Endometriosis is one of the most discussed diagnoses in gynecology.
It is talked about a lot. Written about a lot. And often – with too much certainty.
For some patients, this word becomes an explanation for pain that long had no clear cause. For others – a serious reason to worry about the possibility of pregnancy. Sometimes endometriosis is voiced as a diagnosis almost automatically – even before the full clinical picture has come together.
And the picture is usually more complex.
In real clinical practice, endometriosis is rarely straightforward. It may be accompanied by pronounced symptoms. It may be discovered incidentally. Or it may not be confirmed at all, despite complaints that seem very “typical.”
And this is where the main gap arises – between how endometriosis is described and how it actually presents in the consultation room.
A quiet gap.
But a fundamental one.
This article is not an attempt to simplify the topic.
Nor is it an attempt to frighten.
It is a conversation about what truly matters when we are talking about endometriosis and a specific patient.
Why There Is So Much Confusion Around Endometriosis
Endometriosis as a “Default Diagnosis”
In recent years, endometriosis has increasingly become the first explanation for a wide range of complaints. Lower abdominal pain, painful menstruation, difficulty conceiving – the list is familiar and, at first glance, logical.
Sometimes that logic is justified. Sometimes – premature.
When the cause of symptoms is unclear, there is a desire to provide an immediate answer. To name a diagnosis that explains a lot and sounds convincing. Especially if the patient has already come in with that word in mind.
And at that moment, a substitution risk arises.
Not of the diagnosis.
Of thinking.
Where Medicine Ends and Anxiety Begins
Endometriosis is indeed a complex condition. Many questions remain, and that is normal. Modern medicine does not always operate with rigid boundaries, especially in gynecology.
The problem begins when complexity turns into a background of anxiety. When individual facts are taken out of context, and possible scenarios are perceived as inevitable.
The patient begins to hear not information, but subtext.
And that subtext is frightening.
Pain. Infertility. Surgery.
All at once.
Without clarification.
Why Identical Symptoms Do Not Mean an Identical Diagnosis
One of the main reasons for confusion is the expectation of direct links. There is a symptom – therefore there is a diagnosis. There is a diagnosis – therefore there will be a specific outcome. In real practice, it almost never works that way.
The same complaints may have different origins. The same diagnosis in different women may behave differently. And the severity of symptoms does not always reflect the seriousness of the situation.
That is why a physician never relies on a single sign during consultation. What matters is the combination of data. Their interaction. And how they change over time.
Without this, simplifications begin to work against the patient.
Even if they sound convincing.
What Endometriosis Means in Practice – Not Just in Textbooks
In textbooks, endometriosis is described quite clearly – the presence of tissue similar to the endometrium outside the uterine cavity. The definition is accurate. But for clinical work, it explains almost nothing.
Because in reality, endometriosis is not one diagnosis and not one scenario. It is several different clinical situations united by a common name, yet behaving differently and requiring different approaches.
This is where misunderstanding often arises – the expectation that the mere presence of lesions already determines management.
In practice, it does not.
Endometriosis Is Not One Disease but Different Clinical Forms
Endometriosis may present as superficial lesions, endometriomas, or deep infiltrative forms. These variants differ not only in location but also in clinical significance.
Some forms remain stable for years and do not affect well-being at all. Others may be associated with significant pain or organ dysfunction. And it is impossible to predict the course of the disease solely based on its presence.
The form matters.
But it is not the only factor.
Why the Presence of Lesions and Clinical Symptoms Do Not Always Match
In clinical practice, situations are not uncommon where pronounced endometriotic changes are discovered incidentally – without pain, without complaints, and without any impact on daily life. Conversely, significant symptoms may occur with minimal findings or even in the absence of confirmed endometriosis.
This is one of the most difficult points for patients to understand. It seems logical that “the more changes there are, the worse it should be.” But in gynecology, such linear logic rarely applies.
The body responds not only to the presence of lesions but also to their location, activity, and individual characteristics of neural and hormonal regulation. That is why identical findings may have very different clinical significance.
And this is fundamental.
When Endometriosis Is a Finding, Not the Cause of Complaints
Sometimes endometriosis is detected during an examination performed for an entirely different reason. Formally, the diagnosis is present. But the connection with the current complaints is absent or questionable.
In such situations, it is especially important not to replace clinical thinking with a purely formal approach. The presence of endometriosis does not automatically mean that it is the source of all symptoms. Nor does it mean that something must be done about it immediately.
Sometimes observation is the correct decision.
Sometimes it is the search for another cause of complaints.
And this, too, is part of treatment.
Causes of Endometriosis: What Is Known for Certain and What Remains Hypothetical
When the causes of endometriosis are discussed, there is almost always an expectation of a clear answer. One mechanism. One explanation. That definitive “why.”
Unfortunately – or perhaps fortunately – real clinical practice is more complex. And it is important to understand this from the outset.
Why There Is No Single Universal Cause
To date, there is no single theory that can fully explain the development of endometriosis in all patients. Several hypotheses exist, each explaining only a portion of clinical cases.
These include retrograde menstruation, features of the immune response, hormonal regulation, and genetic predisposition. These mechanisms have been studied for many years and in great detail. Yet none of them functions as a universal key.
This is not a gap in knowledge.
It is the reality of a complex disease.
Heredity, Hormones, Immunity – Where the Real Role Lies
Certain factors do indeed increase the likelihood of developing endometriosis. For example, a family history of the condition or specific hormonal characteristics. However, even when these factors are present, it is impossible to predict in advance whether the disease will develop and how it will manifest.
The immune system, tissue responses to hormonal fluctuations, and individual characteristics of the body all combine into a unique pattern. That is why two patients with similar baseline characteristics may experience completely different disease courses.
This is precisely why the attempt to identify a single “causative factor” often leads away from what truly matters.
Why Searching for a “Culprit Factor” Rarely Helps the Patient
In clinical practice, the question “why did this happen” rarely helps determine management strategy. It is understandable from a human perspective, but from a medical one, it is not always productive.
Even if a leading mechanism is assumed, this does not mean it can be eliminated. Nor does it mean that doing so would change the course of the disease. It is far more important to understand how endometriosis is behaving right now and whether it affects quality of life and reproductive plans.
Sometimes the question “why” remains without a definitive answer.
But this does not prevent well-considered clinical decisions from being made.
Symptoms of Endometriosis: Why Relying on Them Alone Is Risky
When endometriosis is discussed, the conversation almost always quickly shifts to symptoms. First and foremost – pain. This is understandable. Pain is noticeable. It interferes with life. It demands an explanation.
But this is also where the trap most often arises.
Pain Is an Important but Not Mandatory Symptom
Pain can indeed be a manifestation of endometriosis. Sometimes severe. Sometimes progressive. Sometimes linked to the menstrual cycle. All of this is possible.
But other scenarios are just as possible. Endometriosis may occur without pain at all. Or with minimal sensations that are not perceived as a problem for a long time. This is not an exception – it is part of clinical reality.
The absence of pain does not rule out the diagnosis.
But its presence does not automatically confirm it either.
Endometriosis Without Pain Is a Clinical Reality
In clinical practice, situations are not uncommon where endometriosis is detected in women who do not report active complaints. It is identified during examinations performed for other reasons or becomes an incidental finding.
This naturally raises the question – if nothing hurts, does that mean there is no problem. And conversely – if there is pain, does that mean the cause is necessarily endometriosis.
The answer in both cases is the same.
Not necessarily.
When Symptoms Are Present but Endometriosis Is Not
Lower abdominal pain, discomfort during menstruation, a feeling of “heaviness” – these are symptoms with which women consult a gynecologist very frequently. And far from always is endometriosis the cause.
There are many conditions that can produce a similar clinical picture. That is why attempting to establish a diagnosis based solely on sensations almost always leads to errors.
Symptoms are a signal.
But not the answer.
And as long as they are considered outside of context, they tend to increase anxiety rather than help clarify the situation.
How Endometriosis Is Actually Diagnosed
After discussing symptoms, the next question almost inevitably arises – how to confirm the diagnosis. There is a desire for a clear answer. A method that puts everything in place. A test after which no doubts remain.
In practice, things are different.
The Capabilities and Limitations of Ultrasound
Ultrasound examination is the first and most accessible assessment tool. It allows the detection of large endometriotic cysts, structural tissue changes, and indirect signs of disease. In experienced hands, ultrasound can indeed be informative.
However, this method has its limits. Superficial lesions often remain invisible. Deep forms may be masked. And some findings require cautious interpretation, especially when they do not align with the clinical picture.
Ultrasound provides information.
But not always the answer.
Why MRI Does Not Provide Absolute Certainty
Magnetic resonance imaging expands diagnostic possibilities, especially when deep forms of endometriosis are suspected. It helps clarify the localization and extent of the process and assess the involvement of adjacent structures.
Nevertheless, even MRI is not an absolute method. Small lesions may be indistinguishable. Some changes appear nonspecific. And interpretation of results still depends on clinical context.
The technology may be advanced.
Uncertainty still remains.
Laparoscopy – A Gold Standard, or Not Always
For a long time, laparoscopy was considered the definitive method for confirming endometriosis. And indeed, it allows direct visualization of lesions and, if necessary, immediate surgical intervention.
But here, too, there are nuances. Laparoscopy is an invasive procedure. It is not performed solely to уточнить the diagnosis in the absence of clear indications. Moreover, even during laparoscopy, it is not always possible to unequivocally link the detected changes to the patient’s complaints.
The mere presence of lesions is not yet the answer to what should be done next.
When the Absence of Confirmation Is Normal, Not an Error
Sometimes examinations do not yield a definitive result. Symptoms are present, but there is no visual confirmation of endometriosis. Or, conversely, findings exist, but their clinical significance is questionable.
In such situations, it is important to understand that the absence of clear confirmation does not mean the physician “missed something.” It reflects the real limitations of diagnostic methods and the complexity of the disease itself.
Medicine does not always operate with clear boundaries.
And the ability to take this into account is part of a professional approach.
Endometriosis and Reproductive Function
The relationship between endometriosis and reproductive function is one of the most sensitive topics. It is here that the diagnosis begins to be perceived most acutely. Because it concerns not only well-being, but also plans that extend far beyond the current condition.
And here it is especially important not to replace probability with inevitability.
When Endometriosis Truly Affects Conception
Endometriosis can affect fertility. This is a fact. In certain clinical situations, it can indeed make pregnancy more difficult – due to anatomical changes, an inflammatory environment, or involvement of the ovaries or fallopian tubes.
But what matters most is something else: it is not the diagnosis itself that matters, but its specific form and severity. Superficial lesions and minimal changes often do not affect the ability to conceive at all. Even with confirmed endometriosis, pregnancy may occur naturally.
The diagnosis alone does not answer the question of fertility.
Context does.
Situations Where Pregnancy Is Possible Without Treatment
In clinical practice, women with endometriosis are often seen who have no ovulation disorders, preserved ovarian function, and no anatomical barriers to conception. In such cases, active intervention is not always justified.
Sometimes the correct approach is observation. Sometimes it is planning pregnancy without prior treatment. This is not “lost time”, but a conscious decision made with consideration of the clinical picture.
Not everything requires intervention in order not to interfere.
Why the Diagnosis Itself Does Not Equal Infertility
One of the most common mistakes is to perceive endometriosis as a synonym for infertility. This simplification does not withstand practical experience.
Yes, certain forms of the disease carry higher risks. But many other factors have an equal or greater impact on reproductive function – age, ovarian reserve, ovulation regularity, and comorbid conditions.
That is why fertility is always assessed separately. Not through the lens of a single diagnosis, but through the overall reproductive picture.
It is more complex.
But it is honest.
Hormonal Therapy in Endometriosis: Possibilities and Limitations
Hormonal therapy in endometriosis is often perceived as a mandatory stage of treatment. Sometimes as the only possible option. Sometimes as a way to “cure” the disease. This is where expectations most often diverge from reality.
And this is not the patients’ fault.
It is the result of oversimplified explanations.
What Hormones Actually Do
Hormonal medications do not act on endometriosis itself, but on its manifestations. They reduce hormonal stimulation of lesions, decrease the inflammatory response, and as a result may alleviate symptoms, primarily pain.
For many patients, this brings real relief. Well-being improves. Living in a normal rhythm becomes easier. And this is an important outcome.
But it has its limits.
Why Hormonal Therapy Does Not “Cure” Endometriosis
Hormones do not remove lesions and do not eliminate the underlying nature of the disease. After discontinuation of therapy, symptoms may return. Sometimes to the same extent, sometimes in a different form.
This does not mean the therapy was a mistake. It means it has a specific purpose – symptom control, not complete eradication.
And here it is important not to confuse terms.
Control is not the same as elimination.
When Hormones Are Justified – and When They Are Not
Hormonal therapy may be justified in the presence of pronounced symptoms, when stabilization is required, when there are no indications for surgical treatment, or as part of a comprehensive approach.
However, there are also situations where prescribing hormones does not provide the expected benefit. For example, in the absence of symptoms or when complaints are not directly related to endometriosis. In such cases, treatment solely because of the diagnosis is rarely justified.
The decision about therapy is always made individually.
Not based on the name of the diagnosis.
But on its clinical relevance.
Surgical Treatment of Endometriosis: When Surgery Is Truly Necessary
The word “surgery” almost always sounds louder than the rest. Even when it is said calmly. Especially when it concerns a chronic condition.
And here it is crucial to separate two concepts: the presence of endometriosis and the need for surgical intervention. They are not the same.
Indications for Surgery from a Clinical Necessity Perspective
Surgery is considered when endometriosis leads to significant symptoms that cannot be controlled conservatively, or when there are objective anatomical changes affecting organ function.
This may involve severe pain, large endometriotic cysts, involvement of adjacent structures, or impaired tubal patency. In such cases, surgical treatment is aimed not at “eliminating the diagnosis”, but at solving a specific clinical problem.
There is always a goal.
And always a justification.
Why Not Every Case of Endometriosis Requires Surgery
The mere detection of lesions is not an automatic indication for surgery. If the disease does not affect quality of life, does not progress, and does not interfere with reproductive plans, aggressive surgical tactics may be excessive.
Surgery is an intervention. And any intervention must be justified by expected benefit. When the risk outweighs potential gain, the strategy changes.
Sometimes observation is the more reasonable decision.
And this, too, is an active clinical position.
The Role of the Team and the Surgeon’s Experience in Treatment Outcomes
Endometriosis, especially its deep forms, requires precision and a strong understanding of anatomy. In some cases, the intervention involves structures that go beyond the scope of a standard gynecologic operation.
That is why it is not only the fact of surgical treatment that matters, but also the level of the team involved. The surgeon’s experience, coordination between specialists, and a clear understanding of the extent of the procedure – all of this directly affects the outcome.
Surgery is a tool.
Not a universal answer.
But with the right indications – an effective one.
Clinical Cases from Practice
Clinical cases matter not as proof of a diagnosis and not as a demonstration of treatment results. Their value is different – they allow you to see how a doctor makes decisions when there is no universal scenario.
And this is exactly where it becomes clearest why endometriosis cannot be approached as a template.
When the Diagnosis Is Confirmed but Treatment Is Not Required
Patient, 34 years old.
An endometriotic ovarian cyst was detected on a routine ultrasound. No complaints. Menstrual cycle regular, no pain, reproductive plans for the near future not defined.
Formally, the diagnosis is there.
Clinically, there is no problem.
In this situation, active treatment would not improve quality of life, but it could limit it. Therefore, an observation strategy was chosen with regular reassessment.
Doing nothing does not mean ignoring.
It means not intervening without necessity.
When Surgery Truly Changes Quality of Life
Patient, 39 years old.
Years of lower abdominal pain that worsened during menstruation, reduced quality of life, no effect from conservative therapy. Examination findings suggested deep infiltrating endometriosis.
In this case, surgery was considered not as the “final step of treatment”, but as a way to solve a specific clinical task – to reduce pain and restore organ function.
After surgical treatment, symptom severity decreased significantly. It was not the images that changed.
It was the way she felt.
That is the goal of an intervention.
When “Endometriosis” Turned Out Not to Be the Main Problem
Patient, 31 years old.
Complaints of chronic pelvic pain. Endometriosis had previously been presumed based on symptoms. However, after a more in-depth assessment of the clinical picture and test results, it became clear that the detected changes did not explain the intensity of the complaints.
Further evaluation revealed another cause of pain that was not directly related to endometriosis. After the treatment strategy was adjusted, the patient’s condition improved without aggressive gynecologic treatment.
The diagnosis mattered.
But it was not the key.
What the Patient Ultimately Needs to Understand
Endometriosis is a diagnosis that requires understanding, not rushed conclusions. It does not always explain every symptom. It does not always require treatment. And it certainly does not always mean severe consequences.
It is important to remember: in clinical practice, what matters is not the mere fact that endometriosis is present, but how it affects your life specifically – your well-being, reproductive plans, and the quality of everyday experience.
Sometimes the right decision is observation.
Sometimes – medical support.
Sometimes – surgical intervention.
And none of these options is “good” or “bad” on its own.
The decision is always made in context. Based on symptoms, examination findings, age, plans, and how the condition changes over time. That is why universal schemes do not exist – and that is why an individualized approach is not a formality.
Endometriosis is not a sentence.
But it is not a diagnosis to ignore either.
The most important thing is a calm, professional conversation with a doctor who evaluates the situation as a whole, not through the prism of a single report or a single symptom. Such a conversation often provides more clarity than any list of tests.
And that is usually where everything begins.
Clinical Guidelines and Sources
- European Society of Human Reproduction and Embryology (ESHRE). ESHRE Guideline: Endometriosis. 2022 (updated 2024).
- American College of Obstetricians and Gynecologists (ACOG). Practice Bulletin No. 218: Endometriosis. Obstetrics & Gynecology, 2023.
- American Society for Reproductive Medicine (ASRM). Endometriosis and infertility: a committee opinion. Fertility and Sterility, 2022.
- Johnson N.P., Hummelshoj L. Consensus on current management of endometriosis. Human Reproduction, 2013.
- Vercellini P., Vigano P., Somigliana E., Fedele L. Endometriosis: pathogenesis and treatment. Nature Reviews Endocrinology, 2014.
- World Health Organization (WHO). Endometriosis – Fact Sheet and Clinical Overview. Updated 2023.
