What endometriosis is, why the diagnosis is so often delayed, how it is diagnosed now that laparoscopy is no longer required, and how the treatment differs when the priority is pain versus pregnancy.
Endometriosis is not a rare condition. It affects roughly 10% of women and girls of reproductive age — about 190 million worldwide.1 What is remarkable is not how uncommon it is, but how long it takes to name. Studies from several countries put the average delay between the first symptom and the diagnosis at several years, and the single largest reason is that severe period pain gets classified as normal — by families, by employers, and often by the woman herself.2
This page explains what the condition is, how it is actually diagnosed in 2026 (the rules have changed), what each treatment can and cannot deliver, and how the decision differs depending on whether your priority right now is pain or pregnancy.
What endometriosis is
Tissue resembling the lining of the uterus grows outside it — on the ovaries, the pelvic peritoneum, the ligaments behind the uterus, sometimes the bowel or bladder. That tissue responds to the same monthly hormonal signals as the lining inside the uterus: it thickens and bleeds. Inside the uterus that blood leaves. Outside it, it cannot. The result is inflammation, and over years, scarring and adhesions that stick organs to one another.
Two things follow from this that patients are rarely told. First, the amount of disease and the amount of pain correlate poorly — a few small deposits can be agonising, and extensive disease can be nearly silent. Second, because the deposits respond to hormones, anything that stops the hormonal cycle will reduce the symptoms, which is the basis of most medical treatment.
The symptoms worth taking seriously
| Symptom | What makes it suggest endometriosis |
|---|---|
| Period pain | Starts one to three days before bleeding; not controlled by ordinary painkillers; makes you miss work or college |
| Pain during or after intercourse | Deep rather than at the entrance; often worse in certain positions or before the period |
| Chronic pelvic pain | Present between periods, not only with them |
| Bowel or bladder symptoms | Pain on passing stool or urine, cyclical — worse around the period |
| Difficulty conceiving | Present in a substantial proportion; sometimes the only symptom |
| Fatigue | Persistent, and frequently dismissed |
The pattern that should trigger a referral is cyclical symptoms outside the uterus. Pain on defecation that is worse every month around the period is a different story from pain on defecation generally.
How it is diagnosed — and what changed
For decades the rule was that endometriosis could only be confirmed by laparoscopy. Current international guidance has moved away from that. Diagnostic laparoscopy is no longer required before starting treatment: a clinical diagnosis based on history and examination, supported by imaging where imaging is positive, is now considered sufficient to begin management.3,4
| Step | What it shows | Limits |
|---|---|---|
| History and examination | The cyclical pattern; tenderness or nodularity behind the uterus | Examination is often normal in early disease |
| Transvaginal ultrasound | Ovarian endometriomas (“chocolate cysts”); with a skilled operator, deep disease and signs of adhesion | A normal scan does not exclude endometriosis |
| MRI | Deep infiltrating disease, bowel and bladder involvement; used for surgical planning | Not needed in most cases |
| Laparoscopy | Direct visualisation, with the option to treat in the same sitting | Now reserved for treatment, or where diagnosis remains unclear and symptoms are not settling |
There is no reliable blood test. CA-125 is raised in some women with endometriosis and in many without it, and is not a screening test for this condition.
Treatment: match it to what you are trying to achieve
This is the part that most often goes wrong. Endometriosis has no cure, and the treatment that is best for pain is not always the treatment that is best for fertility. The first question in the consultation should be which of the two you are treating now.
If the priority is pain
| Option | What it does | Honest limitation |
|---|---|---|
| NSAIDs | First-line symptom relief | Treats pain, not disease |
| Combined pill, continuous or cyclical | Suppresses the cycle; effective first-line hormonal treatment | Contraceptive — not an option while trying to conceive |
| Progestogens (oral, injectable, implant) | Suppress endometrial activity | Irregular spotting is common in the first months |
| Levonorgestrel intrauterine system | Local progestogen; helpful for pain and heavy bleeding | Takes some months to settle |
| GnRH analogues | Induce a temporary menopausal state | Short-term use; bone density concerns; needs add-back therapy |
| Laparoscopic excision or ablation | Removes or destroys deposits; divides adhesions | Symptoms recur in a meaningful proportion; hormonal treatment afterwards reduces recurrence |
If the priority is pregnancy
Hormonal treatment suppresses endometriosis by suppressing ovulation, so it does not help you conceive — it prevents it. Where fertility is the goal the realistic options are surgery, assisted reproduction, or both in a planned sequence.
- Laparoscopic surgery for early-stage disease improves the chance of natural conception. For endometriomas, the decision is a balance: removing the cyst can improve access and symptoms, but the operation itself can reduce ovarian reserve, so the size of the cyst, your AMH and your age all belong in the discussion before, not after.
- IUI may be offered in mild disease with open tubes.
- IVF bypasses the pelvis altogether and is the route where the disease is advanced, the tubes are affected, or where surgery and time have not worked.
Where these operations are performed. Cosmic Women’s Hospital & IVF Center does not have a surgical robot on site. Dr. Rahul Khatri performs laparoscopic and hysteroscopic surgery at Cosmic, and performs robotic surgery at Apollo Hospital, Gandhinagar, where he is attached as a consultant. If robotic surgery is the right operation for you, it will be scheduled there and this will be explained to you in advance, including the difference in cost.
At Cosmic. Where a woman with endometriosis is also trying to conceive, the surgical and fertility decisions are taken together rather than one at a time — AMH is checked before any planned endometrioma surgery, because a cyst removed without that number is a decision made blind. You will be told, in advance and in writing, what the operation is expected to achieve for pain, and separately what it is expected to achieve for fertility. Those are two different answers.
What to expect over time
Endometriosis is a long-term condition, usually quiet after menopause, and generally managed rather than eliminated. Treatment aims to control symptoms well enough that they stop dictating your life, and to protect fertility where that matters. Recurrence after surgery is common enough that maintenance hormonal treatment is standard for women not trying to conceive.
The most valuable thing you can do before a consultation is to keep a simple record for two cycles: pain scores by day, whether the pain preceded the bleeding, what medication you took, and any bowel or bladder symptoms and their timing. That log is worth more than any single scan.
Sources
- World Health Organization. Endometriosis — fact sheet. who.int
- Zondervan KT, Becker CM, Missmer SA. Endometriosis. New England Journal of Medicine, 2020.
- European Society of Human Reproduction and Embryology. ESHRE Guideline: Endometriosis, 2022. eshre.eu
- National Institute for Health and Care Excellence. NG73: Endometriosis — diagnosis and management. nice.org.uk
- American College of Obstetricians and Gynecologists. Practice Bulletin: Management of Endometriosis. acog.org
Have a symptom you have been putting off?
Cosmic Women’s Hospital & IVF Center runs a general gynaecology OPD in Naroda, Ahmedabad, with in-house ultrasound and laboratory. Bring any previous reports and a rough note of your last few cycle dates — it makes the first consultation far more useful.
77-9383-9383
3rd Floor, The Capital Corporate, Nr. Naroda Muktidham, Naroda, Ahmedabad 382330 · Book an appointment
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Cosmic Women's Hospital
Cosmic Women’s Hospital & IVF Center is a registered Level 2 ART clinic in Naroda, Ahmedabad — obstetrics, gynaecological surgery, IVF and ICSI, with ultrasound in-house and 24-hour emergency obstetric cover. Articles here are written by the clinical team and medically reviewed by Dr. Rahul Khatri or Dr. Bhargavi Khatri before publication.
