Painful Periods: Could It Be Endometriosis?

Menstrual periods: the right place at the right time.

The lining of the uterus (the “womb”) is designed to prepare for an implanted fertilized egg to begin pregnancy. The tissue of this lining is hormonally sensitive and dependent, which allows it to build up or, alternately, be discarded, depending on whether or not a pregnancy occurs. Its dependence on hormones means the tissue can be shed cyclically, occurring “periodically,” every month, unless pregnancy takes over the hormonal support that keeps it intact. This tissue is made up of glands called “endometrium,” or “endometrial tissue,” and contains blood vessels and connective tissue. When it detaches from the uterine wall during a menstrual phase (the “period”), it is shed as tissue debris that is bloody and disorganized.

Endometriosis: the wrong place at the wrong time.

Endometrial tissue is designed to be discarded, not kept inside the body, which is what happens in endometriosis. Endometriosis is nothing more than endometrial tissue in parts of the body other than the uterine wall, so there is no exit for it. The continued cycles will stimulate the accumulated endometriosis, build it up, then allow it to degrade into bloody, irritating smudges within the pelvis. This creates a chronic inflammatory state due to the body’s inflammatory immune system; additionally, the endometrial tissue itself releases its own inflammatory substances. These processes result in pain and, depending on where the endometrial tissue is, the symptoms will involve those organs where it’s present.

The cause of endometriosis: the wrong place at the right time.

What is theorized to cause endometriosis is what’s called “retrograde menstruation,” that is, instead of menstrual tissue being forced out of the uterus and into the vagina where it can be caught by a tampon or sanitary napkin, it is squeezed backwards through the fallopian tubes to drip through their open ends onto the pelvic tissues. Since these openings are close to each ovary, the ovaries are the most frequently involved sites, which can interfere with ovulation itself. Other causes are suspected, also, such as endometrial cells being carried by the blood or remaining from embryonic remnants, which would explain how endometriosis can be present in areas not in continuity with the pelvis, such as in the nose, brain, or lungs.

It gets worse: pelvic adhesive disease.

The body, in its wisdom, will try to wall off areas of infection or inflammation to spare the rest of the body. This is easily seen with an abscess, in which all of the infection and inflammation is walled off in a containment barrier until it bursts to release its contents outside of the body. The same protection is attempted when bowel or bowel fat migrates to an area of inflamed endometrial tissue in the abdomen or pelvis to try to seal it off; even after the area has cooled down, you’re left with an organ (in this case, bowel) stuck to a spot. The small intestines are meant to be floating free so that the passage of feces and gas can go unimpeded without kinks or obstructions. With the intestines being stuck to areas (these attachments are called “adhesions”), the passage of intestinal contents now have to navigate twists and turns that result in distention of the bowel walls and colicky pain. These are “adhesions,” and the condition is called is pelvic adhesive disease.


Just as adhesions can block the smooth passage via intestinal peristalsis, they can also put up roadblocks for an egg in ovulation or for sperm trying to meet that egg for fertilization. As such, endometriosis is a frequent cause of infertility. Besides these mechanical barriers, the chronic inflammation sets up a state non-conducive to conception.

It gets better: with help.

There are medical ways to shrink or tame endometriosis, using a technique that puts a woman into a temporary menopausal state. This can be difficult, because menopause is hard enough without putting a younger woman through it, especially a woman who may anxious to get pregnant. Another way is to use birth control pills continuously—that is, non-cyclically, to eliminate the periods altogether, and with them, the inflammatory phase of the endometrial implants in the pelvis. This also prevents ovulation, the way birth control pills work. Again for the women seeking pregnancy, treating endometriosis with medication that also prevents pregnancy is illogical.

Older methods use testosterone derivatives, but these have problems of virilizing effects, such ashair growth, breast size decrease, acne, and voice deepening. Newer ways are with the “off-label” use of anti-estrogen compounds called “aromatase inhibitors,” used for only the most advanced cases.

Another way: surgery.

Surgery offers many advantages.

Serious business.

Endometriosis is serious business. Besides the physical pain and the interruption in a couple’s family planning, the psychological impact can be crippling. Even when infertility is not a concern, painful sex can make physical intimacy impossible, which risks even the strongest of relationships. There are specialists who use the latest technology to both diagnose and surgically treat this unmerciful disease, especially since it’s true that the sooner it is, the better.
We know, because we’re one of those specialists. Don’t wait. We’re ready to help you.

Ulas Bozdogan, MD

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