Endometriosis at Fitzwilliam Hospital in Peterborough

Endometriosis is a long-term condition where tissue similar to the lining of your womb grows outside your uterus, most commonly on your ovaries, fallopian tubes and pelvic lining. 

These changes can lead to a range of endometriosis symptoms, including significant pelvic pain, heavy periods, fatigue and, for some, difficulties getting pregnant. 

Because it is a chronic condition, many people need ongoing management to keep symptoms under control but with the right endometriosis treatment, the condition can be effectively managed, helping improve comfort, fertility and overall quality of life.

What is endometriosis

Endometriosis is a gynaecology condition where cells that behave like the lining of your womb (the endometrium) begin to grow in places outside your uterus. These cells respond to monthly hormones in the same way as your womb lining as they thicken, break down and bleed during each menstrual cycle.

Inside your uterus, this process leaves your body as a period. But when it happens elsewhere, the blood and tissue become trapped, leading to inflammation, swelling, scarring and adhesions. Over time, this can cause persistent pelvic pain, painful periods, discomfort during sex, bowel or bladder symptoms, and sometimes difficulties getting pregnant.

It’s important to note that this is not the same tissue as the endometrium, but endometrial-like tissue. It behaves similarly, but because it sits outside your womb, it cannot leave your body in the usual way which is why it causes problems.

Where endometriosis can occur

Endometriosis is most often found in your pelvis, but it can develop in many different areas.

Common locations

• Ovaries

• Fallopian tubes

• Peritoneum (the lining of the pelvis)

• Pouch of Douglas (the space behind the uterus)

• Uterosacral ligaments

• Bladder

• Bowel

• Rectum

• Vagina

Rare locations

Although uncommon, endometriosis can also appear in areas outside your pelvis, including the:

• Diaphragm

• Lungs

• Chest wall

• Abdominal wall or previous surgical scars

These rare sites can still respond to monthly hormonal changes and may cause symptoms linked to your menstrual cycle.

Include visual diagram suggestion: Annotated pelvic anatomy showing common endometriosis sites

Book a consultation with a Ramsay gynaecology specialist to begin your diagnosis.

Endometriosis symptoms

Endometriosis affects people in very different ways. Some have extensive endometriosis with very few symptoms, while others have mild disease but severe, debilitating pain. There is no link between how much endometriosis is present and how severe the symptoms feel. This is one of the reasons diagnoses can take time.

Symptoms can also overlap with other conditions, such as irritable bowel syndrome (IBS) or bladder problems, which can make it harder to recognise.

Common symptoms of endometriosis

There are up to 20 symptoms of endometriosis that are commonly suffered by women with endometriosis. These common symptoms include:

Pain symptoms

Pain is the most common feature of endometriosis and may include:

• Severe period pain (dysmenorrhoea) that may be debilitating

• Chronic pelvic pain, either constant or cyclical

• Pain during or after sex (deep dyspareunia)

• Painful bowel movements or urination, especially during periods

• Lower back or abdominal pain

Menstrual symptoms

Endometriosis can affect your menstrual cycle, causing:

• Heavy periods (menorrhagia)

• Periods lasting longer than seven days

• Irregular bleeding

• Spotting between periods

Fertility-related symptoms

• Difficulty getting pregnant / infertility

• Painful ovulation (mittelschmerz)

Gastrointestinal symptoms

These often worsen around menstruation:

• Bloating and abdominal distension

• Diarrhoea or constipation, especially during periods

• Painful bowel movements

• Blood in the stool (in bowel endometriosis)

• Nausea

Urinary symptoms

• Painful urination (dysuria)

• Frequent urination

• Blood in the urine (in bladder endometriosis)

Systemic symptoms

Endometriosis can affect your overall wellbeing, leading to:

• Chronic fatigue and exhaustion

• Low mood, depression or anxiety

Additional symptoms

In rare cases where endometriosis grows outside your pelvis:

• Chest or shoulder pain (diaphragmatic endometriosis)

• Shortness of breath or coughing blood (lung involvement)

• Pain in other affected areas

When do endometriosis symptoms start

Endometriosis can begin at any age after your periods start.

• Symptoms may appear from the first period (menarche)

• Most people are diagnosed in their 20s or 30s

• Diagnosis is often delayed, on average 7 to 10 years from first symptoms

• Symptoms may worsen over time without treatment

• Many people notice improvement after menopause, although this is not guaranteed

Endometriosis stages

Endometriosis is classified into four stages, from minimal to severe. These stages describe how much endometriosis is present, where it is located, and whether adhesions or cysts are involved. 

Importantly, the staging system does not reflect how much pain someone experiences. People with minimal endometriosis may have intense symptoms, while others with extensive endometriosis may have very little pain. Staging helps guide treatment planning rather than predict symptom severity.

Stage 1 - Minimal endometriosis

Stage 1 involves a small amount of endometriosis:

• A few tiny implants or lesions

• Mostly superficial growths

• No significant scarring or adhesions

Even at this early stage, symptoms can still be severe.

Stage 2 - Mild endometriosis

Stage 2 includes:

• A greater number of lesions

• Slightly deeper implants

• Minimal adhesions

Symptoms may be like Stage 1 or more noticeable, depending on where the lesions are located.

Stage 3 - Moderate endometriosis 

Stage 3 is characterised by:

• Numerous deep implants

• Small ovarian cysts called endometriomas (sometimes known as “chocolate cysts”)

• Adhesions, often thin or “filmy,” around the ovaries or fallopian tubes

These changes can begin to affect the movement of pelvic organs.

Stage 4 - Severe endometriosis 

Stage 4 endometriosis is the most extensive form and may include:

• Widespread deep implants

• Large endometriomas on one or both ovaries

• Dense adhesions binding organs together

• Involvement of multiple pelvic organs

• Bowel or bladder endometriosis, which is more common at this stage

Severe endometriosis can cause significant structural changes within the pelvis.

What causes endometriosis?

The exact cause of endometriosis is still not fully understood, but several theories help explain how endometrial-like tissue may begin growing outside the uterus. It’s likely that more than one mechanism is involved, and different causes may apply to different people.

Retrograde menstruation

One of the most widely discussed theories is that menstrual blood flows backwards through your fallopian tubes into your pelvic cavity instead of leaving your body. This blood contains endometrial cells, which can attach to pelvic surfaces and continue to grow, thicken and bleed with each menstrual cycle.

Embryonic cell changes

During puberty, hormones such as oestrogen may stimulate certain embryonic cells to transform into endometrial-like cell growths. These cells can then behave like the lining of your womb, even though they sit outside it.

Transformed peritoneal cells

Cells that line your abdomen (the peritoneum) may change into endometrial-like cells under the influence of hormones or immune system factors. This process is sometimes referred to as “coelomic metaplasia.”

Surgical scar complication

Endometrial cells can occasionally attach to scar tissue after abdominal surgery, such as a caesarean section. These cells may then grow and respond to monthly hormonal changes.

Immune system conditions

Some people may have an immune system that does not recognise or destroy endometrial-like tissue growing outside the uterus. This may allow the tissue to implant and persist.

Endometrial cell transport

Endometrial-like cells may travel to other parts of your body through blood vessels or the lymphatic system. This could help explain rare cases of endometriosis found in the lungs, diaphragm or chest wall.

Risk factors for endometriosis 

Anyone who menstruates can develop endometriosis, but certain factors may increase the likelihood:

• Family history, especially in a mother, sister or daughter

• Never having children

• Starting periods at a young age

• Short menstrual cycles (less than 27 days)

• Heavy or prolonged periods (lasting more than seven days)

• Low body mass index (BMI)

• Structural differences in the uterus

• Immune system disorders

Having one or more risk factors does not mean someone will develop endometriosis, but it may increase the chance.

How is endometriosis diagnosed?

Endometriosis can be challenging to diagnose. Symptoms often overlap with conditions such as IBS or pelvic inflammatory disease, and many people experience delays of 7 to 10 years before receiving a confirmed diagnosis. A specialist assessment is usually needed to piece together symptoms, examination findings and imaging results.

Initial assessment 

Medical history:

Your specialist will begin by exploring your symptoms in detail, including:

• How your pain feels and when it occurs

• Your menstrual history

• Any family history of endometriosis

• How symptoms affect daily life, work, relationships and sexual wellbeing

• Any concerns about fertility

Physical examination:

A pelvic examination may help identify signs of endometriosis, such as:

• Tender nodules behind the uterus

• Pain during examination

• Enlarged ovaries

• Areas of pelvic or abdominal tenderness

This assessment helps guide which tests are needed next.

Diagnostic tests for endometriosis

Imaging:

• Transvaginal ultrasound: 

• Is usually the first imaging test

• Can identify ovarian endometriomas (“chocolate cysts”)

• Is less effective at detecting superficial or peritoneal disease

• MRI scan: 

• Is helpful for diagnosing deep infiltrating endometriosis

• Can show involvement of the bowel, bladder or ligaments

• Is useful for planning surgery if needed

Blood tests:

Blood tests are not diagnostic but may support the assessment.

• CA-125 can be raised in endometriosis, but also in many other conditions

• Tests may be used to rule out other causes of symptoms and assess general health

Laparoscopy (gold standard):

A laparoscopy is the only way to confirm endometriosis with certainty. It is:

• Performed under general anaesthetic using keyhole surgery

• Allows direct visualisation of the pelvis

• Biopsies can be taken to confirm the diagnosis

• Endometriosis can often be treated at the same time (excision or ablation)

• Enables accurate staging of the disease

Because it is a surgical procedure, laparoscopy is usually recommended when symptoms are significant, imaging suggests endometriosis, or fertility is affected.

Endometriosis treatment

Endometriosis is a long-term condition, and while there is no cure, many treatments can help manage your symptoms and improve your quality of life. Treatment is always individualised, considering your symptoms, age, fertility goals and how endometriosis affects your daily life.

The main aims of endometriosis treatment are to:

• Manage your pain

• Improve your day-to-day wellbeing

• Preserve or improve your fertility

• Reduce inflammation and prevent progression

Your specialist will work with you to find the approach that best suits your needs.

Medical treatment for endometriosis

Pain relief and hormonal treatments

Many people start with medical treatment to help control symptoms and regulate the menstrual cycle.

Combined oral contraceptive pill

Often used as a first-line option, the pill can:

• Regulate or lighten periods

• Reduce pain

• Suppress endometriosis activity

• Be taken cyclically or continuously to stop periods altogether

Progestogen-only options

These treatments thin the lining of your womb and can be particularly effective for endometriosis. They include:

• Progestogen-only pill

• Contraceptive injection (Depo-Provera)

• Contraceptive implant (Nexplanon)

• Mirena intrauterine system (IUS)

Progestogen-only options help reduce bleeding and pain and may slow the growth of endometrial-like tissue.

GnRH agonists and antagonists

These medications create a temporary, reversible “medical menopause” by switching off ovarian hormone production. They are:

• Very effective for symptom control

• Usually prescribed for short-term use (around 6 months)

• Often combined with “add-back” HRT to protect bone health and reduce side effects

Examples include Zoladex and Prostap.

Common side effects may include hot flushes and reduced bone density, which is why careful monitoring is important.

Surgical treatments for endometriosis

Surgery may be recommended when:

• Medical treatment hasn’t helped

• Pain is severe or affecting your quality of life

• Endometriomas (ovarian cysts) are present

• Deep infiltrating endometriosis is suspected

• Your fertility is affected

• Your bowel or bladder may be involved

Laparoscopic excision surgery

This is the gold standard surgical treatment for endometriosis. It involves:

• Keyhole surgery through 3 or 4 small incisions

• Removing (excision) or destroying (ablation) endometriosis lesions

• Removing endometriomas

• Releasing adhesions

Recovery is usually quicker than with open surgery, and many people experience significant symptom relief.

Deep excision surgery

For deep infiltrating endometriosis, more complex surgery may be needed. This may involve:

• A multidisciplinary team (e.g., colorectal or urology specialists)

• Longer operating times

• Removal of affected areas of bowel or bladder if necessary

Deep excision surgery often provides high rates of symptom improvement.

Hysterectomy

A hysterectomy is considered a last-resort option and usually only when:

• Other treatments have not helped

• Symptoms are severe

• Your family is complete

It may include removal of your ovaries (oophorectomy). A hysterectomy is not a cure for endometriosis, but it can be helpful for people who also have adenomyosis. It requires careful discussion with your specialist.

Nerve surgery

Procedures such as presacral neurectomy or LUNA (laparoscopic uterine nerve ablation) are now rarely performed due to limited evidence of benefit.

Fertility treatment for endometriosis 

Endometriosis is a leading cause of infertility. It can affect your fertility by:

• Distorting your pelvic anatomy

• Reducing your egg quality

• Blocking your fallopian tubes

• Lowering your ovarian reserve, especially when endometriomas are present

• Increasing inflammation in your pelvis

Fertility treatment options

Depending on your situation, your specialist may recommend:

• Surgery to remove endometriosis or adhesions

• Ovulation induction

• IUI (intrauterine insemination)

• IVF, which is often the most effective option

• Fertility preservation (egg freezing), especially if extensive surgery is planned

Lifestyle management for endometriosis

Lifestyle changes can complement medical or surgical treatment and help improve your overall wellbeing. They include:

• Diet - some people find an anti-inflammatory diet helpful

• Exercise - regular, gentle movement can reduce your pain and improve your mood

• Pain management - TENS machines, heat therapy and acupuncture may offer relief

• Psychological support - endometriosis can significantly affect your mental health, and counselling or support groups can be valuable

Adenomyosis vs Endometriosis

Although adenomyosis and endometriosis are different conditions, they can occur together. Around 20% of people with endometriosis also have adenomyosis. Both are influenced by similar hormones, but they affect the body in different ways and often need different treatment approaches.

Living with Endometriosis

Endometriosis is a long-term condition, and managing it often means finding the right balance of medical treatment, lifestyle strategies and emotional support. Many people live full, active lives with endometriosis, but it can take time to understand what works best for you.

Managing chronic endometriosis

Living with ongoing symptoms can be challenging, but a combination of approaches can help improve day-to-day comfort and wellbeing.

• Pain management strategies - may include medication, heat therapy, physiotherapy, or complementary therapies such as acupuncture. Read more information on pelvic pain management.

• Pacing and energy conservation - learning to balance activity and rest can help reduce flare-ups and fatigue.

• Flare-up management - identifying triggers and having a plan for difficult days can make symptoms more manageable.

• Working with pain specialists - some people benefit from input from a multidisciplinary pain team.

• Medication management - regular reviews ensure your treatment remains effective and tailored to your needs.

Impact on daily life

Endometriosis can affect many areas of your life, not just your physical health and include:

• Work and career - pain, fatigue and medical appointments may require adjustments or flexible working.

• Relationships and intimacy - pain during sex and emotional strain can affect relationships, and open communication can be helpful.

• Social life and activities - fluctuating symptoms may make plans harder to manage.

• Mental health - anxiety, low mood and frustration are common. Support from counsellors, psychologists or support groups can make a real difference.

• Support networks - friends, family and peer communities can provide understanding and practical help.

Endometriosis and pregnancy

Many people with endometriosis can conceive naturally.

• Most can become pregnant, though it may take longer.

• Symptoms often improve during pregnancy due to hormonal changes.

• Endometriosis can return after pregnancy, especially once periods resume.

If you are planning a pregnancy, your specialist can discuss treatment options to support fertility and optimise your chances of conceiving.

Endometriosis after menopause

Symptoms usually lessen after menopause as hormone levels fall, but experiences vary.

• Most people notice significant improvement. However, a small number of people continue to have symptoms after menopause.

• HRT may reactivate symptoms, so treatment choices should be discussed with a specialist.

It is rare for endometriosis to develop for the first time after menopause.

Endometriosis treatment at Ramsay Health Care

At Ramsay Health Care, endometriosis care is delivered by experienced gynaecologists who specialise in diagnosing and treating this complex condition. Our teams offer individualised treatment plans, advanced laparoscopic surgery, and access to multidisciplinary support that are all designed to reduce pain, protect fertility and improve long-term wellbeing.

Patients choose Ramsay for our short waiting times, continuity of care, and compassionate, consultant-led approach. Whether you need medical management, specialist imaging, fertility support or complex excision surgery, you’ll be guided by experts who understand the impact endometriosis can have on every part of life.

Book a consultation with our endometriosis specialists to discuss your treatment options.

Endometriosis FAQs