Medically reviewed by Dr. Shweta Agarwal, MBBS, DGO. Last updated: June 2026.
Information on this page is educational and does not replace a medical consultation. Outcomes depend on individual clinical factors.
What exactly is endometriosis, and why does it cause pain?
Endometriosis occurs when endometrium-like tissue implants outside the uterus. Each month, hormonal changes trigger this tissue to grow, break down, and bleed — just as the lining inside the uterus does. But unlike normal menstrual blood, which exits through the cervix, this blood has no route out. It accumulates, causes local inflammation, and over time forms adhesions (scar tissue) and cysts — the most common of which, on the ovaries, are called endometriomas (sometimes called "chocolate cysts" because of their dark content).
The severity of endometriosis is classified in four stages (I–IV) based on the extent and depth of implants:
| Stage | Description |
|---|---|
| I (Minimal) | Small, superficial implants; few or no adhesions |
| II (Mild) | More implants; small adhesions |
| III (Moderate) | Many deep implants; endometriomas; adhesions |
| IV (Severe) | Extensive implants; large endometriomas; dense adhesions; distorted anatomy |
Importantly, stage does not always predict symptom severity or fertility impact — some women with Stage I have severe pain, while others with Stage IV conceive naturally.
In Marathi and Hindi, endometriosis is known as एंडोमेट्रियोसिस (endometriosis) — a word your doctor may also use in consultation.
What are the symptoms of endometriosis?
The hallmark symptom is pelvic pain that is worse during menstruation — but endometriosis can cause a range of symptoms, and some women have none at all. The most common include:
- Painful, heavy periods (dysmenorrhoea): Cramping that is not relieved by standard painkillers and interferes with daily activities. Pain typically begins 1–2 days before a period and lasts through it.
- Chronic pelvic pain: Lower abdominal or lower back discomfort that persists outside the menstrual cycle.
- Pain during or after intercourse (dyspareunia): Deep pelvic pain, often described as sharp or aching.
- Painful bowel movements or urination during periods: Particularly when endometriosis involves the bowel or bladder.
- Bloating and digestive discomfort: Nausea, bloating, or constipation around menstruation.
- Difficulty conceiving: Infertility is sometimes the first — and only — sign, discovered during a fertility evaluation.
- Heavy or irregular periods: Including intermenstrual spotting.
How is endometriosis diagnosed?
Endometriosis is often delayed in diagnosis — on average by several years — because its symptoms overlap with other conditions and because mild disease may show no abnormality on routine investigations.
Clinical history and physical examination
Dr. Shweta Agarwal begins with a detailed history of your pain patterns, menstrual cycle, and any difficulty conceiving. A pelvic examination may reveal tenderness, nodularity, or a fixed, retroverted uterus — signs that suggest endometriosis.
Pelvic ultrasound
A transvaginal ultrasound can detect endometriomas (ovarian cysts caused by endometriosis) and assess ovarian reserve. It cannot reliably detect superficial peritoneal implants or adhesions. See our fertility diagnostics page for more on the full diagnostic assessment.
MRI (selected cases)
An MRI may be recommended when deep infiltrating endometriosis (involving bowel, bladder, or ureters) is suspected, or before planning surgical management.
Diagnostic laparoscopy — the definitive test
A definitive diagnosis of endometriosis requires a laparoscopy: a minimally invasive surgical procedure in which a thin camera is inserted through a small incision to directly visualise the pelvis. It is the only test that confirms endometriosis with certainty. At the same time, any implants or endometriomas can often be treated. Laparoscopy is not required in every case — it is recommended when the clinical picture is strong and when medical management alone has been insufficient, or when fertility is the primary concern.
How does endometriosis affect fertility?
Endometriosis is associated with infertility in a significant proportion of affected women. The mechanisms are multiple and not fully understood, but include:
- Distorted pelvic anatomy: Adhesions can block or kink fallopian tubes, preventing sperm from reaching the egg or the fertilised egg from reaching the uterus.
- Inflammatory environment: Endometriosis creates chronic pelvic inflammation. Inflammatory mediators in the peritoneal fluid can impair sperm function and egg–sperm interaction.
- Reduced ovarian reserve: Endometriomas on the ovaries and the surgery to remove them can reduce the number of available eggs. AMH (anti-Müllerian hormone) levels — a marker of ovarian reserve — are often lower in women with ovarian endometriosis.
- Impaired egg quality: The inflammatory and oxidative environment around the ovaries can affect egg development and quality.
- Implantation difficulties: Altered uterine environment and immune factors associated with endometriosis may affect embryo implantation.
However, endometriosis does not mean infertility is inevitable. Many women with mild to moderate endometriosis conceive naturally. Others respond to fertility treatment. The right approach depends on your stage of disease, ovarian reserve, partner's sperm, and how long you have been trying.
What are the management and treatment options for endometriosis?
Treatment is tailored to your goals — pain relief, fertility, or both — your stage of disease, age, and ovarian reserve.
Pain management (when pregnancy is not an immediate goal)
- NSAIDs (anti-inflammatory painkillers): Reduce prostaglandin-driven pain; most effective when started before a period.
- Hormonal suppression: The combined oral contraceptive pill, progestins, or GnRH analogues suppress ovarian hormonal cycling, reducing endometrial implant activity and pain. These are not suitable when trying to conceive.
- Lifestyle: An anti-inflammatory diet (rich in omega-3 fatty acids, vegetables, and low in processed foods) and regular gentle exercise may help reduce symptom burden as a complement to medical treatment.
Surgical management — laparoscopy
When endometriomas are large, pain is debilitating despite medical management, or anatomy is distorted, laparoscopic surgery is indicated. The goal is excision (removal) of implants and drainage or cystectomy of endometriomas, while preserving as much healthy ovarian tissue as possible. Surgery can improve natural conception rates in moderate-to-severe disease and may improve IVF outcomes by removing a hostile ovarian environment — though the evidence on IVF outcomes post-surgery for endometriomas is nuanced and discussed individually.
Fertility treatments
IUI (Intrauterine Insemination): For women with mild (Stage I–II) endometriosis, patent tubes, and adequate ovarian reserve, IUI combined with ovulation induction may be recommended. It places prepared sperm directly into the uterus, reducing the distance sperm must travel through a potentially inflamed pelvis.
IVF (In Vitro Fertilisation): IVF is indicated for moderate-to-severe endometriosis (Stage III–IV), blocked or damaged tubes, reduced ovarian reserve, failed IUI cycles, or when the partner has a significant sperm factor. IVF bypasses the pelvic environment entirely — eggs are retrieved and fertilised in the in-house embryology lab at Aansh, under the care of Senior Clinical Embryologist Aayush Agarwal, Ph.D., and the resulting embryo is transferred to the uterus without the sperm needing to navigate the pelvis.
Fertility diagnostics: Before recommending any fertility treatment, a complete workup — AMH, antral follicle count, partner's semen analysis, and uterine cavity assessment — helps build the most appropriate plan.
Treatment cost varies by approach. An IVF cost & 0% EMI page details indicative ranges and financing options. Final cost depends on individual clinical evaluation — see Costs & EMI for current pricing.
When should I see a specialist about endometriosis?
You should consult Dr. Shweta Agarwal if:
- Your period pain is severe enough to disrupt daily activities, work, or school.
- Standard painkillers (paracetamol, ibuprofen) do not adequately control your menstrual pain.
- You have been trying to conceive for 6 months or more without success (or 12 months if under 35 with no other symptoms).
- You experience deep pain during intercourse.
- A pelvic cyst has been found on ultrasound.
- Your periods are heavy, prolonged, or associated with bowel or bladder symptoms.
Early evaluation matters — endometriosis is a progressive disease in many (though not all) women. Earlier diagnosis protects both your quality of life and your fertility options.