 2016). "Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015". Lancet. 388 (10053): 1459–1544. doi:10.1016/S0140-6736(16)31012-1. PMC   5388903 . PMID   27733281.
  9. ↑ "About endometriosis". Eunice Kennedy Shriver National Institute for Child Health and Human Development. 21 February 2020. Archived from the original on 25 September 2025.
  10. ↑ Braundmeier AG, Fazleabas AT (24 July 2009). "The non-human primate model of endometriosis: research and implications for fecundity". Molecular Human Reproduction. 15 (10). The European Society of Human Reproduction and Embryology (published October 2009): 577–586. doi:10.1093/molehr/gap057. PMC   2744471 . PMID   19633013.
  11. ↑ "Endometriosis". Johns Hopkins Medicine. Retrieved 11 January 2025.
  12. ↑ "What is endometriosis?". Endometriosis UK. Retrieved 11 January 2025.
  13. ↑ "Endometriosis Is More Than Just 'Painful Periods'". Yale Medicine. Retrieved 12 October 2023.
  14. 1 2 Culley L, Law C, Hudson N, Denny E, Mitchell H, Baumgarten M, et al. (1 November 2013). "The social and psychological impact of endometriosis on women's lives: a critical narrative review". Human Reproduction Update. 19 (6): 625–39. doi: 10.1093/humupd/dmt027 . hdl: 2086/8845 . PMID   23884896.
  15. ↑ Nnoaham KE, Hummelshoj L, Webster P, d'Hooghe T, de Cicco Nardone F, de Cicco Nardone C, et al. (August 2011). "Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries". Fertility and Sterility. 96 (2): 366–373.e8. doi:10.1016/j.fertnstert.2011.05.090. PMC   3679489 . PMID   21718982.
  16. 1 2 3 4 5 6 Zondervan KT, Becker CM, Missmer SA (March 2020). "Endometriosis". The New England Journal of Medicine. 382 (13): 1244–1256. doi:10.1056/NEJMra1810764. PMID   32212520. S2CID   214644045.
  17. ↑ Velarde MC, Bucu ME, Habana MA (November 2023). "Endometriosis as a highly relevant yet neglected gynecologic condition in Asian women". Endocrine Connections. 12 (11): e230169. doi: 10.1530/EC-23-0169 . PMC   10563646 . PMID   37676242. "Compared with Caucasian women, Asian women are more likely to be diagnosed with endometriosis (odds ratio (OR) 1.63, 95% CI 1.03–2.58) (14). Filipinos, Indians, Japanese, and Koreans are among the top Asian ethnicities who are more likely to have endometriosis than Caucasian women (17)."
  18. ↑ Solnik & Sanders 2025, p. 14-15.
  19. 1 2 3 4 "Endometriosis". Office on Women's Health. 24 October 2025. Archived from the original on 26 September 2025. Retrieved 31 October 2025.
  20. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 As-Sanie S, Mackenzie SC, Morrison L, Schrepf A, Zondervan KT, Horne AW, et al. (2025). "Endometriosis" . JAMA. 334 (1): 64–78. doi:10.1001/jama.2025.2975. PMID   40323608.
  21. ↑ Hsu AL, Khachikyan I, Stratton P (June 2010). "Invasive and noninvasive methods for the diagnosis of endometriosis". Clin Obstet Gynecol. 53 (2): 413–9. doi:10.1097/GRF.0b013e3181db7ce8. PMC   2880548 . PMID   20436318.
  22. 1 2 Van den Bosch T, Van Schoubroeck D (August 2018). "Ultrasound diagnosis of endometriosis and adenomyosis: State of the art" . Best Practice & Research. Clinical Obstetrics & Gynaecology. 51: 16–24. doi:10.1016/j.bpobgyn.2018.01.013. PMID   29506961. S2CID   3759091.
  23. ↑ Andres MP, Arcoverde FV, Souza CC, Fernandes LF, Abrão MS, Kho RM (February 2020). "Extrapelvic Endometriosis: A Systematic Review". Journal of Minimally Invasive Gynecology . 27 (2): 373–389. doi: 10.1016/j.jmig.2019.10.004 . PMID   31618674.
  24. ↑ Gruber TM, Lange K, Ebeling GS, Henrich W, Mechsner S (2025). "Scar endometriosis, a form of abdominal wall endometriosis–a neglected obstetrical complication?". Archives of Gynecology and Obstetrics. 312 (1): 1–8. doi:10.1007/s00404-024-07834-2. ISSN   1432-0711. PMC   12176990 . PMID   39607442.
  25. ↑ Koninckx PR, Ussia A, Mashiach R, Vilos G, Martin DC (September 2021). "Endometriosis Can Cause Pain at a Distance". Journal of Obstetrics and Gynaecology Canada. 43 (9). Elsevier BV: 1035–1036. doi: 10.1016/j.jogc.2021.06.002 . PMID   34481578. S2CID   237422801.
  26. 1 2 Stratton P, Berkley KJ (2011). "Chronic pelvic pain and endometriosis: translational evidence of the relationship and implications". Human Reproduction Update. 17 (3): 327–46. doi:10.1093/humupd/dmq050. PMC   3072022 . PMID   21106492.
  27. ↑ Colette S, Donnez J (July 2011). "Are aromatase inhibitors effective in endometriosis treatment?". Expert Opinion on Investigational Drugs. 20 (7): 917–31. doi:10.1517/13543784.2011.581226. PMID   21529311. S2CID   19463907.
  28. 1 2 Gałczyński K, Jóźwik M, Lewkowicz D, Semczuk-Sikora A, Semczuk A (November 2019). "Ovarian endometrioma - a possible finding in adolescent girls and young women: a mini-review". Journal of Ovarian Research. 12 (1) 104. doi: 10.1186/s13048-019-0582-5 . PMC   6839067 . PMID   31699129. CC-BY icon.svg Text was copied from this source, which is available under a Creative Commons Attribution 4.0 International License Archived 16 October 2017 at the Wayback Machine .
  29. 1 2 "What are the symptoms of endometriosis?". National Institutes of Health. Archived from the original on 27 January 2021. Retrieved 4 October 2018.
  30. ↑ Brown J, Farquhar C (March 2014). "Endometriosis: an overview of Cochrane Reviews". The Cochrane Database of Systematic Reviews. 2014 (3) CD009590. doi:10.1002/14651858.cd009590.pub2. PMC   6984415 . PMID   24610050.
  31. 1 2 Ballard K, Lane H, Hudelist G, Banerjee S, Wright J (June 2010). "Can specific pain symptoms help in the diagnosis of endometriosis? A cohort study of women with chronic pelvic pain". Fertility and Sterility. 94 (1): 20–7. doi: 10.1016/j.fertnstert.2009.01.164 . PMID   19342028.
  32. ↑ Wolthuis AM, Meuleman C, Tomassetti C, D'Hooghe T, de Buck van Overstraeten A, D'Hoore A (November 2014). "Bowel endometriosis: colorectal surgeon's perspective in a multidisciplinary surgical team". World Journal of Gastroenterology. 20 (42): 15616–23. doi: 10.3748/wjg.v20.i42.15616 . PMC   4229526 . PMID   25400445.
  33. ↑ Sarofim M, Attwell-Heap A, Trautman J, Kwok A, Still A (November 2019). "Unusual case of acute large bowel obstruction: endometriosis mimicking sigmoid malignancy". ANZ Journal of Surgery. 89 (11): E542 –E543. doi:10.1111/ans.14869. PMID   30277298. S2CID   52902719.
  34. ↑ ESHRE 2022, p. 149.
  35. ↑ Reis FM, Coutinho LM, Vannuccini S, Luisi S, Petraglia F (January 2020). "Is Stress a Cause or a Consequence of Endometriosis?". Reproductive Sciences. 27 (1): 39–45. doi:10.1007/s43032-019-00053-0. PMID   32046437. S2CID   209896867.
  36. ↑ Ueda Y, Enomoto T, Miyatake T, Fujita M, Yamamoto R, Kanagawa T, et al. (June 2010). "A retrospective analysis of ovarian endometriosis during pregnancy". Fertility and Sterility. 94 (1): 78–84. doi: 10.1016/j.fertnstert.2009.02.092 . PMID   19356751.
  37. ↑ Saraswat L (2015). "ESHRE2015: Endometriosis associated with a greater risk of complications in pregnancy". endometriosis.org. European Society of Human Reproduction and Embryology. Archived from the original on 13 February 2024. Retrieved 14 February 2024.
  38. 1 2 Berlac JF, Hartwell D, Skovlund CW, Langhoff-Roos J, Lidegaard Ø (June 2017). "Endometriosis increases the risk of obstetrical and neonatal complications". Acta Obstetricia et Gynecologica Scandinavica. 96 (6): 751–760. doi:10.1111/aogs.13111. PMID   28181672.
  39. ↑ Gandhi J, Wilson AL, Liang R, Weissbart SJ, Khan SA (11 November 2020). "Sciatic endometriosis: A narrative review of an unusual neurogynecologic condition". Journal of Endometriosis and Pelvic Pain Disorders. 13 (1). SAGE Publications: 3–9. doi:10.1177/2284026520970813. ISSN   2284-0265. S2CID   228834273.
  40. ↑ Wise J (April 2016). "Women with endometriosis show higher risk for heart disease". BMJ. 353 i1851. doi:10.1136/bmj.i1851. PMID   27036948. S2CID   28699291.
  41. ↑ Kvaskoff M, Mahamat-Saleh Y, Farland LV, Shigesi N, Terry KL, Harris HR, et al. (February 2021). "Endometriosis and cancer: a systematic review and meta-analysis". Human Reproduction Update. 27 (2). Oxford University Press (OUP): 393–420. doi:10.1093/humupd/dmaa045. hdl: 20.500.11820/fa3c779d-3cc7-4d0d-b93a-d7176fd8244d . PMID   33202017.
  42. ↑ Jia SZ, Leng JH, Shi JH, Sun PR, Lang JH (October 2012). "Health-related quality of life in women with endometriosis: a systematic review". Journal of Ovarian Research. 5 (1) 29. doi: 10.1186/1757-2215-5-29 . PMC   3507705 . PMID   23078813.
  43. ↑ Low WY, Edelmann RJ, Sutton C (February 1993). "A psychological profile of endometriosis patients in comparison to patients with pelvic pain of other origins". Journal of Psychosomatic Research. 37 (2): 111–116. doi:10.1016/0022-3999(93)90077-S. PMID   8463987.
  44. ↑ Culley L, Law C, Hudson N, Denny E, Mitchell H, Baumgarten M, et al. (1 November 2013). "The social and psychological impact of endometriosis on women's lives: a critical narrative review". Human Reproduction Update. 19 (6): 625–39. doi:10.1093/humupd/dmt027. hdl:2086/8845. PMID 23884896.
  45. ↑ Nnoaham KE, Hummelshoj L, Webster P, d'Hooghe T, de Cicco Nardone F, de Cicco Nardone C, et al. (August 2011). "Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries". Fertility and Sterility. 96 (2): 366–373.e8. doi:10.1016/j.fertnstert.2011.05.090. PMC 3679489. PMID 21718982.
  46. 1 2 3 4 5 6 Fauser BC, Diedrich K, Bouchard P, Domínguez F, Matzuk M, Franks S, et al. (2011). "Contemporary genetic technologies and female reproduction". Human Reproduction Update. 17 (6): 829–47. doi:10.1093/humupd/dmr033. PMC   3191938 . PMID   21896560.
  47. ↑ Bischoff F, Simpson JL (April 2004). "Genetics of endometriosis: heritability and candidate genes". Best Practice & Research. Clinical Obstetrics & Gynaecology. 18 (2): 219–232. doi:10.1016/j.bpobgyn.2004.01.004. PMID   15157639.
  48. ↑ Davila GW (18 July 2023). "Endometriosis: Practice Essentials, Background, Pathophysiology". Medscape Reference. Retrieved 3 November 2025.
  49. ↑ Giudice LC, Kao LC (2004). "Endometriosis". Lancet. 364 (9447): 1789–1799. Bibcode:2004Lanc..364.1789G. doi:10.1016/S0140-6736(04)17403-5. PMID   15541453. S2CID   208788714.
  50. ↑ Montgomery GW, Mortlock S, Giudice LC (February 2020). "Should Genetics Now Be Considered the Pre-eminent Etiologic Factor in Endometriosis?". Journal of Minimally Invasive Gynecology . 27 (2): 280–286. doi:10.1016/j.jmig.2019.10.020. PMC   7863762 . PMID   31683028.
  51. ↑ Vassilopoulou L, Matalliotakis M, Zervou MI, Matalliotaki C, Krithinakis K, Matalliotakis I, et al. (May 2019). "Defining the genetic profile of endometriosis". Experimental and Therapeutic Medicine. 17 (5): 3267–3281. doi:10.3892/etm.2019.7346. PMC   6447774 . PMID   30988702.
  52. ↑ Rahmioglu N, Nyholt DR, Morris AP, Missmer SA, Montgomery GW, Zondervan KT (September 2014). "Genetic variants underlying risk of endometriosis: insights from meta-analysis of eight genome-wide association and replication datasets". Human Reproduction Update. 20 (5): 702–716. doi:10.1093/humupd/dmu015. PMC   4132588 . PMID   24676469.
  53. ↑ "MUC16 mucin 16, cell surface associated [Homo sapiens (human)] - Gene - NCBI". ncbi.nlm.nih.gov. Archived from the original on 13 November 2018. Retrieved 13 November 2018.
  54. ↑ "FN1 fibronectin 1 [Homo sapiens (human)] - Gene - NCBI". ncbi.nlm.nih.gov. Archived from the original on 8 June 2019. Retrieved 13 November 2018.
  55. ↑ Sapkota Y, Steinthorsdottir V, Morris AP, Fassbender A, Rahmioglu N, De Vivo I, et al. (May 2017). "Meta-analysis identifies five novel loci associated with endometriosis highlighting key genes involved in hormone metabolism". Nature Communications. 8 (1) 15539. Springer Science and Business Media LLC. Bibcode:2017NatCo...815539S. doi:10.1038/ncomms15539. PMC   5458088 . PMID   28537267.
  56. ↑ "GeneCards®: The Human Gene Database". www.genecards.org. Weizmann Institute of Science. Archived from the original on 7 February 2024. Retrieved 7 February 2024.
  57. 1 2 Giudice LC (June 2010). "Clinical practice. Endometriosis". The New England Journal of Medicine. 362 (25): 2389–98. doi:10.1056/NEJMcp1000274. PMC   3108065 . PMID   20573927.
  58. ↑ Treloar SA, Bell TA, Nagle CM, Purdie DM, Green AC (June 2010). "Early menstrual characteristics associated with subsequent diagnosis of endometriosis". American Journal of Obstetrics and Gynecology. 202 (6): 534.e1–6. doi:10.1016/j.ajog.2009.10.857. PMID   20022587.
  59. ↑ Nnoaham KE, Webster P, Kumbang J, Kennedy SH, Zondervan KT (September 2012). "Is early age at menarche a risk factor for endometriosis? A systematic review and meta-analysis of case-control studies". Fertility and Sterility. 98 (3): 702–712.e6. doi:10.1016/j.fertnstert.2012.05.035. PMC   3502866 . PMID   22728052.
  60. ↑ Anger DL, Foster WG (January 2008). "The link between environmental toxicant exposure and endometriosis". Frontiers in Bioscience. 13 (13): 1578–93. doi: 10.2741/2782 . PMID   17981650. S2CID   12813384.
  61. ↑ Guo SW (2004). "The link between exposure to dioxin and endometriosis: a critical reappraisal of primate data". Gynecologic and Obstetric Investigation. 57 (3): 157–73. doi:10.1159/000076374. PMID   14739528. S2CID   29701466.
  62. ↑ Guo SW, Simsa P, Kyama CM, Mihályi A, Fülöp V, Othman EE, et al. (October 2009). "Reassessing the evidence for the link between dioxin and endometriosis: from molecular biology to clinical epidemiology". Molecular Human Reproduction. 15 (10): 609–24. doi: 10.1093/molehr/gap075 . PMID   19744969.
  63. 1 2 3 Ahn C, Jeung EB (March 2023). "Endocrine-Disrupting Chemicals and Disease Endpoints". International Journal of Molecular Sciences. 24 (6): 5342. Bibcode:2023IJMSc..24.5342A. doi: 10.3390/ijms24065342 . PMC   10049097 . PMID   36982431.
  64. 1 2 Rumph JT, Stephens VR, Archibong AE, Osteen KG, Bruner-Tran KL (2020). "Environmental Endocrine Disruptors and Endometriosis". Advances in Anatomy, Embryology, and Cell Biology. Advances in Anatomy, Embryology and Cell Biology. Vol. 232. pp. 57–78. doi:10.1007/978-3-030-51856-1_4. ISBN   978-3-030-51855-4. PMC   7978485 . PMID   33278007.
  65. ↑ Clark L (22 September 2025). "A deeper understanding of endometriosis is suggesting new treatments" . New Scientist (3562). London: New Scientist Ltd (published 27 September 2025). ISSN   0262-4079. Archived from the original on 27 September 2025. Retrieved 29 September 2025.
  66. ↑ Shigesi N, Harris H, Fang H, Ndungu A, Lincoln M, Cotsapas C, et al. (April 2025). "The phenotypic and genetic association between endometriosis and immunological diseases". Human Reproduction. 40 (6). The International Endometriosis Genome Consortium and the 23andMe Research Team: 1195–1209. doi:10.1093/humrep/deaf062. PMC   12127507 . PMID   40262193.
  67. ↑ Aziz M, Beaton M, Aziz M, Opoku-Anane J, Elhadad N (18 June 2025). "Endometriosis and autoimmunity: a large-scale case-control study of endometriosis and 10 distinct autoimmune diseases". npj Women's Health. 3 (1) 36. doi:10.1038/s44294-025-00086-8. PMC   12176652 . PMID   40547362.
  68. 1 2 3 4 5 van der Linden PJ (November 1996). "Theories on the pathogenesis of endometriosis". Human Reproduction. 11 (Suppl 3): 53–65. doi: 10.1093/humrep/11.suppl_3.53 . PMID   9147102.
  69. 1 2 3 4 Hufnagel D, Li F, Cosar E, Krikun G, Taylor HS (September 2015). "The Role of Stem Cells in the Etiology and Pathophysiology of Endometriosis". Seminars in Reproductive Medicine. 33 (5): 333–40. doi:10.1055/s-0035-1564609. PMC   4986990 . PMID   26375413.
  70. ↑ Malvezzi H, Marengo EB, Podgaec S, Piccinato CA (August 2020). "Endometriosis: current challenges in modeling a multifactorial disease of unknown etiology". Journal of Translational Medicine. 18 (1) 311. Springer Science and Business Media LLC. doi: 10.1186/s12967-020-02471-0 . PMC   7425005 . PMID   32787880.
  71. ↑ Pašalić E, Tambuwala MM, Hromić-Jahjefendić A (2023). "Endometriosis: Classification, pathophysiology, and treatment options" . Pathology - Research and Practice. 251 154847. doi:10.1016/j.prp.2023.154847. ISSN   0344-0338. PMID   37844487.
  72. ↑ Thibodeau LL, Prioleau GR, Manuelidis EE, Merino MJ, Heafner MD (April 1987). "Cerebral endometriosis. Case report". Journal of Neurosurgery. 66 (4): 609–10. doi: 10.3171/jns.1987.66.4.0609 . PMID   3559727.
  73. ↑ Rodman MH, Jones CW (April 1962). "Catamenial hemoptysis due to bronchial endometriosis". The New England Journal of Medicine. 266 (16): 805–8. doi:10.1056/nejm196204192661604. PMID   14493132.
  74. ↑ Gleicher N, el-Roeiy A, Confino E, Friberg J (July 1987). "Is endometriosis an autoimmune disease?". Obstetrics and Gynecology. 70 (1): 115–22. PMID   3110710.
  75. ↑ Capellino S, Montagna P, Villaggio B, Sulli A, Soldano S, Ferrero S, et al. (June 2006). "Role of estrogens in inflammatory response: expression of estrogen receptors in peritoneal fluid macrophages from endometriosis". Annals of the New York Academy of Sciences. 1069 (1): 263–7. Bibcode:2006NYASA1069..263C. doi:10.1196/annals.1351.024. PMID   16855153. S2CID   35601442.
  76. ↑ Redwine DB (October 2002). "Was Sampson wrong?". Fertility and Sterility. 78 (4): 686–93. doi: 10.1016/S0015-0282(02)03329-0 . PMID   12372441.
  77. ↑ Young VJ, Brown JK, Saunders PT, Horne AW (2013). "The role of the peritoneum in the pathogenesis of endometriosis". Human Reproduction Update. 19 (5): 558–69. doi: 10.1093/humupd/dmt024 . PMID   23720497.
  78. ↑ Lee KH, Hong JS, Jung HJ, et al. "Imperforate Hymen: A Comprehensive Systematic Review." J Clin Med. 2019;8(1):56.
  79. ↑ Bulun SE, Yilmaz BD, Sison C, et al. "Endometriosis caused by retrograde menstruation." Fertil Steril. 2022;118(4):713–732.
  80. ↑ Lamceva J, Popovska S, Jovanovska V, et al. "The Main Theories on the Pathogenesis of Endometriosis." Biomedicines. 2023;11(3):776.
  81. 1 2 Sampson JA (1927). "Peritoneal endometriosis due to the menstrual dissemination of endometrial tissue into the peritoneal cavity". Am J Obstet Gynecol. 14 (4): 422–469. doi:10.1016/S0002-9378(15)30003-X.
  82. ↑ Signorile PG, Baldi F, Bussani R, D'Armiento M, De Falco M, Baldi A (April 2009). "Ectopic endometrium in human foetuses is a common event and sustains the theory of müllerianosis in the pathogenesis of endometriosis, a disease that predisposes to cancer". Journal of Experimental & Clinical Cancer Research. 28 (1) 49. doi: 10.1186/1756-9966-28-49 . PMC   2671494 . PMID   19358700.
  83. ↑ Wellbery C (October 1999). "Diagnosis and treatment of endometriosis". American Family Physician. 60 (6). American Academy of Family Physicians: 1753–62, 1767–8. PMID   10537390. Archived from the original on 6 June 2011. Retrieved 26 July 2011.
  84. ↑ Laschke MW, Giebels C, Menger MD (2011). "Vasculogenesis: a new piece of the endometriosis puzzle". Human Reproduction Update. 17 (5): 628–36. doi: 10.1093/humupd/dmr023 . PMID   21586449.
  85. ↑ Morotti M, Vincent K, Brawn J, Zondervan KT, Becker CM (2014). "Peripheral changes in endometriosis-associated pain". Human Reproduction Update. 20 (5): 717–36. doi:10.1093/humupd/dmu021. PMC   4337970 . PMID   24859987.
  86. ↑ Yuk JS, Park EJ, Seo YS, Kim HJ, Kwon SY, Park WI (March 2016). "Graves Disease Is Associated With Endometriosis: A 3-Year Population-Based Cross-Sectional Study". Medicine. 95 (10) e2975. doi:10.1097/MD.0000000000002975. PMC   4998884 . PMID   26962803.
  87. ↑ Giudice LC, Kao LC (2004). "Endometriosis". Lancet. 364 (9447): 1789–99. Bibcode:2004Lanc..364.1789G. doi:10.1016/S0140-6736(04)17403-5. PMID   15541453. S2CID   208788714.
  88. 1 2 3 4 5 6 Scutiero G, Iannone P, Bernardi G, Bonaccorsi G, Spadaro S, Volta CA, et al. (2017). "Oxidative Stress and Endometriosis: A Systematic Review of the Literature". Oxidative Medicine and Cellular Longevity. 2017 7265238. doi: 10.1155/2017/7265238 . PMC   5625949 . PMID   29057034.
  89. ↑ Torraco A, Di Nicolantonio S, Cardisciani M, Ortu E, Pietropaoli D, Altamura S, et al. (14 May 2025). "Meta-Analysis of 16S rRNA Sequencing Reveals Altered Fecal but Not Vaginal Microbial Composition and Function in Women with Endometriosis". Medicina. 61 (5): 888. doi: 10.3390/medicina61050888 . ISSN   1648-9144. PMC   12112980 . PMID   40428846.
  90. ↑ [ page needed ]Murray MT, Pizzorno J (2012). The Encyclopedia of Natural Medicine (3rd ed.). New York, NY: Simon and Schuster.
  91. ↑ Asante A, Taylor RN (2011). "Endometriosis: the role of neuroangiogenesis". Annual Review of Physiology. 73: 163–82. doi:10.1146/annurev-physiol-012110-142158. PMID   21054165.
  92. 1 2 3 4 5 6 7 8 9 Horne AW, Missmer SA (2022). "Pathophysiology, diagnosis, and management of endometriosis". BMJ. 379 e070750. doi:10.1136/bmj-2022-070750. ISSN   1756-1833. PMID   36375827.
  93. ↑ Elizur SE, Mostafa J, Berkowitz E, Orvieto R (1 October 2025). "Endometriosis and infertility: pathophysiology, treatment strategies, and reproductive outcomes". Archives of Gynecology and Obstetrics. 312 (4): 1037–1048. doi:10.1007/s00404-025-08124-1. ISSN   1432-0711. PMC   12414060 . PMID   40689964.
  94. 1 2 Pugsley Z, Ballard K (June 2007). "Management of endometriosis in general practice: the pathway to diagnosis". The British Journal of General Practice. 57 (539): 470–6. PMC   2078174 . PMID   17550672.
  95. ↑ American Society For Reproductive (May 1997). "Revised American Society for Reproductive Medicine classification of endometriosis: 1996". Fertility and Sterility. 67 (5): 817–21. doi: 10.1016/S0015-0282(97)81391-X . PMID   9130884.
  96. ↑ Zhang X, He T, Shen W (October 2020). "Comparison of physical examination, ultrasound techniques and magnetic resonance imaging for the diagnosis of deep infiltrating endometriosis: A systematic review and meta-analysis of diagnostic accuracy studies". Experimental and Therapeutic Medicine. 20 (4). Spandidos Publications: 3208–3220. doi:10.3892/etm.2020.9043. PMC   7444323 . PMID   32855690.
  97. 1 2 3 4 "Endometriosis – Diagnosis, treatment and patient experiences". Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU). 4 May 2018. Archived from the original on 19 January 2021. Retrieved 13 June 2018.
  98. 1 2 Fang J, Piessens S (June 2018). "A step-by-step guide to sonographic evaluation of deep infiltrating endometriosis". Sonography. 5 (2): 67–75. doi: 10.1002/sono.12149 .
  99. ↑ Solnik & Sanders 2025, p. 94.
  100. ↑ Solnik & Sanders 2025, p. 93.
  101. 1 2 Nisenblat V, Bossuyt PM, Farquhar C, Johnson N, Hull ML (February 2016). "Imaging modalities for the non-invasive diagnosis of endometriosis". The Cochrane Database of Systematic Reviews. 2016 (2) CD009591. doi:10.1002/14651858.cd009591.pub2. PMC   7100540 . PMID   26919512.
  102. ↑ Quesada J, Härmä K, Reid S, Rao T, Lo G, Yang N, et al. (2023). "Endometriosis: A multimodal imaging review". European Journal of Radiology. 158 110610. doi:10.1016/j.ejrad.2022.110610. ISSN   0720-048X. PMID   36502625.
  103. ↑ ESHRE 2022, p. 30.
  104. ↑ Solnik & Sanders 2025, p. 10.
  105. ↑ Han L, Garcia R, Busca A, Parra-Herran C (November 2023). Turashvili G, Skala SL (eds.). "Endometriosis". Pathology Outlines. Archived from the original on 7 August 2020. Retrieved 18 March 2020.
  106. ↑ Crump J, Suker A, White L (2024). "Endometriosis: A review of recent evidence and guidelines". Australian Journal of General Practice. 53 (1–2): 11–18. doi: 10.31128/AJGP/04-23-6805 . PMID   38316472.
  107. ↑ Pašalić E, Tambuwala MM, Hromić-Jahjefendić A (2023). "Endometriosis: Classification, pathophysiology, and treatment options" . Pathology - Research and Practice. 251 154847. doi:10.1016/j.prp.2023.154847. ISSN   0344-0338. PMID   37844487.
  108. ↑ "What are the treatments for endometriosis?". NICHD - Eunice Kennedy Shriver National Institute of Child Health and Human Development. 21 February 2020. Retrieved 12 January 2025.
  109. ↑ "Update on pharmacologic treatment for endometriosis- related pain". Women's Healthcare. 7 June 2020. Archived from the original on 3 October 2021. Retrieved 3 October 2021.
  110. ↑ NICE 2024, pp. 11–12.
  111. 1 2 Chen I, Kives S, Zakhari A, Nguyen DB, Goldberg HR, Choudhry AJ, et al. (2025). Cochrane Central Editorial Service (ed.). "Progestagens for pain symptoms associated with endometriosis". Cochrane Database of Systematic Reviews. 2025 (10): CD002122. doi:10.1002/14651858.CD002122.pub3. PMC  12509269. PMID   41065045.{{cite journal}}: CS1 maint: article number as page number (link)
  112. ↑ Brown J, Crawford TJ, Datta S, Prentice A (May 2018). "Oral contraceptives for pain associated with endometriosis". The Cochrane Database of Systematic Reviews. 2018 (5) CD001019. Wiley. doi:10.1002/14651858.cd001019.pub3. PMC   6494634 . PMID   29786828.
  113. 1 2 Veth VB, van de Kar MM, Duffy JM, van Wely M, Mijatovic V, Maas JW (2023). Cochrane Gynaecology and Fertility Group (ed.). "Gonadotropin-releasing hormone analogues for endometriosis". Cochrane Database of Systematic Reviews. 2023 (6). doi:10.1002/14651858.CD014788.pub2.
  114. ↑ Garzon S, Laganà AS, Barra F, Casarin J, Cromi A, Raffaelli R, et al. (December 2020). "Aromatase inhibitors for the treatment of endometriosis: a systematic review about efficacy, safety and early clinical development". Expert Opinion on Investigational Drugs. 29 (12). Informa UK Limited: 1377–1388. doi:10.1080/13543784.2020.1842356. PMID   33096011. S2CID   225058751.
  115. ↑ Fu J, Song H, Zhou M, Zhu H, Wang Y, Chen H, et al. (July 2017). "Progesterone receptor modulators for endometriosis". The Cochrane Database of Systematic Reviews. 2017 (7) CD009881. Wiley. doi:10.1002/14651858.cd009881.pub2. PMC   6483151 . PMID   28742263.
  116. ↑ Brown J, Crawford TJ, Allen C, Hopewell S, Prentice A (January 2017). "Nonsteroidal anti-inflammatory drugs for pain in women with endometriosis". The Cochrane Database of Systematic Reviews. 1 (1) CD004753. doi:10.1002/14651858.CD004753.pub4. PMC   6464974 . PMID   28114727.
  117. ↑ ESHRE 2022, pp. 35–36.
  118. ↑ ESHRE 2022, p. 48.
  119. ↑ ESHRE 2022, pp. 48, 51.
  120. 1 2 Solnik & Sanders 2025, p. 27.
  121. ↑ "Laparoscopic (keyhole) surgery for endometriosis". NHS Gloucestershire Hospitals. 2024. Retrieved 21 November 2025.
  122. ↑ ESHRE 2022, p. 50.
  123. ↑ Muraskin A (16 July 2023). "Endometriosis, a painful and often overlooked disease, gets attention in a new film". NPR. Archived from the original on 17 July 2023. Retrieved 17 July 2023.
  124. ↑ ESHRE 2022, p. 55.
  125. ↑ ESHRE 2022, pp. 54–55.
  126. ↑ "Endometriosis". NHS. 27 August 2024. Retrieved 21 November 2025.
  127. ↑ ESHRE 2022, pp. 60–61.
  128. ↑ Samy A, Taher A, Sileem SA, Abdelhakim AM, Fathi M, Haggag H, et al. (January 2021). "Medical therapy options for endometriosis-related pain, which is better? A systematic review and network meta-analysis of randomized controlled trials". Journal of Gynecology Obstetrics and Human Reproduction. 50 (1) 101798. Elsevier BV. doi:10.1016/j.jogoh.2020.101798. PMID   32479894. S2CID   219173190.
  129. 1 2 3 4 "Endometrios – diagnostik, behandling och bemötande". sbu.se (in Swedish). Statens beredning för medicinsk och social utvärdering (SBU); Swedish Agency for Health Technology Assessment and Assessment of Social Services. 4 May 2018. p. 121. Archived from the original on 13 June 2018. Retrieved 13 June 2018.
  130. 1 2 [ non-primary source needed ]Wurn BF, Wurn LJ, Patterson K, King CR, Scharf ES (2011). "Decreasing dyspareunia and dysmenorrhea in women with endometriosis via a manual physical therapy: Results from two independent studies". Journal of Endometriosis and Pelvic Pain Disorders. 3 (4): 188–196. doi:10.5301/JE.2012.9088. PMC   6154826 .
  131. ↑ Solnik & Sanders 2025, p. 28-29.
  132. 1 2 Solnik & Sanders 2025, p. 29.
  133. ↑ ESHRE 2022, p. 118.
  134. ↑ ESHRE 2022, p. 12.
  135. ↑ ESHRE 2022, p. 13.
  136. ↑ NICE 2024, pp. 18–19.
  137. ↑ Chen I, Veth VB, Choudhry AJ, Murji A, Zakhari A, Black AY, et al. (November 2020). "Pre- and postsurgical medical therapy for endometriosis surgery". The Cochrane Database of Systematic Reviews. 11 (12) CD003678. doi:10.1002/14651858.CD003678.pub3. PMC   8127059 . PMID   33206374.
  138. 1 2 NICE 2024, p. 19, 28.
  139. ↑ ESHRE 2022, p. 83.
  140. 1 2 Shafrir AL, Farland LV, Shah DK, Harris HR, Kvaskoff M, Zondervan K, et al. (August 2018). "Risk for and consequences of endometriosis: A critical epidemiologic review". Best Practice & Research. Clinical Obstetrics & Gynaecology. 51: 1–15. doi:10.1016/j.bpobgyn.2018.06.001. PMID   30017581. S2CID   51679656. Archived from the original on 23 October 2020. Retrieved 23 August 2020.
  141. ↑ "Endometriosis Ultrasound: Procedure, Diagnosis, & Follow Up". Cleveland Clinic. Archived from the original on 7 March 2022. Retrieved 7 March 2022.
  142. ↑ Buck Louis GM, Hediger ML, Peterson CM, Croughan M, Sundaram R, Stanford J, et al. (August 2011). "Incidence of endometriosis by study population and diagnostic method: the ENDO study". Fertil. Steril. 96 (2): 360–5. doi:10.1016/j.fertnstert.2011.05.087. PMC   3143230 . PMID   21719000.
  143. ↑ Li R, Zhang L, Liu Y (7 June 2025). "Global and regional trends in the burden of surgically confirmed endometriosis from 1990 to 2021". Reproductive Biology and Endocrinology. 23 (1): 88. doi: 10.1186/s12958-025-01421-z . ISSN   1477-7827. PMC   12144762 . PMID   40483411.
  144. 1 2 Brosens I (2012). Endometriosis: Science and Practice. John Wiley & Sons. p. 3. ISBN   978-1-4443-9849-6.
  145. ↑ Nothnick WB (June 2011). "The emerging use of aromatase inhibitors for endometriosis treatment". Reproductive Biology and Endocrinology. 9: 87. doi: 10.1186/1477-7827-9-87 . PMC   3135533 . PMID   21693036.
  146. ↑ Bulun SE, Zeitoun K, Sasano H, Simpson ER (1999). "Aromatase in aging women". Seminars in Reproductive Endocrinology. 17 (4): 349–58. doi:10.1055/s-2007-1016244. PMID   10851574. S2CID   25628258.
  147. ↑ Batt RE, Mitwally MF (December 2003). "Endometriosis from thelarche to midteens: pathogenesis and prognosis, prevention and pedagogy". Journal of Pediatric and Adolescent Gynecology. 16 (6): 337–47. doi:10.1016/j.jpag.2003.09.008. PMID   14642954.
  148. ↑ Marsh EE, Laufer MR (March 2005). "Endometriosis in premenarcheal girls who do not have an associated obstructive anomaly". Fertility and Sterility. 83 (3): 758–60. doi: 10.1016/j.fertnstert.2004.08.025 . PMID   15749511.
  149. 1 2 Guo SW (11 March 2009). "Recurrence of endometriosis and its control". Human Reproduction Update. 15 (4): 441–61. doi: 10.1093/humupd/dmp007 . PMID   19279046.
  150. ↑ Batt RE (2011). A history of endometriosis. London: Springer. pp. 13–38. doi:10.1007/978-0-85729-585-9. ISBN   978-0-85729-585-9.
  151. 1 2 3 4 5 6 7 8 9 Nezhat C, Nezhat F, Nezhat C (December 2012). "Endometriosis: ancient disease, ancient treatments". Fertility and Sterility. 98 (6 Suppl): S1-62. doi: 10.1016/j.fertnstert.2012.08.001 . PMID   23084567.
  152. ↑ Sampson JA (March 1927). "Metastatic or Embolic Endometriosis, due to the Menstrual Dissemination of Endometrial Tissue into the Venous Circulation". Am. J. Pathol. 3 (2): 93–110.43. PMC   1931779 . PMID   19969738.
  153. ↑ Meigs JV (November 1941). "Endometriosis—Its Significance". Ann. Surg. 114 (5): 866–74. doi:10.1097/00000658-194111000-00007. PMC   1385984 . PMID   17857917.
  154. ↑ Barbieri RL (January 1992). "Hormonal therapy of endometriosis". Infertility and Reproductive Medicine Clinics of North America. 3 (1): 187–200. The hormonal therapy of endometriosis continues to evolve. In the 1940s and 1950s, high-dose testosterone and diethylstilbestrol regimens were the only hormonal agents available in the treatment of endometriosis. These agents, although efficacious, were associated with intolerable side effects. The current armamentarium of hormonal GnRH analogues, danazol, and synthetic progestins is efficacious and has fewer side effects.
  155. 1 2 3 Aiman J (6 December 2012). Infertility: Diagnosis and Management. Springer Science & Business Media. pp. 261–. ISBN   978-1-4613-8265-2.
  156. 1 2 3 4 Josimovich JB (11 November 2013). Gynecologic Endocrinology. Springer Science & Business Media. pp. 387–. ISBN   978-1-4613-2157-6.
  157. 1 2 3 4 Kistner RW (1995). Kistner's Gynecology: Principles and Practice. Mosby. p. 263. ISBN   978-0-8151-7479-0.
  158. ↑ Barra F, Grandi G, Tantari M, Scala C, Facchinetti F, Ferrero S (April 2019). "A comprehensive review of hormonal and biological therapies for endometriosis: latest developments". Expert Opin Biol Ther. 19 (4): 343–360. doi:10.1080/14712598.2019.1581761. hdl: 11380/1201437 . PMID   30763525. S2CID   73455399.
  159. ↑ Gallagher K (31 March 2021). "Irish songwriter Ruth Anne opens up on her debilitating fight with endometriosis". Irish Mirror. Archived from the original on 11 April 2023. Retrieved 11 April 2023.
  160. ↑ "Endometriosis showed me we need better ways to talk about women's pain | Emma Barnett". TheGuardian.com . 22 October 2020.
  161. ↑ Hayden J (11 May 2020). "'Nearly broke me' Spice Girls' Emma Bunton describes struggling to conceive with endometriosis". Her.ie . Retrieved 28 May 2021.
  162. ↑ "Alexa Chung Reveals Her Battle With Endometriosis—And Taps Into an Empowering Online Community". Vogue. 18 July 2019. Archived from the original on 11 April 2023. Retrieved 11 April 2023.
  163. ↑ "Champions Corner: Collins unleashes the best tennis of her career after life-changing surgery". Women's Tennis Association. Archived from the original on 2 February 2022. Retrieved 3 March 2022.
  164. ↑ "Watch: Olivia Culpo Shares Emotional Details of Her Endometriosis Journey". Sports Illustrated.
  165. ↑ "Lena Dunham Gives Health Update Following Battle with Endometriosis". People. Archived from the original on 11 April 2023. Retrieved 11 April 2023.
  166. ↑ "Congresswoman Abby Finkenauer Opens Up About Her Struggle With Endometriosis". Glamour. 5 March 2020. Retrieved 17 December 2021.
  167. ↑ "EXCLUSIVE: Bethenny Frankel in Tears Over Recent Health Scare: 'I Really Tried to Hold It All Together'". Entertainment Tonight. 22 June 2016. Archived from the original on 11 April 2023. Retrieved 11 April 2023.
  168. ↑ "Blossom Ball 2009 – Whoopi Goldberg". Endometriosis Foundation of America. 27 November 2007. Retrieved 21 January 2021.
  169. ↑ "Radio presenter Mel Greig's shocking photo shows reality of living with endometriosis". News.com.au . 28 March 2018. Archived from the original on 13 November 2018. Retrieved 21 January 2021.
  170. ↑ Iasimone A (7 January 2017). "Halsey undergoes surgery to treat endometriosis". Billboard . Retrieved 27 November 2018.
  171. ↑ "Emma Hayes: Chelsea manager has emergency hysterectomy because of endometriosis". BBC Sport. BBC. 13 October 2022. Archived from the original on 28 December 2022. Retrieved 28 December 2022.
  172. ↑ Murray R (9 September 2017). "Julianne Hough opens up about endometriosis: 'I just thought it was normal'". Today . Archived from the original on 13 November 2018. Retrieved 21 January 2021.
  173. ↑ "Julianne Hough Won't Let Endometriosis Stop Her From Having a Family With Brooks Laich: "We've Discussed Options"". Endometriosis : Causes - Symptoms - Diagnosis - and Treatment. 23 April 2018. Archived from the original on 31 December 2023. Retrieved 31 December 2023.
  174. ↑ Olya G (24 March 2017). "Julianne Hough Opens Up About Her Struggle with Endometriosis". Peoplemag. Archived from the original on 31 December 2023. Retrieved 31 December 2023.
  175. ↑ Hustwaite B (14 August 2018). "Endometriosis: The pain sucks, but so does just getting a diagnosis". Hack on Triple J . Archived from the original on 18 August 2018. Retrieved 21 January 2021.
  176. ↑ Dye J (8 March 2023). "On International Women's Day, Bindi Irwin reveals 10-year struggle with endometriosis". Australian Broadcasting Corporation News. Archived from the original on 9 March 2023. Retrieved 10 March 2023.
  177. ↑ "Why Jaime King Decided It Was Time to Talk About Her Years-Long Fertility Struggle". E! Online. 24 April 2022. Retrieved 11 April 2023.
  178. ↑ "Padma Lakshmi shares her struggle with endometriosis". Redbook . 17 October 2011. Archived from the original on 2 November 2020. Retrieved 9 March 2021– via YouTube.
  179. ↑ Hajdu D (30 November 2012). "'80s Pop". The New York Times . ISSN   0362-4331. Archived from the original on 29 June 2017. Retrieved 11 April 2023.
  180. ↑ "No Kidding: Jillian Michaels is Not "Doing That" to Her Body". Bitch Media. 7 February 2011. Archived from the original on 11 April 2023. Retrieved 11 April 2023.
  181. ↑ "Monica's Second Surgery For Her Endometriosis Was 'Very Hard' And She 'Ended Up Having Multiple Blood Transfusions'". MadameNoire. 9 June 2021. Archived from the original on 11 April 2023. Retrieved 11 April 2023.
  182. ↑ Wilson-Beevers H (28 September 2022). "Marilyn Monroe's battle with endometriosis is often ignored – but it's a vital part of her story". Cosmopolitan. Archived from the original on 11 April 2023. Retrieved 11 April 2023.
  183. ↑ Henderson W (14 June 2017). "Tia Mowry Releases a Cookbook for Women With Endometrosis". Endometriosis News. Archived from the original on 11 April 2023. Retrieved 11 April 2023.
  184. ↑ Devereux N (19 August 2015). "Sinead O'Connor tells of illness hell: "I'm in a bad way"". Archived from the original on 5 August 2023. Retrieved 5 August 2023.
  185. ↑ Vargas A. "12 celebrities who have opened up about having endometriosis". Insider. Retrieved 6 August 2021.
  186. ↑ Shultz CL (19 November 2024). "Florence Pugh Says It Was a 'Mind-Boggling Realization' to Learn She Had to Freeze Her Eggs at 27". People. Archived from the original on 19 November 2024. Retrieved 19 November 2024.
  187. ↑ Scott E (12 June 2016). "Daisy Ridley opened up about her struggle with endometriosis". Cosmopolitan . Archived from the original on 8 August 2016. Retrieved 29 June 2021.
  188. ↑ "Emma Roberts shares how her undiagnosed endometriosis affected her pregnancy journey". Self . Condé Nast. 11 November 2020. Retrieved 15 July 2021.
  189. ↑ "EFA2011: Susan Sarandon speaks up about endometriosis". Endometriosis.org. Archived from the original on 11 April 2023. Retrieved 11 April 2023.
  190. ↑ "Amy Schumer 'feeling good' after endometriosis surgery and liposuction". The Independent Tribune. 20 January 2022. Archived from the original on 11 April 2023. Retrieved 11 April 2023.
  191. ↑ "'General Hospital': Kirsten Storms opens up about return – The TV Guy – Orlando Sentinel". 25 December 2012. Archived from the original on 25 December 2012. Retrieved 18 October 2021.
  192. ↑ Haller S. "Gabrielle Union says she probably can't get pregnant because of adenomyosis. What exactly is that?". USA Today. Retrieved 11 April 2023.
  193. ↑ Staff Writer. "Another victim of the 'Dancing With The Stars' curse". The Columbus Dispatch. Archived from the original on 19 January 2024. Retrieved 31 December 2023.
  194. ↑ Richenthal M (30 October 2008). "Lacey Schwimmer is Also Sick". TV Fanatic. Archived from the original on 31 December 2023. Retrieved 31 December 2023.
  195. ↑ "Lena Dunham, Julianne Hough and More Who've Opened Up About Endometriosis Battles: "You Don't Have to Ignore Pain"". E! Online. 23 March 2017. Archived from the original on 31 December 2023. Retrieved 31 December 2023.
  196. ↑ Mazziotta J (5 February 2021). "Chrissy Teigen says endometriosis surgery was 'a toughie' but better than 'the pain of endo'". People . Archived from the original on 15 July 2021. Retrieved 15 July 2021.
  197. ↑ "Yellow Wiggle Emma Watkins opens up about the agony of endometriosis". PerthNow . 16 March 2019. Archived from the original on 6 February 2020. Retrieved 21 January 2021.
  198. ↑ "Mae Whitman: 'Endometriosis Is Like Being Shot With a Cannonball in the Stomach'". Glamour. 21 May 2020. Archived from the original on 11 April 2023. Retrieved 11 April 2023.
  199. ↑ "Jessica Williams on the 'Debilitating' Symptom That Led to Her Endometriosis Diagnosis". Self. 12 April 2022. Archived from the original on 11 April 2023. Retrieved 11 April 2023.
  200. ↑ Dervish-O'Kane R (27 December 2022). "Leah Williamson, captain of the Lionesses, is our January cover star". Women's Health. Hearst UK. Archived from the original on 28 December 2022. Retrieved 28 December 2022.
  201. 1 2 Gao X, Outley J, Botteman M, Spalding J, Simon JA, Pashos CL (December 2006). "Economic burden of endometriosis". Fertility and Sterility. 86 (6): 1561–72. doi: 10.1016/j.fertnstert.2006.06.015 . PMID   17056043. S2CID   20623034.
  202. ↑ Koltermann KC, Dornquast C, Ebert AD, Reinhold T (2017). "Economic Burden of Endometriosis: A Systematic Review". Ann Reprod Med Treat. 2 (2m): 1015. S2CID   32839234.
  203. ↑ Grundström H, Hammar Spagnoli G, Lövqvist L, Olovsson M (2020). "Healthcare Consumption and Cost Estimates Concerning Swedish Women with Endometriosis". Gynecologic and Obstetric Investigation. 85 (3): 237–244. doi: 10.1159/000507326 . PMID   32248191. S2CID   214811610.
  204. ↑ Soliman AM, Coyne KS, Gries KS, Castelli-Haley J, Snabes MC, Surrey ES (July 2017). "The Effect of Endometriosis Symptoms on Absenteeism and Presenteeism in the Workplace and at Home". Journal of Managed Care & Specialty Pharmacy. 23 (7): 745–754. doi: 10.18553/jmcp.2017.23.7.745 . PMC   10398072 . PMID   28650252.
  205. ↑ Snowdon C (5 February 2025). "Women with endometriosis earn less, research shows". BBC. Retrieved 5 February 2025.
  206. ↑ As-Sanie S, Black R, Giudice LC, Gray Valbrun T, Gupta J, Jones B, et al. (August 2019). "Assessing research gaps and unmet needs in endometriosis". American Journal of Obstetrics and Gynecology. 221 (2): 86–94. doi:10.1016/j.ajog.2019.02.033. PMID   30790565. S2CID   73480251.
  207. ↑ Hudelist G, Fritzer N, Thomas A, Niehues C, Oppelt P, Haas D, et al. (December 2012). "Diagnostic delay for endometriosis in Austria and Germany: causes and possible consequences". Human Reproduction. 27 (12): 3412–6. doi: 10.1093/humrep/des316 . PMID   22990516.
  208. ↑ "Test d'auto-évaluation du JOGC". Journal of Obstetrics and Gynaecology Canada. 25 (12): 1046–1051. December 2003. doi:10.1016/s1701-2163(16)30350-4. ISSN   1701-2163.
  209. ↑ Quibel A, Puscasiu L, Marpeau L, Roman H (June 2013). "[General practitioners and the challenge of endometriosis screening and care: results of a survey]". Gynécologie, Obstétrique & Fertilité. 41 (6): 372–80. doi:10.1016/j.gyobfe.2012.02.024. PMID   22521982.
  210. ↑ Arruda MS, Petta CA, Abrão MS, Benetti-Pinto CL (April 2003). "Time elapsed from onset of symptoms to diagnosis of endometriosis in a cohort study of Brazilian women". Human Reproduction. 18 (4): 756–9. doi: 10.1093/humrep/deg136 . PMID   12660267.
  211. ↑ Bullo S, Weckesser A (15 November 2021). "Addressing Challenges in Endometriosis Pain Communication Between Patients and Doctors: The Role of Language". Frontiers in Global Women's Health. 2 764693. doi: 10.3389/fgwh.2021.764693 . ISSN   2673-5059. PMC   8634326 . PMID   34870277.
  212. ↑ Shade GH, Lane M, Diamond MP (24 June 2011). "Endometriosis in the African American woman—racially, a different entity?". Gynecological Surgery. 9: 59–62. doi: 10.1007/s10397-011-0685-5 . S2CID   6288739.
  213. ↑ Hoffman KM, Trawalter S, Axt JR, Oliver MN (April 2016). "Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites". Proceedings of the National Academy of Sciences of the United States of America. 113 (16): 4296–301. Bibcode:2016PNAS..113.4296H. doi: 10.1073/pnas.1516047113 . PMC   4843483 . PMID   27044069.
  214. 1 2 Matías-González Y, Sánchez-Galarza AN, Flores-Caldera I, Rivera-Segarra E (March 2021). ""Es que tú eres una changa": stigma experiences among Latina women living with endometriosis". Journal of Psychosomatic Obstetrics and Gynaecology. 42 (1): 67–74. doi:10.1080/0167482X.2020.1822807. PMC   8893272 . PMID   32964770. S2CID   221862356.
  215. 1 2 Sims OT, Gupta J, Missmer SA, Aninye IO (August 2021). "Stigma and Endometriosis: A Brief Overview and Recommendations to Improve Psychosocial Well-Being and Diagnostic Delay". International Journal of Environmental Research and Public Health. 18 (15): 8210. doi: 10.3390/ijerph18158210 . PMC   8346066 . PMID   34360501.
  216. ↑ Kocas HD, Rubin LR, Lobel M (September 2023). "Stigma and mental health in endometriosis". European Journal of Obstetrics & Gynecology and Reproductive Biology. 19 100228. Elsevier BV. doi: 10.1016/j.eurox.2023.100228 . PMC   10465859 . PMID   37654520.
  217. ↑ Henry JE (27 May 2022). "Period Stigma and the Unacknowledged System of Oppression". Stanford | Digital Education. Archived from the original on 24 November 2023. Retrieved 24 November 2023.
  218. ↑ Pant A, Moar K, K Arora T, Maurya PK (2023). "Biomarkers of endometriosis" . Clinica Chimica Acta. 549 117563. doi:10.1016/j.cca.2023.117563. ISSN   0009-8981. PMID   37739024.
  219. ↑ Agostinis C, Battista N, Costanzo M (2021). "The Search for Biomarkers in Endometriosis: a Long and Windy Road". Reproductive Sciences. 28 (10): 2751–2766. doi:10.1007/s43032-021-00668-2.
  220. ↑ Grammatis AL, Georgiou EX, Becker CM (August 2021). "Pentoxifylline for the treatment of endometriosis-associated pain and infertility". The Cochrane Database of Systematic Reviews. 2021 (8) CD007677. doi:10.1002/14651858.CD007677.pub4. PMC   8407096 . PMID   34431079. S2CID   237294362.
  221. 1 2 Saunders PT, Horne AW (May 2021). "Endometriosis: Etiology, pathobiology, and therapeutic prospects". Cell. 184 (11). Elsevier BV: 2807–2824. doi: 10.1016/j.cell.2021.04.041 . hdl: 20.500.11820/bb7ded31-cc3d-449e-a0dc-ce4b1a0531d2 . PMID   34048704. S2CID   235226513.

Cited sources

This article incorporates text in the public domain as a Swedish government "utterance" by URL§9

This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.