Endometriosis: symptoms, diagnosis, treatment and its link to fertility

Some cramps are uncomfortable.

And some cramps make you cancel plans, miss work, curl up in bed or organize the whole month around your next period.

When period pain repeatedly interferes with your life, it deserves to be investigated.

Endometriosis is a chronic condition that can cause severe pain, bowel and urinary symptoms, discomfort during sex and difficulty getting pregnant. Even so, many people spend years being told that what they feel is just a “difficult period”.

The World Health Organization estimates that the disease affects approximately 10% of women of reproductive age worldwide — around 190 million people.

That's why talking about endometriosis is also about learning to recognize when something that has been normalized deserves attention.

What is endometriosis?

The inside of the uterus is lined with a tissue called the endometrium.

In endometriosis, tissue similar to the endometrium grows outside the uterus, and can reach areas such as:

• the ovaries;
• the fallopian tubes;
• the peritoneum;
• the bowel;
• the bladder;
• other structures in the pelvis.

This tissue can trigger inflammation and, over time, contribute to the formation of adhesions and scarring.

Depending on the location and depth of the lesions, the disease can be classified into different forms, such as superficial endometriosis, ovarian endometriosis — when so-called endometriomas may form — and deep endometriosis.

Why does endometriosis happen?

There is still no single explanation for why some people develop endometriosis and others don't.

The hypotheses being studied involve hormonal, genetic and immune factors, as well as mechanisms related to the menstrual cycle itself.

In other words: a person doesn't develop endometriosis because they did something wrong.

And, to this day, there is no guaranteed way to prevent the disease.

What are the main symptoms of endometriosis?

The way endometriosis shows up varies a lot.

Some people have extensive lesions and relatively few symptoms.

Others have severe pain even when imaging tests show only subtle changes or no visible lesion.

The most common symptoms include:

• severe menstrual cramps;
• recurrent or chronic pelvic pain;
• pain during or after penetrative sex;
• pain when passing stool during your period;
• pain or other urinary symptoms related to the cycle;
• cyclical bowel changes;
• heavy menstrual bleeding in some people;
• difficulty getting pregnant.

There are also people with endometriosis with no apparent symptoms. In some cases, the disease is only identified during an infertility workup or for another reason.

Are very strong cramps normal?

Feeling some discomfort during your period can happen.

But pain that:

• keeps you from working or studying;
• makes you miss commitments;
• causes vomiting or severe malaise;
• repeatedly requires painkillers;
• gets progressively worse;
• interferes with sex;
• appears when passing stool or urinating during your period;

shouldn't simply be normalized.

Not every strong cramp means endometriosis, but this pattern deserves medical evaluation.

You don't have to wait until the pain becomes unbearable to seek help.

Why does it sometimes take so long to find out?

This is one of the biggest problems related to endometriosis.

Brazil's Ministry of Health reports that the average time to diagnosis in Brazil is approximately seven years. The WHO points to diagnostic delays of 4 to 12 years in different settings around the world.

Part of this delay happens because the symptoms can be confused with other conditions.

But there's another problem too: the normalization of period pain.

**“You're just very sensitive to pain.”**

may end up taking a long time to seek a more in-depth investigation.

Pain that disrupts your routine deserves to be taken seriously.

How is it diagnosed?

There's no single test that settles every case.

The investigation usually starts with a conversation with the health professional.

That's why information such as:

• when the pain appears;
• how it relates to your menstrual cycle;
• intensity;
• bowel symptoms;
• urinary symptoms;
• pain during sex;
• attempts to get pregnant;

can help a lot.

Depending on the case, tests such as a specialized transvaginal ultrasound and pelvic MRI may be ordered.

Laparoscopy may be recommended in certain situations, both for diagnosis and for treatment.

But there's been an important change in how the disease is managed today:

it is not necessary to operate on everyone just to start treating suspected endometriosis.

Brazil's Ministry of Health states that, when symptoms are consistent with the disease, treatment can begin even before confirmation by surgery or imaging, depending on the clinical evaluation.

Does a normal test rule out endometriosis?

Not always.

Some people have significant symptoms without visible changes on initial tests.

The Ministry of Health itself points out that there may be severe symptoms even when imaging tests show no changes.

That's why, when symptoms persist, the investigation shouldn't end with just:

**“The ultrasound came back normal.”**

The result needs to be interpreted together with the symptoms, the clinical exam and the patient's history.

Can endometriosis be cured?

Currently, there is no definitive cure for endometriosis.

But there are treatments that can reduce symptoms, control pain and greatly improve quality of life.

Treatment is individualized.

What works for one person may not be the best option for another.

Factors taken into account include:

• pain intensity;
• location and extent of the disease;
• age;
• desire to get pregnant;
• response to previous treatments;
• possible side effects;
• impact of the disease on quality of life.

How is endometriosis treated?

Treatment may involve medication, surgery or a combination of both approaches.

Hormonal treatment

When there's no plan to get pregnant at that time, hormonal medications can be used to reduce activity related to the menstrual cycle and control pain.

Depending on the case, options may include:

• combined hormonal contraceptives;
• progestins;
• hormonal IUD;
• medications that act on the hormonal axis, such as GnRH analogues or antagonists.

The choice needs to be individualized.

Pain management

Painkillers and anti-inflammatory drugs can also be used to manage pain, depending on the clinical situation.

They treat the symptom but don't eliminate endometriosis lesions.

Surgery

In some cases, surgery may be recommended to remove lesions, endometriomas or adhesions, or to treat structures affected by the disease.

This doesn't mean everyone with endometriosis needs an operation.

The recommendation depends on symptoms, location of the disease, reproductive plans, previous treatments and other individual factors.

Can endometriosis make it harder to get pregnant?

It can.

**“people with endometriosis can't get pregnant”.**

The second statement is wrong.

The disease can affect fertility in different ways, especially when there are changes in the ovaries or fallopian tubes, adhesions or inflammatory processes in the pelvis.

Even so, many people with endometriosis get pregnant naturally or with the help of fertility treatments.

That's why the wish to have children needs to be part of the conversation about treatment.

If I want to get pregnant, does the treatment change?

It can change quite a bit.

Some of the medications used to control endometriosis symptoms work by blocking or reducing ovulation and are therefore not used in the same way when someone is actively trying to conceive.

In this scenario, the gynecologist may assess factors such as:

• age;
• ovarian reserve;
• how long you've been trying;
• the partner's semen quality, when applicable;
• the condition of the fallopian tubes;
• presence of endometriomas;
• location of the lesions.

Depending on the case, follow-up with a fertility specialist, surgery or assisted reproduction techniques may be recommended.

Receiving an endometriosis diagnosis, therefore, does not automatically mean receiving an infertility diagnosis.

Does pregnancy cure endometriosis?

No.

Some people notice their symptoms improve during pregnancy because of the hormonal changes of this period.

But that doesn't mean the disease has gone away.

Brazil's Ministry of Health warns that a temporary improvement is not a cure and that follow-up remains important.

That's why getting pregnant shouldn't be treated as a kind of “treatment” for endometriosis.

Can endometriosis affect emotional health?

It can — and this deserves space in the conversation.

Living for years with pain, appointments, tests, changes in your sex life, work difficulties or uncertainty about fertility can significantly affect emotional well-being.

The WHO recognizes the impact of endometriosis on mental health, relationships, sexuality, work and quality of life. Brazil's Ministry of Health also includes psychological support as an important part of care.

Treating the disease shouldn't mean looking only at a lesion found on a test.

It means looking at the person who is living with it.

When should you see a gynecologist?

It's worth talking to a health professional if you repeatedly have symptoms such as:

• very strong menstrual cramps;
• frequent pelvic pain;
• pain during sex;
• pain when passing stool or urinating, especially during your period;
• bowel symptoms that get worse cyclically;
• difficulty getting pregnant;
• period symptoms that disrupt your routine.

In the SUS (Brazil's public health system), your local Basic Health Unit (UBS) can be the point of entry. Primary care can carry out the initial evaluation, start care and refer you to specialist care when needed.

One simple thing can help a lot: track your symptoms

If you suspect endometriosis, try tracking your symptoms over a few cycles.

**whether the pain made you stop what you were doing.**

This record can make your appointment much more productive.

And there's something else important here: it helps you notice patterns that, living one day at a time, can sometimes go unnoticed.

You don't have to learn to live with disabling pain

Maybe you've heard for years that periods are just painful.

Maybe you've learned to plan commitments around which days you'll probably spend lying down.

Or maybe you're only now discovering that some symptoms you always considered normal deserve to be looked into.

It doesn't necessarily mean you have endometriosis.

But it does mean that your pain deserves an explanation.

In Nilu, you can track your symptoms and cycle and use Luna to organize information and questions before an appointment.

Instead of arriving at the doctor's office trying to remember how the last six months went, you can arrive with something much more useful:

“My pain shows up like this, on these days, in these situations, and it's affecting my life in this way.”

This information can make a difference on the path to a diagnosis and appropriate treatment.

Sources consulted

Brazil's Ministry of Health: updated page on endometriosis, symptoms, diagnosis, treatment, fertility and care available through the SUS (Brazil's public health system).

Clinical Protocol and Therapeutic Guidelines for Endometriosis ("Protocolo Clínico e Diretrizes Terapêuticas da Endometriose") — Brazil's Ministry of Health: version updated in July 2026.

World Health Organization (WHO): information on the prevalence, symptoms, impact, diagnosis and treatment of endometriosis.

*This content is for informational purposes and does not replace the evaluation, diagnosis or individualized guidance of a gynecologist or other health professionals.*