Endometriosis

What is endometriosis?

Endometriosis is a chronic, often painful condition in which tissue similar to the lining of the uterus—called the endometrium—grows outside the uterus. While it most commonly affects areas within the pelvic cavity, such as the ovaries, fallopian tubes, and the tissue lining the pelvis, endometrial-like tissue can also be found on the bladder, bowel, or in rare cases, beyond the pelvic organs.

Unlike normal endometrial tissue that sheds during menstruation through the vagina, the tissue outside the uterus has no way to exit the body. This leads to accumulation of old menstrual blood. As the body tries to remove this tissue there is resultant inflammation, irritation, and the formation of scar tissue (adhesions). Over time, this can cause a wide range of symptoms that vary significantly from one individual to another—not just in intensity, but also in type and location.

Endometriosis is not simply a reproductive disorder. While it is widely known for its link to infertility, many individuals with no plans for pregnancy struggle with the often-debilitating effects of the condition. These include chronic pelvic pain, fatigue, painful periods (dysmenorrhea), painful bowel movements or urination (especially during menstruation), lower back pain, bloating, and pain during or after sex. The exact cause of endometriosis remains unknown, though several theories exist, including retrograde menstruation, immune system dysfunction, and genetic predisposition. 

What causes endometriosis? 

The exact cause of endometriosis remains uncertain, but several theories and contributing factors have been proposed. It is likely that the condition results from a combination of genetic, hormonal, immunological, and environmental influences.

• Retrograde menstruation — this is one of the most widely discussed theories. It suggests that during menstruation, some of the menstrual blood flows backward through the fallopian tubes into the pelvic cavity instead of leaving the body. This backflow carries endometrial cells, which can then implant on pelvic organs and tissues. However, retrograde menstruation also occurs in many people without endometriosis, so it does not fully explain the condition.

• Immune system dysfunction — an impaired immune response may allow misplaced endometrial-like cells to survive, implant, and grow outside the uterus. Some research suggests that individuals with endometriosis may have altered immune system activity that fails to recognise and eliminate this misplaced tissue.

• Coelomic metaplasia — this theory proposes that certain cells in the pelvic cavity, originally formed from the same embryonic tissue as the uterus, can transform into endometrial-like cells under specific conditions. This could explain cases of endometriosis in people who do not menstruate or in areas far from the uterus.

• Genetic and hereditary factors — endometriosis tends to run in families. Having a first-degree relative (such as a mother or sister) with the condition increases the risk. Specific genes and genetic variations are currently being studied to better understand their role in disease development.

• Hormonal influences —
  • Estrogen appears to play a key role in the growth and maintenance of endometrial-like tissue and can flare endometriosis . Endometriotic lesions often contain oestrogen receptors which can contribute to local inflammation and pain.
  • Progesterone resistance - Progesterone on the other hand suppresses endometriosis. Endometriosis is primarily attributed to dysregulation of progesterone receptors (PRs). This altered Progesterone receptor activity contributes to various pathological features of endometriosis, including pain, infertility, and inflammation. 

• Environmental factors — some research suggests a possible link between exposure to certain environmental toxins (such as dioxins and PCBs) and an increased risk of developing endometriosis. However, this connection is still being studied and is not yet fully understood.

It is important to note that no single cause applies to every case. Endometriosis likely develops due to a combination of the above factors, which also help explain why symptoms and severity can vary so widely among individuals.

What are the symptoms of endometriosis? 

Endometriosis presents differently for each individual. Some people may have severe symptoms, while others have none at all, despite the presence of extensive disease. Symptoms often extend beyond reproductive health and can significantly affect quality of life, especially when the condition is not recognised early.

The most common symptoms include:

• Pelvic pain — this is the hallmark symptom. It may feel sharp, cramping, or persistent, and can occur before, during, or between menstrual periods. Pain may also worsen over time.

• Painful periods (dysmenorrhea) — menstrual cramps associated with endometriosis often begin earlier, last longer, and feel more intense than typical period pain. Over-the-counter medications may offer little relief.

• Pain during or after sex (dyspareunia) — endometriosis affecting the lower pelvis or behind the uterus can make intercourse painful, especially with deeper penetration.

• Pain with bowel movements or urination — this often occurs during menstruation when endometrial-like tissue affects the bladder or bowel. Some individuals also experience cyclical gastrointestinal symptoms such as diarrhoea, constipation, or bloating.

• Chronic lower back or abdominal pain — persistent pain in these areas may not always coincide with the menstrual cycle.

• Fatigue — ongoing chronic  inflammation and the body’s response to chronic pain can lead to deep, unrelenting fatigue that is often underestimated or misunderstood.

• Heavy or irregular menstrual bleeding — some individuals may experience menorrhagia (heavy periods), spotting between periods, or prolonged cycles.

• Gastrointestinal discomfort — endometriosis is often mistaken for IBS (Irritable Bowel Syndrome) due to overlapping symptoms like bloating, nausea, and changes in bowel habits.

Not all symptoms are gynaecological. Endometriosis can affect multiple systems, particularly when lesions are located on the bladder, bowel, or distant organs. In rare cases, it can even affect the diaphragm or lungs, leading to chest or shoulder pain during menstruation.

What complications can arise if endometriosis is left untreated?

Although endometriosis is a benign condition, it can lead to several physical and emotional complications, especially when left undiagnosed or untreated. These complications can impact day-to-day functioning, relationships, and overall well-being, even in individuals who are not concerned with fertility.

• Chronic pelvic pain — one of the most common and debilitating complications, chronic pelvic pain can become persistent, occurring outside of the menstrual cycle. Over time, it may interfere with work, physical activity, and quality of life.

• Adhesions and scar tissue — endometriosis can trigger inflammation that leads to the formation of adhesions—bands of fibrous tissue that cause organs to stick together. This can result in restricted mobility of pelvic organs, pain with movement, and difficulty during medical or surgical procedures.

• Ovarian cysts (endometriomas) — these are cysts filled with old blood, sometimes referred to as “chocolate cysts,” which can form when endometrial-like tissue grows on the ovaries. They may cause pain, disrupt ovarian function, and occasionally rupture.

• Bowel and bladder dysfunction — when endometriosis involves the bowel or bladder, individuals may experience painful bowel movements, rectal bleeding, bloating, urinary urgency, or pain during urination, especially during menstruation. In severe cases, the condition may lead to partial bowel obstruction or require surgical intervention.

• Nerve involvement — in rare but serious cases, endometriosis can affect nerves in the pelvis or lower back, leading to radiating pain, numbness, or leg weakness. These symptoms may be misdiagnosed as musculoskeletal or neurological issues.

• Mental and emotional strain — living with a chronic, unpredictable condition can take a toll on emotional health. Many individuals report anxiety, depression, or feelings of isolation, especially when their symptoms are dismissed or misunderstood. Fatigue, pain, and social limitations further compound this emotional burden.

Who is at risk of endometriosis in Singapore? 

Endometriosis affects around 10% of women of reproductive age worldwide, and women in Singapore are no exception. While the condition can affect anyone with a uterus, certain factors may increase the likelihood of developing it—some of which are particularly relevant in the local context.

• Family history of endometriosis — women with a first-degree relative (mother, sister, or daughter) diagnosed with endometriosis are significantly more likely to develop the condition themselves.

• Early onset of menstruation — starting periods before the age of 12 has been linked to higher lifetime risk, possibly due to longer cumulative exposure to menstrual cycles.

• Short menstrual cycles — cycles shorter than 24 days may be associated with more frequent menstruation and increased retrograde flow, contributing to risk.

• Heavy or prolonged menstrual bleeding — excessive menstrual flow increases the amount of endometrial-like tissue available to implant outside the uterus.

• Never having given birth — women who have not had children may have a slightly higher risk, although the reasons are not entirely understood.

• Low body mass index (BMI) — a lower BMI has been associated with increased risk, potentially due to hormonal differences that affect oestrogen levels.

• High oestrogen exposure — elevated levels of oestrogen, either naturally or through certain medications, can promote the growth of endometrial-like tissue.

• Ethnic background — studies suggest that Asian women, including those in Singapore, may experience more severe forms of endometriosis compared to women of other ethnicities.

• Exposure to environmental toxins — chemicals like dioxins and PCBs may influence hormone levels and immune response, possibly increasing susceptibility.

• Delayed diagnosis or symptom dismissal — endometriosis is often misdiagnosed or overlooked, especially when symptoms are mistaken for normal menstrual discomfort. In Singapore, the average time to diagnosis is around four years—shorter than the global average, but still a concern.

How is endometriosis diagnosed? 

Diagnosing endometriosis can be challenging because its symptoms often overlap with other conditions such as irritable bowel syndrome (IBS), pelvic inflammatory disease (PID), or ovarian cysts. Many women experience a delay in diagnosis due to the normalisation of menstrual pain or the absence of visible findings on routine scans. A thorough and layered approach is often needed. 

• Detailed medical history — your doctor will begin by discussing your symptoms, menstrual patterns, pain severity, digestive or urinary issues, and any family history of endometriosis.

• Pelvic examination — a physical exam may help detect areas of tenderness, nodules, or pelvic masses, especially if deeper endometriosis or adhesions are present. However, early or superficial lesions may not be felt.

• Ultrasound scan — a transvaginal or pelvic ultrasound can identify larger endometriotic cysts (endometriomas) or ovarian involvement. It may also reveal signs of adhesions, but cannot detect small or superficial lesions.

• MRI (Magnetic Resonance Imaging) — MRI offers a more detailed view of pelvic structures and is especially helpful in mapping deep infiltrating endometriosis (DIE), particularly in the bowel, bladder, or ligaments.

• Diagnostic laparoscopy — this is one of the commonly used methods for confirming endometriosis. It is a minimally invasive surgical procedure, where a thin camera (laparoscope) is inserted through a small incision in the abdomen to directly visualise and biopsy any suspected lesions. It allows for both diagnosis and, in many cases, treatment in the same setting. It is not commonly used in endometriosis diagnosis these days.

• Histopathological confirmation — if a biopsy is taken during laparoscopy, the tissue is sent for analysis to confirm the presence of endometrial-like cells outside the uterus.

• Exclusion of other conditions — because symptoms can mimic other disorders, your doctor may rule out gastrointestinal or urinary causes before confirming a diagnosis of endometriosis.

What are the treatment options for endometriosis in Singapore? 

Endometriosis is a chronic condition, but with the right management, symptoms can be controlled, and quality of life significantly improved. The goal is to relieve symptoms, slow disease progression, and improve overall well-being. 

At Holistic Gynaecology & Fertility, we use a personalised and integrative approach to endometriosis care, combining medical treatment, surgical precision, and supportive lifestyle strategies according to each individual’s needs. 

Medical interventions

• Pain relief medications — non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or mefenamic acid are often the first line of treatment for reducing menstrual cramps and pelvic pain. These dmay offer effective symptom control but do not treat the cause but offer effective symptom control for many.

• Hormonal therapies — hormonal treatment helps suppress the growth and activity of endometrial-like tissue by lowering oestrogen levels. Available options include:

• Combined oral contraceptives — help regulate periods and reduce pain by preventing ovulation.

• Progestin-only treatments — include pills, injections (e.g. Depo-Provera), and hormonal IUDs, which thin the uterine lining and reduce menstrual flow.

• GnRH agonists and antagonists — temporarily suppress oestrogen production, leading to a menopause-like state that may shrink endometriotic lesions. These are usually used for short-term management due to side effects like hot flashes and bone loss.

Surgical options

• Laparoscopic surgery — this minimally invasive procedure is used for both diagnosis and treatment. It allows surgeons to remove or destroy endometrial implants, drain endometriomas, and release adhesions.

• Excision surgery — preferred in many cases, this technique removes lesions entirely, which helps provide better long-term pain relief compared to ablation.

• Definitive surgery — in some cases, particularly where pain is severe and unresponsive to other treatments, hysterectomy with or without oophorectomy (removal of the ovaries) may be considered.

Lifestyle changes

• Diet and nutrition — anti-inflammatory diets rich in whole grains, fruits, vegetables, omega 3 fatty acids, and low in processed foods may help ease symptoms. Some patients benefit from reducing dairy, gluten, or red meat based on individual tolerance.

• Stress management — chronic stress may worsen pain perception and hormonal imbalance. Techniques such as mindfulness, yoga, deep breathing, or counselling can help improve coping and symptom control.

• Regular exercise — low-impact activities like walking, swimming, or Pilates may improve circulation, reduce inflammation, and support hormonal regulation.

Complementary therapies

• Pelvic physiotherapy — specialised physiotherapists can help release tight pelvic floor muscles, improve posture, and reduce musculoskeletal pain associated with endometriosis.

• Acupuncture and Traditional Chinese Medicine (TCM) — some women find relief from pain and improved cycle regulation with acupuncture or herbal therapies. These should always be guided by trained practitioners.

• Supplements and naturopathic support — certain vitamins, such as Vitamin D, omega-3s, and magnesium, may support overall wellness. However, these should be used under guidance to avoid interactions with prescribed medications.

Endometriosis requires long-term management and treatment plans may change over time depending on your symptoms, response to therapy, and life stage. 

Summary 

Endometriosis is a chronic condition where tissue similar to the lining of the uterus grows outside the womb, causing inflammation, pain, and the formation of scar tissue. While the exact cause is unknown, factors such as genetics, immune dysfunction, hormonal influences, and environmental exposures may contribute. 

If left untreated, endometriosis can lead to complications such as adhesions, ovarian cysts, and a reduced quality of life, making early diagnosis and treatment paramount. 

If you are experiencing symptoms or have concerns about endometriosis, schedule a consultation with us  for thorough evaluation and personalised treatment plan.