Many women consider painful periods to be a normal part of their life. However, the pain may signal a far more serious condition–endometriosis. Endometriosis is a chronic inflammatory disorder in which tissue similar to the lining of the uterus grows outside the uterus at abnormal sites in the body. These lesions react to the hormone, oestrogen and in line with the menstrual cycle, lead to repeated cycles of inflammation and fibrosis. Over time, this inflammatory process can also damage surrounding organs and tissues.
Endometriosis presents in three main forms. The first involves tiny deposits on the peritoneum, the lining of the abdominal cavity. The second form is the development of ovarian cysts known as “chocolate cysts,” which contain old blood. The third and most severe form consists of deep fibrotic lesions that invade organs and can cause significant structural damage.
The condition affects an estimated 10 to 12% of women, most commonly between the ages of 25 and 29. Endometriosis causes a wide range of symptoms from severe pain during menstruation, urinary symptoms or gastrointestinal issues such as bloating, constipation, or diarrhoea. These are often dismissed as ordinary menstrual discomfort, gastrointestinal disturbances, or even psychological complaints. Normalization of menstrual pain leads to many young girls growing up believing that severe period pain is something they must tolerate. As a result, there can be a delay of four to seven years between the onset of symptoms and a confirmed diagnosis.
Diagnosing endometriosis is a challenge as routine investigations frequently appear normal and imaging methods can miss many lesions, especially the small peritoneal deposits. Accurate detection requires specialized imaging techniques and trained clinicians who follow specific protocols during ultrasound. An MRI can also help in certain cases but again requires special expertise.
The only definitive method of diagnosis remains diagnostic laparoscopy. This minimally invasive procedure uses a small camera to inspect the abdominal cavity and identify suspicious lesions, which are then confirmed through histopathology. However, even during surgery, recognition of lesions depends heavily on the expertise of the surgeon as endometriotic lesions may present atypically.
Endometriosis is also increasingly being recognised as one of the hidden causes of infertility, particularly among women living in urban environments. In a healthy couple, the chance of conception in any given month ranges between 10 and 20%. In women with endometriosis, this can fall to between 1 and 10%. Overall, around 30 to 50% of women diagnosed with the condition experience infertility.
For many patients, the disease is discovered only when they seek treatment for infertility. In that sense, endometriosis often behaves like a “silent disease,” progressing quietly until it significantly affects reproductive health. Studies suggest that nearly half of the women who seek fertility treatment are found to have endometriosis, an indication of how long the disease has gone undetected.
How does endometriosis lead to infertility? Endometrial tissue growing around the ovaries and fallopian tubes leads to inflammation and scarring, which affects the normal anatomy and transport of eggs. The disease also alters the immune environment around the egg, reducing the likelihood of fertilisation. In some cases, it interferes with embryo implantation. If ovarian cysts are present, the quantity and quality of eggs is further affected.
Recent research also suggests that endometriosis may be increasingly concentrated in urban populations. A large study in Spain found that 73.6% of those diagnosed with endometriosis lived in urban areas. There was a consistent increase in prevalence over a decade. Several factors associated with urban living may contribute to the rising incidence. Sedentary lifestyles, high stress levels, and environmental exposures are increasingly being examined as potential triggers that worsen symptoms.
Higher diagnosis rates were seen among women from higher socioeconomic backgrounds, possibly because they have greater access to medical care and are more likely to seek treatment for symptoms such as chronic pelvic pain. The study also revealed the economic burden of the disease. Nearly 29% of affected women had taken sick leave due to endometriosis-related symptoms.
Early diagnosis is critical. When detected and treated in time, the progression of endometriosis can be slowed and irreversible damage to organs and nerves may be prevented. Early intervention also offers the best chance of preserving fertility.
Endometriosis is not simply a painful menstrual condition. It is a complex inflammatory disease that affects physical health, reproductive potential, emotional wellbeing, and economic productivity. As awareness grows, it is essential to recognise that severe period pain is not normal and should never be ignored. Acknowledging the real impact of delayed diagnosis is the first step toward improving outcomes for millions of women living with this silent but debilitating disease.
This article is authored by Dr Anshumala Shukla-Kulkarni, head, Minimally Invasive Gynaecology, Gynaecology Laparoscopic and Robotic Surgery, Kokilaben Dhirubhai Ambani Hospital, Mumbai.
