Endometriosis & Pelvic Pain: Specialist Assessment and Management

The average time from first symptoms to a confirmed diagnosis of endometriosis is still around eight years. That figure is not a footnote — it represents years of dismissed pain, misattributed symptoms, and women being told that severe periods are simply something to put up with. In my practice, I am committed to a different approach: to listening carefully, investigating thoroughly, and ensuring that no woman leaves my clinic feeling that her pain has been minimised or ignored. Pelvic pain is real, it has causes, and it deserves investigation.

What Is Endometriosis?

Endometriosis is a chronic inflammatory condition in which tissue similar to the lining of the uterus (the endometrium) grows outside the uterus. It is most commonly found on the ovaries, the fallopian tubes, the peritoneum (the lining of the pelvis), and the bowel or bladder. In severe cases, it can affect the ureters, the diaphragm, and other structures outside the pelvis.

Like the uterine lining, these deposits respond to the monthly hormonal cycle: they bleed each month, but with nowhere for that blood to go. Over time, this causes inflammation, scarring, the formation of adhesions (bands of fibrous tissue that stick organs together), and, in the ovaries, the development of endometrioma cysts — sometimes called "chocolate cysts" due to the appearance of the old blood within them.

Endometriosis affects approximately one in ten women of reproductive age — roughly 1.5 million women in the UK alone. It is not a rare condition; it is a commonly underdiagnosed one.

Symptoms That Should Not Be Dismissed

Endometriosis does not always present in predictable ways, and symptom severity does not always correlate with the extent of disease. A woman with mild endometriosis may be in considerable pain, while another with extensive disease may have few symptoms. This variability contributes to delayed diagnosis. The symptoms I assess include:

• Severe, debilitating period pain (dysmenorrhoea) — pain that interferes with work, school, or daily life and is not adequately controlled by over-the-counter analgesia
• Deep pelvic pain — chronic pain in the pelvis, lower abdomen, or lower back, occurring outside of menstruation
• Deep dyspareunia — pain during or after sexual intercourse, particularly with deep penetration, which commonly indicates involvement of the pouch of Douglas or uterosacral ligaments
• Dyschezia — pain with bowel movements, particularly during menstruation, suggesting posterior compartment disease
• Bladder symptoms — pain when passing urine, urinary frequency, or haematuria (blood in urine) around the time of menstruation
• Fatigue — a pervasive, often overlooked feature of endometriosis, driven by chronic inflammation and pain
• Heavy or irregular periods — often coexisting with or worsened by associated adenomyosis
• Difficulty conceiving — endometriosis is found in up to 50% of women investigated for infertility

I want to be clear about something that many of my patients have never been told: pain with periods is not normal. It is common, but common and normal are not the same thing. If your periods have ever caused you to miss work, take strong painkillers, or limit your activities, that warrants investigation.

Adenomyosis: Endometriosis's Overlooked Sibling

Adenomyosis is a related but distinct condition in which endometrial glands and stroma invade the muscular wall of the uterus (the myometrium). The result is a uterus that is often enlarged, tender, and prone to heavy, painful periods. For many years, adenomyosis was only diagnosable via hysterectomy specimen. Today, high-quality MRI and, in experienced hands, transvaginal ultrasound have made it possible to diagnose adenomyosis non-invasively.

Adenomyosis and endometriosis frequently coexist, and each can exacerbate the symptoms of the other. In my practice, I assess for both conditions as a matter of course when investigating pelvic pain or heavy periods, because treating one while missing the other can lead to persistently poor outcomes.

How I Diagnose Endometriosis

Diagnosis begins with a thorough clinical history. I take time to map out the exact character, timing, location, and severity of your pain, and to understand how it affects your daily life. A careful pelvic examination can reveal tenderness, nodularity on the uterosacral ligaments, a fixed retroverted uterus, or adnexal masses — all of which raise clinical suspicion.

Pelvic ultrasound (ideally transvaginal) is the first-line imaging investigation and can identify endometriomas with reasonable sensitivity. However, standard ultrasound has significant limitations for detecting peritoneal disease, superficial deposits, and deep infiltrating endometriosis.

MRI of the pelvis is the imaging modality of choice for deep infiltrating endometriosis (DIE) — disease involving the bowel, bladder, ureters, or other deep pelvic structures. It provides detailed anatomical mapping that is essential for surgical planning.

Diagnostic laparoscopy with histological confirmation remains the gold standard for definitive diagnosis. I discuss the role of laparoscopy with each patient individually, taking into account her symptoms, imaging findings, and clinical goals. Not every woman needs immediate surgical diagnosis, particularly if she is asymptomatic and imaging is reassuring — but where symptoms are significant and medical treatments have not provided adequate relief, laparoscopy is often the appropriate next step.

Management Options

Management of endometriosis is highly individualised and takes into account symptom burden, desire for fertility, extent of disease, and the patient's own preferences. There is no single correct approach.

Medical management aims to suppress ovarian cycling and reduce oestrogen-driven stimulation of endometriotic deposits. Options include:

• The combined oral contraceptive pill — particularly taken continuously to reduce the number of bleed episodes
• Progestogens — norethisterone, desogestrel, or the Mirena intrauterine system (IUS), which delivers localised progestogen and can dramatically reduce menstrual pain and bleeding
• GnRH analogues — medications that induce a temporary, reversible menopausal state, used for more severe disease and typically in combination with add-back hormonal therapy to protect bone density

Surgical management aims to remove or destroy endometriotic tissue. The preferred technique is excision (cutting the disease out) rather than ablation (burning it), as excision is associated with lower recurrence rates and allows histological confirmation. I have strong connections with specialist endometriosis surgeons and can refer appropriately when surgery is required.

Complementary and supportive approaches play an important role alongside medical and surgical treatment. An anti-inflammatory diet, reduction of dietary triggers, targeted supplementation (omega-3 fatty acids, magnesium), specialist pelvic physiotherapy to address myofascial pain and pelvic floor dysfunction, and psychological support for chronic pain are all aspects I discuss with my patients. Managing endometriosis well is a whole-person endeavour.

What to Expect at Your Consultation

Your first appointment with me will focus on listening. I want to understand your full history — when your symptoms began, how they have evolved, what has been tried, what investigations you have already had, and what matters most to you in terms of outcomes. I will perform a clinical examination where appropriate, and we will discuss a diagnostic and management plan together. If imaging is needed, I can arrange this promptly and review the results with you directly, in clinical context.

I approach endometriosis as a long-term condition requiring a long-term partnership. Appointments are not rushed, and you will leave with a clear explanation of what I believe is happening and a realistic roadmap for what comes next.

When to Seek Specialist Input

1. Your period pain is severe enough to limit your daily activities, work, or school
2. You experience pelvic pain at times other than your period
3. Sex is painful, particularly with deep penetration
4. You have pain when opening your bowels or passing urine, especially around your period
5. You have been trying to conceive for six months or more without success
6. You have been previously diagnosed with endometriosis but feel your symptoms are not well controlled
7. Imaging or previous surgery has suggested endometriosis but you have not had specialist follow-up
8. You have been told "everything looks normal" but the pain persists

Please do not wait years before seeking help — and please do not accept pain as an inevitable feature of being a woman. You deserve answers, and you deserve effective treatment. I am here to provide both.