Endometriosis is a gynaecological condition where cells similar to those that line the uterus (the endometrium) grow outside the uterus — often on the ovaries, fallopian tubes, and pelvic ligaments. These cells behave like normal endometrial tissue, thickening and breaking down during each menstrual cycle. However, because this tissue has no way to exit the body, it can cause inflammation, scarring, and pain, especially during menstruation.
It’s estimated that around 1 in 10 women are affected by endometriosis. Among women experiencing fertility challenges, the number can be as high as 40% to 50%. The actual figures may be even higher, as many women remain undiagnosed — often dismissing their symptoms as “normal period pain.”
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Stages of Endometriosis
Endometriosis can vary in severity, and doctors typically classify it into four stages based on the location, amount, depth, and size of the endometrial growths:
- Stage 1: Minimal
A few small lesions or superficial spots of endometrial tissue are found on the ovaries or pelvic lining. Mild inflammation may be present. - Stage 2: Mild
More lesions and shallow implants are found on the ovaries and pelvic surfaces. - Stage 3: Moderate
Multiple lesions and deeper implants appear on the ovaries and pelvic area. Small cysts and adhesions (scar tissue) may also form. - Stage 4: Severe
Extensive deep implants and large cysts develop on the ovaries and surrounding pelvic organs, such as the bladder, ureters, or bowels.
Related Condition: Adenomyosis
In some cases, endometrial tissue grows into the muscular wall of the uterus itself — a condition known as adenomyosis. While related, adenomyosis differs from endometriosis in where the tissue grows and can cause symptoms such as heavy bleeding and painful periods.
What Are the Symptoms of Endometriosis?
One of the most common signs of endometriosis is severe menstrual pain. This happens because the endometrial-like tissue growing outside the uterus also thickens and bleeds during menstruation. However, unlike normal menstrual tissue, it has no way to exit the body — causing inflammation, irritation, and pain.
While mild discomfort during periods can be normal, pain that interferes with your daily life is not. If you find yourself missing work, avoiding social activities, or relying heavily on pain medication just to get through your cycle, it’s important to speak with a doctor.
Other common symptoms include:
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Heavy or prolonged menstrual bleeding
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Cold sweats, nausea, or feeling faint during periods
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A frequent urge to pass motion, especially during menstruation
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Painful urination, particularly during your period
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Pain during or after sexual intercourse
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Lower back or pelvic pain
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Bloating or abdominal swelling
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Persistent fatigue
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Difficulty conceiving (infertility)
What Causes Endometriosis?
The exact cause of endometriosis remains unclear, but several theories have been proposed. The most widely accepted explanation is retrograde menstruation — a condition where menstrual blood flows backward through the fallopian tubes into the pelvic cavity instead of leaving the body. This backflow carries endometrial cells to other organs such as the ovaries, rectum, and pelvic ligaments, where they may attach, grow, and cause inflammation.
However, not all women with retrograde menstruation develop endometriosis, suggesting that other factors — such as genetics, immune system dysfunction, or hormonal influences — may also play a role.
When endometrial tissue grows deep into surrounding structures, it can affect nearby nerves, leading to severe pelvic or back pain, or even shooting pain down the legs. In more advanced cases, endometrial growths can constrict the ureters (the tubes that carry urine from the kidneys to the bladder), potentially obstructing urine flow and, if left untreated, leading to kidney complications.
Am I at Risk of Developing Endometriosis?
While the exact causes of endometriosis are still unknown, certain factors may increase your likelihood of developing the condition:
- Family history: Genetics can play a role; having a close relative with endometriosis may raise your risk.
- Reproductive history: Delaying childbirth, having fewer pregnancies, or not giving birth at all may contribute.
- Medical conditions: Any condition that interferes with normal menstrual flow can be a factor.
- Lifestyle factors: For example, alcohol consumption may slightly increase risk.
Being aware of these risk factors can help you stay vigilant about your symptoms and seek help early. If you experience symptoms such as severe menstrual pain, painful intercourse, or difficulty conceiving, it’s important to seek help from a gynaecologist, ideally one who specialises in endometriosis. Early diagnosis matters. Identifying endometriosis early can open up more treatment and management options, often non-surgical, before the condition progresses to a stage where surgery becomes necessary.
How Do I Know if I Have Endometriosis?
To determine whether you have endometriosis, a gynaecologist will start with a thorough assessment of your symptoms and family history. This usually includes a pelvic ultrasound, which can detect some endometrial cysts, but a definitive diagnosis often requires a laparoscopic examination. Laparoscopy is a minimally invasive surgical procedure performed under local or general anesthesia. During the procedure, a thin, pencil-like instrument called a laparoscope is inserted through a small incision in the abdomen. This allows the doctor to visualise any endometrial implants in the pelvic or abdominal area and determine the most suitable treatment plan. Sometimes, small biopsies are taken to evaluate the abnormal tissue further.
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Treatment Options
For more advanced or persistent cases, surgical treatment may be recommended. Surgery typically falls into two categories: conservative and definitive.
- Conservative surgery is preferred for women who wish to have children in the future. The goal is to remove as much endometrial tissue as possible while preserving the uterus and ovaries, maintaining fertility.
- Definitive surgery may be considered for women who have completed childbearing, particularly in cases involving adenomyosis. This can include a hysterectomy (removal of the uterus), with or without removal of the ovaries, depending on the severity of endometriosis. Note that after a hysterectomy, pregnancy is no longer possible.
Because surgery can impact ovarian function and requires recovery time, doctors aim to perform the first procedure as thoroughly as possible, minimising the need for repeat surgeries and reducing the risk of endometriosis recurrence.
What Are the Complications of Endometriosis?
If left untreated, endometriosis can progress and affect more pelvic organs, with implants growing deeper into tissues. When capillaries and nerves are involved, pain can become more severe. Endometrial growth on organs, such as the rectum, may lead to rectal pain or painful bowel movements.
Infertility is another common complication. Endometriosis often affects the pelvic ligaments and ovaries, which are close to the fallopian tubes. Inflammation in these areas can cause blockages in the tubes, making it difficult to conceive naturally. In some cases, assisted reproductive technologies like IVF may be required.
There is also a slightly increased risk of endometriosis-related cancers, most commonly ovarian cancer. Women with endometriosis have about 2 to 3 times higher risk compared to the general population. For reference, the lifetime risk of ovarian cancer in the average woman is about 1 in 80.
Key Things to Know About Endometriosis
- Endometriosis is a chronic condition, with symptoms often improving only after menopause.
- You don’t have to suffer in silence. Effective treatment options are available in Singapore to manage pain and other symptoms.
- If pain is affecting your daily life or fertility, it’s important to consult a gynaecologist as early as possible.
- Awareness and early intervention are crucial — they can prevent situations where even surgery may not fully resolve symptoms or infertility.
Book an appointment with Dr Sivahami Sivananthan, Consultant Gynaecologist and Obstetrician from Astra Women’s Specialists based at Core Clinic, today to discuss your options and get expert care.
Featured Contributor:
Astra Women's Specialists
Dr Sivahami
Obstetrician and Gynaecologist
Astra Women's Specialists is part of the Women’s Health arm of Singapore Medical Group (SMG), with a network of Obstetrics & Gynaecology clinics and a Breast Care Centre, helmed by specialists dedicated to women’s health and wellness.
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