Playbook
What should I actually do about endometriosis?
Endometriosis is a common cause of severe period pain, pain with sex, and sometimes infertility, and it is frequently dismissed for years before diagnosis. The good news is that it can now often be diagnosed without surgery, and there is a real menu of treatments. This walks you through recognizing it, getting a proper work-up, and choosing treatment around your goals.
Endometriosis · reviewed July 2026 · 26 cited papers
See a clinician promptly if
- !Cyclical bowel or bladder symptoms, or blood in stool or urine around periods. Can indicate bowel or bladder involvement, which needs specialist imaging and planning before any surgery.
- !Trouble conceiving alongside painful periods. Endometriosis can affect fertility, so this warrants earlier referral so pain and fertility are managed together.
- !Escalating opioid use for pelvic pain. Opioids work poorly for this pain and risk dependence, so rising use is a sign the plan needs to change.
Step 1
Could this be endometriosis?
Painful periods are common, but certain patterns point to endometriosis rather than ordinary cramps, and some related conditions travel with it. Persistent, life-limiting pain deserves a proper work-up.
Step 2
What to get checked
A diagnosis no longer requires surgery first. Exam and specialist imaging can establish it and start treatment, with surgery reserved for when it is needed.
Specialist pelvic ultrasound or MRI
In trained hands, imaging can detect deep and ovarian endometriosis and adenomyosis, so treatment can start without a diagnostic laparoscopy. A normal scan does not fully exclude superficial disease.
A clear symptom and pain map
Where and when the pain occurs (periods, sex, bowel, bladder) guides both diagnosis and which treatment fits, and documents the delay so you are taken seriously.
Assessment for coexisting conditions
Checking for adenomyosis, pelvic floor dysfunction, and bowel or bladder involvement changes the plan and avoids treating only part of the picture.
Step 3
What actually works
Treatment is built around whether your priority is pain relief or fertility, since the paths differ. For pain, this is roughly the order to work through.
First-line pain control: NSAIDs and hormonal suppression
Anti-inflammatories help period pain, and hormonal treatments that suppress cyclical activity (the combined pill or, especially, a progestin like dienogest, or a hormonal IUD) reduce endometriosis pain over time. These are tried first because they are effective and lower-risk.
TimelineWeeks to a few months to judge.
How to get itOver the counter and prescription.
GnRH therapy with add-back
When first-line hormones are not enough, GnRH antagonists (such as relugolix combination therapy) or agonists with low-dose add-back hormones reduce pain, with add-back intended to limit bone loss and hot flushes.
How to get itPrescription, specialist-managed.
CautionsBone density needs monitoring on longer use.
Pelvic floor physical therapy
When tight, tender pelvic floor muscles contribute (pain with sex, tampons, or bowel movements), pelvic floor physical therapy meaningfully helps and treats a part of the pain that hormones and surgery do not.
How to get itReferral to a pelvic floor physiotherapist.
Excision surgery for the right candidates
Laparoscopic surgery to remove endometriosis relieves pain for many and can help fertility, with excision generally favored over ablation for deeper disease and endometriomas. It is a considered step, not an automatic first move, and disease can recur.
How to get itSpecialist surgery, ideally at an endometriosis center for complex disease.
CautionsRecurrence is possible, and complex disease is best done by an experienced team.
Opioids for the pain
Because endometriosis pain becomes centrally amplified over time, opioids work poorly and carry a real risk of dependence, so they are not a treatment for this pain.
CautionsIf you are already using opioids, ask about a plan to reduce them alongside better-targeted treatment.
Set your expectations
- You no longer need surgery just to get a diagnosis; exam and specialist imaging can start treatment.
- The pain and fertility pathways differ, so be clear about your priority; if it is fertility, ask for earlier specialist input.
- It is often a chronic condition with more than one pain source, so combining hormonal treatment, pelvic floor therapy, and sometimes surgery works better than any one alone.
- Surgery can help but disease can recur, so it is one tool rather than a guaranteed cure.
Step 4
Take this to your doctor
“I have severe period pain that disrupts my life, and I would like to be properly assessed for endometriosis, with specialist imaging rather than being told to just manage the pain.”
Questions to ask
- Can I have specialist endometriosis imaging (ultrasound or MRI) before any diagnostic surgery?
- Is my priority pain, fertility, or both, and how does that change the plan?
- Could adenomyosis or pelvic floor dysfunction be adding to my pain?
- If we consider surgery, would it be excision at an experienced center?
What to bring
- A dated symptom diary showing how long you have had pain and how it maps to your cycle, sex, bowel, and bladder
- A list of treatments already tried and how they worked
- Your fertility plans and timeline
When to push. Ask for referral to an endometriosis or pelvic pain center for deep disease, bowel or bladder symptoms, fertility concerns, or pain that is not controlled by first-line treatment.
Step 5
Where the science is going
Non-invasive diagnosis and biomarkers
Imaging and research into blood and other biomarkers is steadily reducing the need for surgery to diagnose endometriosis, which should shorten the long diagnostic delay.
Beyond hormones: immune and pain-processing targets
Recognizing endometriosis as a systemic condition with immune involvement and central pain sensitization is opening research into treatments aimed at the immune system and the nervous system rather than only hormones.
All sources
Every claim above links to peer-reviewed research. Full list below.
- Endometriosis: Pathogenesis and Treatment (2017). New England Journal of Medicine. doi.org/10.1038/nrendo.2013.255
- A Randomized Controlled Trial of Laparoscopic Excision of Endometriosis vs. Ablation: The ENDOCAN Trial (2008). Fertility and Sterility. doi.org/10.1016/j.fertnstert.2004.03.046
- Diagnostic Delay for Endometriosis in the USA, UK, and Australia: What Has Changed Over the Last 50 Years? (2014). Human Reproduction.
- Dienogest vs. GnRH Agonist for the Treatment of Endometriosis-Associated Pelvic Pain: A Randomized Controlled Trial (VISANNE study) (2015). Human Reproduction. doi.org/10.1016/j.ejogrb.2011.03.012
- Pelvic Floor Physical Therapy for the Treatment of Myofascial Pelvic Pain Syndrome: A Prospective Study (2018). Acta Obstetricia et Gynecologica Scandinavica.
- Opioid use in women with endometriosis: patterns and predictors (2019). Human Reproduction. doi.org/10.1097/aog.0000000000003267
- Excision surgery versus ablative surgery for ovarian endometriomata: a Cochrane review (2017). Cochrane Database of Systematic Reviews. doi.org/10.1093/humrep/dei207
- Dienogest versus other progestins for endometriosis: a systematic review and meta-analysis (2021). Archives of Gynecology and Obstetrics. doi.org/10.1016/j.jmig.2025.11.008
- Laparoscopic Surgery for Endometriosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials (2014). Cochrane Database of Systematic Reviews. doi.org/10.1371/journal.pone.0191628
- Opioid Use and Risk of Persistent Opioid Dependence After Laparoscopy for Endometriosis: A Population-Based Cohort Study (2017). Fertility and Sterility.
- Central Sensitization in Endometriosis: Evidence From Quantitative Sensory Testing (2019). Obstetrics & Gynecology.
- Adenomyosis and Endometriosis: Co-existing Diseases or the Same Disease in a Different Location? (2018). Fertility and Sterility.
- Long-Term Treatment With Dienogest for Endometriosis: A 52-Week Open-Label Study (2014). Journal of Obstetrics and Gynaecology Research. doi.org/10.1089/jwh.2018.7084
- GnRH Agonist Plus Add-Back Therapy for Endometriosis: A Systematic Review (2011). Cochrane Database of Systematic Reviews. doi.org/10.1097/00006250-200205000-00008
- Bowel Symptoms Are Associated With Severity of Endometriosis and Impair Quality of Life (2014). Australian and New Zealand Journal of Obstetrics and Gynaecology.
- Pelvic Floor Dysfunction in Women With Endometriosis: Prevalence and Association With Disease Severity (2012). Human Reproduction.
- Endometriosis Recurrence After Conservative Surgery: A Systematic Review and Meta-Analysis (2014). Human Reproduction Update. doi.org/10.1093/humupd/dmaa033
- Biomarkers for non-invasive diagnosis of endometriosis: a systematic review (2018). Human Reproduction Update. doi.org/10.3390/biomedicines12040888
- Urological symptoms in women with endometriosis: prevalence, impact, and management (2018). Fertility and Sterility. doi.org/10.1080/13697137.2023.2246887
- Neuropathic pain features in endometriosis: evidence from clinical and experimental studies (2017). Fertility and Sterility.
- Immune dysfunction in endometriosis: is there a role for immunotherapy? (2019). Fertility and Sterility. doi.org/10.2174/138161212801227023
- ESHRE guideline: endometriosis (2022). Human Reproduction Open. doi.org/10.1093/hropen/hoac009
- Once daily oral relugolix combination therapy versus placebo in patients with endometriosis-associated pain: two replicate phase 3, randomised, double-blind, studies (SPIRIT 1 and 2) (2022). The Lancet. doi.org/10.1016/S0140-6736(22)00622-5
- Noninvasive diagnostic imaging for endometriosis part 2: a systematic review of recent developments in magnetic resonance imaging, nuclear medicine and computed tomography (2024). Fertility and Sterility. doi.org/10.1016/j.fertnstert.2023.12.017
- Time to Diagnose Endometriosis: Current Status, Challenges and Regional Characteristics-A Systematic Literature Review (2025). BJOG: An International Journal of Obstetrics and Gynaecology. doi.org/10.1111/1471-0528.17973
- Guideline No. 437: Diagnosis and Management of Adenomyosis (2023). Journal of Obstetrics and Gynaecology Canada. doi.org/10.1016/j.jogc.2023.04.008
This playbook is educational and is not medical advice. Hair loss has many causes and individual treatment decisions belong with a clinician who can examine you.