Endometriosis: Symptoms, Diagnosis, and Treatment — What Your Doctor Wants You to Know

Written by Dr. Kathryn Kline, MD, Board-Certified Family Medicine Physician | Medically reviewed by Dr. Casey Dean, DO | Trinity Family Medicine

Last medically reviewed: October 2026

About the author: Dr. Kathryn Kline is a board-certified family medicine physician (ABFM) who treats women's hormonal and reproductive health concerns, chronic pelvic pain, and menstrual disorders for patients across Texas through primary care and telehealth.

Endometriosis affects roughly 1 in 10 women of reproductive age — an estimated 190 million worldwide, according to the World Health Organization — yet it still takes an average of about 7 years to be diagnosed. If your periods have always been "just bad," if pain keeps you home from work or school, or if you've been told the discomfort is normal, this is the article worth reading. Endometriosis is a real, treatable medical condition, and in 2026 you no longer need surgery just to begin treatment. This guide explains what endometriosis (sometimes shortened to "endo") actually is, how doctors recognize it, and what modern treatment looks like — including a major shift in how the condition is diagnosed.

Quick Summary: Key Facts at a Glance

Emergency warning: Seek emergency care for sudden, severe pelvic pain — especially one-sided pain — with fainting, heavy bleeding, fever, or vomiting. These symptoms can have causes unrelated to endometriosis, such as ovarian torsion or a ruptured ovarian cyst; call 911 or go to the nearest emergency room.

What Is Endometriosis?

Endometriosis is a chronic condition in which tissue similar to the lining of the uterus grows outside the uterus — most often on the ovaries, fallopian tubes, and the tissue lining the pelvis. Each month this tissue responds to hormones the way the uterine lining does: it thickens, breaks down, and bleeds. But because it has no way to leave the body, it triggers inflammation, scarring, and the formation of adhesions (bands of scar tissue that can bind organs together).

The World Health Organization classifies endometriosis as a chronic inflammatory disease with no current cure, where the goal of treatment is to control symptoms and limit long-term impact. It is not an infection, it is not contagious, and it is not caused by anything you did.

What this means in plain English: endometriosis is a chronic inflammatory disease, not simply "bad cramps" — and pain that disrupts daily life deserves evaluation.

What Are the Symptoms of Endometriosis?

The hallmark symptoms of endometriosis are painful periods and chronic pelvic pain, but the condition can show up in several ways. According to Mayo Clinic and the WHO, common symptoms include:

One of the most important and under-appreciated facts: the severity of pain does not reliably indicate how advanced the disease is. You can have minimal visible disease with disabling pain, or extensive disease with few symptoms. This is why endometriosis is staged surgically by how much tissue is present — not by how much it hurts.

A single symptom is a clue, not a diagnosis. Painful periods alone do not confirm endometriosis, and other conditions — including uterine fibroids, adenomyosis (when uterine-lining tissue grows into the muscular wall of the uterus), ovarian cysts, pelvic inflammatory disease, irritable bowel syndrome and its gut-brain pain, and interstitial cystitis (a painful bladder condition) — can cause overlapping symptoms. That is what a clinical evaluation is designed to sort out.

What Causes Endometriosis, and Who Is at Risk?

The exact cause of endometriosis is not fully established, and no single theory explains every case. Researchers believe several mechanisms contribute, including "retrograde menstruation" (menstrual blood flowing backward through the fallopian tubes into the pelvis), hormonal and immune factors, inflammation, and genetics. Estrogen is thought to fuel the growth of endometriosis tissue, which is why most treatments work by lowering or blocking estrogen's effect.

Factors associated with a higher risk include starting periods at an early age, short menstrual cycles, heavy or long periods, never having given birth, and — importantly — having a mother or sister with endometriosis. Having risk factors does not mean you will develop it, and many women with endometriosis have none of them.

How Is Endometriosis Diagnosed?

Endometriosis is now diagnosed primarily from your symptoms and a physical exam, with imaging added when needed — and as of 2026, treatment can begin on that basis without first requiring surgery. Doctors call this a presumptive (clinical) diagnosis — a working diagnosis made without surgical proof. This is a major change in how the condition is evaluated and treated.

In early 2026, the American College of Obstetricians and Gynecologists (ACOG) published its first-ever Clinical Practice Guideline on the subject — Diagnosis of Endometriosis, Clinical Practice Guideline No. 11, in the March 2026 issue of Obstetrics & Gynecology. According to that guideline, ACOG strongly recommends that a presumptive (clinical) diagnosis made through a symptom history, a physical examination, or both is enough to begin empiric treatment while evaluation continues. For imaging, ACOG recommends transvaginal ultrasound (a scan using a wand placed in the vagina) as the usual first test, with transabdominal ultrasound (a scan over the lower belly) as an alternative when the transvaginal scan is not appropriate, and pelvic MRI when deeper disease needs a closer look. The guideline recommends against using blood tests (biomarkers) to make a likely diagnosis.

Historically, a definitive diagnosis required diagnostic laparoscopy — a surgery in which a camera is inserted through a small incision to look for and biopsy the tissue — and that requirement contributed heavily to the long diagnostic delay. Surgery with a tissue biopsy remains the only way to confirm endometriosis under the microscope and is still appropriate in many situations, but it is no longer required before starting treatment.

What this means in plain English: symptoms and an exam can support a presumptive diagnosis and start treatment, without waiting for surgery to "prove" something is wrong. This change is designed specifically to shorten the years-long delay so many women experience.

Dr. Kline's clinical perspective: The most useful shift in 2026 is that a patient no longer has to wait for surgery before treatment can be discussed when symptoms strongly suggest endometriosis — which means a conversation that too often took years can start now.

Do You Need Surgery to Diagnose Endometriosis?

No — surgery is not required before treatment can begin. Many women can be started on treatment based on a clinical assessment alone, with ultrasound used as the first imaging step when appropriate. A normal ultrasound does not rule out endometriosis, because the most common superficial disease often cannot be seen on imaging. Surgery is reserved for cases where the diagnosis is uncertain, where tissue confirmation would change the plan, where deep or ovarian disease is suspected, or when medical treatment has not controlled symptoms.

How Is Endometriosis Treated?

Endometriosis treatment aims to control pain, slow the disease, and protect fertility — not to cure it — and it is usually a stepwise plan that starts with the least invasive options. Treatment is individualized based on your symptoms, your age, and whether you are trying to conceive.

Each class has trade-offs. NSAIDs can irritate the stomach and affect the kidneys with heavy use. Hormonal contraceptives can cause breakthrough bleeding or mood changes, and estrogen-containing methods carry a small increased risk of blood clots. GnRH medicines work by lowering estrogen, so they can cause menopause-like effects such as hot flashes and loss of bone strength. That is why they are often combined with low-dose add-back hormones and used for a limited time. A clinician should review these trade-offs with you before you start any medication.

Which Medications Are FDA-Approved for Endometriosis Pain?

Two oral GnRH antagonist options carry specific FDA approvals for endometriosis-associated pain. Elagolix (Orilissa) was approved by the FDA in July 2018 for the management of moderate-to-severe pain associated with endometriosis. Relugolix combination therapy (Myfembree — relugolix, estradiol, and norethindrone acetate) was approved by the FDA in August 2022 for the management of moderate-to-severe endometriosis pain in premenopausal women for up to 24 months. In the phase 3 SPIRIT trials, 75% of women taking the relugolix combination achieved a clinically meaningful reduction in menstrual pain at 24 weeks, compared with 27–30% on a placebo (an inactive pill). Average loss of bone strength was less than 1% over one year.

FDA approval describes what a drug is cleared to treat; which option fits you is a clinical decision your prescriber makes with you based on your symptoms, other health conditions, and goals.

Endometriosis and Fertility: What's the Connection?

Endometriosis is a leading cause of infertility, though many women with it still conceive. According to the American Society for Reproductive Medicine, endometriosis is found in roughly 24% to 50% of women evaluated for infertility, though estimates vary by population and study. If you are trying to get pregnant, hormonal suppression is generally paused, and care usually shifts toward a gynecologist or fertility specialist, since surgery or assisted reproductive technology such as IVF may be considered. If fertility is a current goal, raise it early so your treatment plan can be built around it rather than against it.

Can You Treat Endometriosis During Pregnancy?

Mostly no — the standard medications are not used in pregnancy. Hormonal contraceptives and GnRH agonists and antagonists are designed to prevent or suppress ovulation and are not used while pregnant. NSAIDs are generally avoided in pregnancy, particularly in the third trimester, because of risks to the fetus. If you are pregnant or trying to conceive, pain management is handled differently and should always be guided by your clinician; confirm any medication with your doctor, and see ACOG's patient guidance for what is considered acceptable.

Do Diet and Lifestyle Changes Help?

They may ease symptoms for some women, but they are not a substitute for medical treatment. Regular exercise, an anti-inflammatory eating pattern, and stress reduction are reasonable to try and are generally good for overall health, but the evidence that any specific diet treats endometriosis itself remains limited. Think of lifestyle steps as support alongside — not instead of — proven therapy.

When Should You See a Doctor?

See a clinician if period pain limits your daily activities, if you have pain during sex, or pain with bowel movements or urination, or if you are having trouble getting pregnant. This is especially true if any of these problems run in your family. A clinician's job is first to identify what is causing your pain, rule out other conditions such as fibroids, ovarian cysts, or pelvic infection, and then discuss a treatment plan with you. The years so many women spend being told their pain is normal are exactly what the 2026 guideline change is meant to shorten.

A telehealth clinician can assess whether your symptoms are consistent with endometriosis, start first-line treatment such as NSAIDs and hormonal therapy when appropriate, and coordinate ultrasound imaging or a gynecology referral when it is needed. You can begin all of this without an in-person visit. Trinity Family Medicine offers direct-pay telehealth visits across Texas starting at $49.99, with the same physician at each visit, and you can book online or call 817-932-4022. Some situations — deep disease, suspected ovarian involvement, or a search for a surgical diagnosis — still need in-person gynecologic or surgical care, and emergency symptoms always need emergency care.

If a hormonal condition such as PCOS is also on your mind, or if the low mood and exhaustion that often accompany chronic pain are weighing on you, those are treatable too — our guide to recognizing and treating depression explains when that warrants care.

Frequently Asked Questions About Endometriosis

The Bottom Line

Endometriosis is a common, chronic, and frequently overlooked condition — but it is also treatable, and the path to help is shorter than it used to be. If your periods or pelvic pain are interfering with your life, you do not need to wait years or undergo surgery just to be taken seriously. A clinical evaluation can start today, first-line treatment can often begin through a telehealth visit, and the goal of care is to meaningfully reduce your pain and protect your long-term health.

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