SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Endometriosis — Diagnosis, Pain & Fertility

Endometriosis is a common, long-term cause of pelvic pain and infertility that is often diagnosed late. This sheet gives how to suspect it, how to diagnose it without waiting for surgery, the pain treatment ladder, surgery, and care when she wants to conceive.

🎯 AT A GLANCE — ENDOMETRIOSIS

Endometriosis is tissue like the lining of the womb growing outside the uterus, most often on the ovaries and pelvic peritoneum; it causes inflammation, pain and infertility

About 10% of women of reproductive age are affected, roughly 190 million worldwide (WHO)

It takes on average 4 to 12 years to be diagnosed; painful periods are too often dismissed as normal

There is no cure; treatment controls symptoms and protects fertility, and it can start without surgery

25–50% of women with infertility have endometriosis (WHO)

Think of it in any girl or woman with severe period pain, pain with sex, painful bowel or bladder symptoms, or trouble conceiving.

🚨 REFER URGENTLY OR ESCALATE IF…

Sudden severe pelvic pain with fever, fainting or a tender mass — think of a ruptured or twisted endometrioma, or another acute surgical cause (from memory)

A pelvic mass with solid parts, rapid growth, ascites, or suspicious scan features — manage as a possible ovarian cancer; refer to a gynaecological oncology service (from memory)

Cyclical blood in urine or stool, or pain with passing urine or stool — possible bladder or bowel disease; refer to a specialist centre (from memory)

Back or flank pain, or a dilated kidney on scan — deep disease can block a ureter and silently damage the kidney; image the urinary tract and refer (from memory)

Pain or bleeding after menopause in a woman with known endometriosis — needs evaluation; disease can stay active and transform rarely

STEP 1 · UNDERSTAND IT — what it is and how it presents

🔬 WHAT IT IS AND WHO GETS IT

Lesions respond to hormones, bleed and cause inflammation and scarring; deep endometriosis means lesions more than 5 mm below the peritoneal surface

Main forms: superficial peritoneal disease, ovarian endometrioma (the “chocolate cyst”), and deep endometriosis involving bowel, bladder, ureter or uterosacral ligaments

Most likely mechanisms: retrograde menstruation (Sampson’s theory) together with immune, hormonal and genetic factors; the cause is not fully known (from memory)

Risk factors: family history, early menarche, short cycles, and conditions that obstruct menstrual outflow

It can occur outside the pelvis, in the abdomen or chest, and may be present after menopause

🩺 SYMPTOMS TO ASK ABOUT

Pain

Severe period pain (dysmenorrhoea)

Deep pain during sex (dyspareunia)

Chronic pelvic pain; shoulder-tip pain

Bowel and bladder

Painful bowel movements (dyschezia)

Cyclical bloating, nausea or diarrhoea

Painful urination at periods

Bleeding and fertility

Heavy periods or spotting

Difficulty getting pregnant

Tiredness and low mood

Life impact

School or work absence

Effects on relationships and sex

Anxiety and depression

Symptom severity does not match the stage of disease: a woman with small lesions can have severe pain.

STEP 2 · DIAGNOSE — history, imaging, and when to operate

🧭 THE DIAGNOSTIC PATHWAY

Examination can find deep nodules or an endometrioma, but its accuracy is low; a normal examination does not rule it out

Use ultrasound or MRI; a negative scan does not exclude superficial disease

Do not use blood, menstrual or tissue biomarkers (including CA-125) to diagnose it

Laparoscopy is no longer the gold standard; use it when imaging is negative and empirical treatment failed or is not suitable. Histology confirms lesions but a negative result does not exclude disease

Consider the Endometriosis Fertility Index (EFI) when planning fertility after surgery

🧒 ADOLESCENTS AND OLDER WOMEN

Adolescents: suspect it with chronic or cyclical pelvic pain, school absence, family history, early menarche or an obstructed outflow tract

Use transvaginal ultrasound where appropriate; CA-125 is not recommended

First line: hormonal contraceptive or progestogen, including the LNG-IUS; NSAIDs when hormones are not an option

Tell adolescents how the disease can affect ovarian reserve

After menopause: disease can remain active; surgery may confirm the diagnosis, and aromatase inhibitors may help if surgery is not possible

STEP 3 · TREAT THE PAIN — ladder of treatment

💊 MEDICAL TREATMENT OF PAIN

Step	Options	Points to remember
1 · Analgesia	NSAIDs or other analgesics, alone or together	Offer from the start; take with food; check kidney and stomach risks (from memory)
2 · Hormones, first line	Combined pill (may be taken continuously for period pain), progestogens (for example dienogest), LNG-IUS, etonogestrel implant	Hormonal treatment is an option for all; use shared decision-making. Irregular bleeding is common with progestogens
3 · Second line	GnRH agonists with combined add-back therapy; GnRH antagonists may be considered	Add-back therapy prevents bone loss; antagonists are a second-line option for pain
4 · Refractory pain	Aromatase inhibitors, alone or with other hormones	For pain that has not responded to other medical or surgical treatment; may not suit women who want to conceive
Supportive care	Physiotherapy, cognitive behavioural therapy, pain services	Include psychological support, especially with deep or ovarian disease

Do not give hormones before surgery to improve operative outcomes. After surgery, hormonal treatment may be offered if pregnancy is not desired right away. Product choice and doses depend on local availability: follow your protocol.

🔪 SURGERY

Surgery is one option for pain, by laparoscopy; excision may be considered over ablation

Endometrioma: cystectomy rather than drainage and coagulation, taking care to protect the ovary

Deep endometriosis: surgery may reduce pain and improve quality of life; refer to a centre of expertise

Hysterectomy: only for women who no longer want children and did not respond to conservative treatment; it may not cure the symptoms

Recurrence is common without postoperative hormonal treatment, so discuss it before the operation

Counsel before surgery: effect on ovarian reserve, risk of bowel, bladder and ureter injury, and chance of recurrence.

STEP 4 · INFERTILITY — protecting the chance of pregnancy

👶 WHEN SHE WANTS TO CONCEIVE

Hormonal suppression does not improve fertility; do not use it for that purpose, and do not use it after surgery just to raise pregnancy rates

Mild disease (stage I/II): laparoscopic surgery may be offered; IUI with ovarian stimulation may be used

Endometrioma or deep disease: surgery may help natural conception in symptomatic women, but weigh the risk to ovarian reserve

Assisted reproduction (IVF/ICSI) is indicated for tubal damage, male factor, a low EFI, or failure of other treatment; it does not raise the recurrence rate

Do not routinely operate before IVF for stage I/II disease or endometrioma; operate for pain or if follicles cannot be reached

Discuss fertility preservation when ovarian disease is extensive; its benefit is not yet certain

⚠️ COMMON PITFALLS

Telling a girl that painful periods are normal

Waiting for laparoscopy before starting treatment

Relying on CA-125 or a normal scan to rule it out

Using GnRH analogues without add-back therapy

Treating the scan and ignoring the woman’s pain and distress

Operating on an endometrioma before IVF without a clear reason

Using oestrogen-only hormone therapy after menopause in a woman with endometriosis

Memory Aid

PAIN

Four reminders for the woman with suspected endometriosis.

P

Period pain that stops life — believe her and ask about school and work

A

Ask about sex, bowel and bladder pain — these point to deeper disease

I

Image, do not wait for surgery — ultrasound or MRI, then treat

N

Next step by plan — pain ladder or fertility plan, and refer when deep disease or a suspicious mass is found

Remember: endometriosis is a long-term condition; shared decisions, steady follow-up and psychological support matter as much as the drug or the operation.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. Checked against: the WHO endometriosis fact sheet (October 2025: prevalence, symptoms, delay to diagnosis, treatment options) and the ESHRE 2022 endometriosis guideline (diagnosis, imaging, laparoscopy, hormonal and surgical treatment, infertility, adolescents, menopause). Items marked “from memory” (mechanism, ovarian cancer warning signs, acute and urinary tract warnings, analgesic cautions) were not checked, and specific drug doses are intentionally not given. Guidelines differ between countries and products differ in availability: follow your local protocol and involve a senior gynaecologist.