How can we define endometriosis?
Endometriosis is a disorder mostly painful in which tissue that is lining the inside of the uterus also called endometrium grows outside of uterus. It usually involves the ovaries, fallopian tubes and the tissue lining the pelvis. Though rarely can also be found in other areas such as the bladder, bowel and other pelvic organs. It can affect women of any age, mainly between the reproductive ages of 15 and 49 according to NICE guidelines.
With each menstrual cycle, the endometrial tissue thickens, breaks down and bleeds (menstruation). Due to this tissue has no way of exiting the body it becomes trapped thus causing severe pain during menstrual periods and bleeding inside the pelvis.
Endometrial cysts can be caused if the ovaries are involved which are called endometriomas and can also be seen by an ultrasound. If the surrounding tissue in the pelvis is involved then scar tissue and adhesions can cause the formation of fibrous tissue and organs to be stuck together, also staging the severity of endometriosis from superficial to deep infiltrating.   
What are the symptoms?
One of the main symptoms which is associated with endometriosis is pain during menstrual periods as mentioned before. Pain can be experienced differently between patients and can be an indicator of the extend and spread of the disorder. Furthermore, endometriosis can be misdiagnosed due to symptoms that are mistaken or even confused with disorders like irritable bowel disease (IBS) or pelvic inflammatory disease (PID).  
The most common can be:
- Dysmenorrhea – Cramp like pain before and during menstrual period. Can radiate to the back or even experienced as abdominal pain.
- Dyspareunia – Pain during sexual intercourse.
- Metrorrhagia – Excessive heavy menstrual periods or between periods.
- Infertility – Often endometriosis is missed and diagnosed in patients seeking treatment.
- Other signs – Diarrhea, constipation, bloating or nausea can be experienced during menstrual cycle.
What causes endometriosis?
The mechanism is not certain, though different explanations have been discussed:
- Retrograde menstruation. Blood during menstruation flows back through the fallopian tubes inside the pelvic cavity following the endometrial cells attaching to the wall and to the surrounding organs causing more pain during menstrual periods over the time.
- Surgical scar transformation – During gynecological surgeries the endometrial cells can attach to surgical incisions causing pain on the area related (cesarian section, hysterectomy, removal of salpinx or ovary or even both)
- Endometrial cell transport – Transported via blood vessels or lymphatic system throughout the body.
- Embryonic cell transport – Hormones may transform embryonic cells into endometrial like cell implants.
- Immune system disorder – Endometrial tissue outside the endometrium which cannot be recognized and fought by the immune system.
- Transformation of peritoneal cells – Also known as ‘induction theory’ meaning due to hormones embryonic cells are being transformed into endometrial like cell implants.
- Early age menstruation
- Early menopause
- Short and heavy menstrual periods
- Higher levels of estrogen
- Low body mass index
- First-degree relatives with endometriosis
- Infertility: Impaired fertility. A majority of women with endometriosis have difficulty in getting pregnant therefore patients that seek medical help are being diagnosed after a medical examination. Due to different stage of endometriosis which can worsen over time it may affect and obstruct the fallopian tube or even damage the sperm or egg.
- Cancer: Higher than expected rates of ovarian cancer in patients with endometriosis. Still the risk is relatively low.
Diagnosing endometriosis can be challenging. A thorough background and a physical examination is needed.
- Pelvic examination for manual palpation in identifying any abnormalities like cysts on your ovaries. Unfortunately, small areas of endometriosis cannot be field.
- Ultrasound transvaginal or transabdominally for a better view of the reproductive organs. An ultrasound cannot be definite but it can identify cysts associated with endometriosis called endometriomas.
- Magnetic resonance imaging (MRI): MRI can used for surgical planning in giving detailed information and size of endometrial lesions.
- Laparoscopy is used as an identification procedure looking for signs of endometrial implants and biopsy or even coagulation of the lesions can be performed.
- Recent research has shown in 2020 that endometriosis patients have certain chemical modifications to their DNA which in the future may be used to help the diagnosis without the need of surgery 
Treatment of endometriosis mostly involves medication such as pain medication and hormone therapy or surgery. The first appointment is quite vital in understanding the approach and lay a treatment plan depending on the severity of symptoms and signs which might affect the patient’s quality of life.
Firstly, conservative treatment is recommended and then surgery might be advised if the initial treatment is unsuccessful.
- Pain such as paracetamol and anti-inflammatory drugs (NSAIDs) to help with painful menstrual cramps can be used.
- Hormonal contraceptives such as birth control pills, patches, intrauterine devices, contraceptive injections or implants, Gonadotropin-releasing hormone agonists and antagonists are sometimes effective in reducing or even eliminating the pain.
This is not though a permanent solution as the symptoms can easily return when stopping a treatment. Conservative surgery in removing endometriosis implants while preserving the uterus and ovaries may increase the chance of success of being pregnant and may even decrease the pain. Nowadays, laparoscopically a minimally invasive surgical procedure is the most preferable way as most of the cases can be treated this way instead of going through with an abdominal procedure. 
Fertility treatments and regimes can be discussed when having difficulty with getting pregnant. We strongly advice to prepare your questions beforehand so we can help you in the best possible way.
Women suffering with endometriosis can adapt to certain lifestyle changes that has shown to have some effect and might help.
- Eating right as research has shown that a link between diets low in fruits and vegetables and high in red meat encourages the body in producing chemicals called prostaglandins leading to more estrogen production. Meaning more further growth of endometrial tissue. Food high in omega-3 fatty acids can be helpful. Avoid excess consumption of alcohol and coffee which has shown higher risk.
- Exercise can be a great way to improve circulation and help nutrients and oxygen to flow to the system. Women who exercise may have less estrogen levels and lighter periods therefore, helping the symptoms of endometriosis over time and by exercising stress is reduced and the brain releases endorphins, chemicals which can relieve pain.
- Alternative methods such as natural therapies can also be used though unfortunately little research supports the benefit of relieving the symptoms of endometriosis. Such therapies include acupuncture, massage, herbal medicine, counseling. 
Endometriosis diagnosis is usually long and delayed which can affect negatively the quality of life and patient health outcomes. In describing the severity and staging of endometriosis from minimal to severe can be challenging but also crucial for the best possible treatment plan for women seeking council either for infertility reasons or symptoms that lead to endometriosis.