What is Endometriosis?

Endometriosis is a GYN condition that happens when tissue from the lining of the uterus  – the endometrial lining – grows outside of the uterus to other organs in the pelvis and abdomen. Important points about diagnosing and treating endometriosis:


Pain during and around the cycle is the number one complaint from patients with endometriosis, ranging from mild to incapacitating – so severe that normal activities are impossible. Other symptoms include:

  • Pain with Intercourse
  • Pelvic Pressure and Back Pain
  • Pain with Bowel Movements and Urination
  • Fatigue
  • Less common symptoms include: Constant pain, Nausea – Vomiting – Diarrhea, Pain with Bowel Movements and Urination, Heavy and Irregular bleeding.

Infertility is a very common result of Endometriosis and can be present in most patients with the disease.


Can only be made by minimally invasive Laparoscopic surgery. Why?

  • Endometriosis “implants” are too small to be detected and cannot be seen by imaging studies such as ultrasound, MRI, CT scan and others:
  • Cannot be made by your OBGYN in the office by “telling you” that you have the disease, or by pelvic exam which is very inaccurate.

Delay in Care/Complications

The MAIN  reason endometriosis progresses, causes severe pain and fertility and complications is due to a Delay in Care.  A delay in the diagnosis and treatment of endometriosis is very common, and is usually due to:

  • OBGYN’s performing ultrasounds or MRIs that are “normal” and delaying the diagnosis of endometriosis by referring the patient to other specialists  for evaluation of pain
  • OBGYN’s ignoring the symptoms of pain and infertility, and prescribing birth control pills. Birth control pills do NOT stop endometriosis and will NOT treat advanced stage disease.
  • OBGYN’s NOT performing laparoscopic surgery to determine the presence and stage of endometriosis
  • OBGYN’s performing laparoscopic surgery and not removing all disease, or “ablating” or burning the endometriosis, not removing it, causing further growth of the disease.


Endometriosis is a “surgically staged” disease. This means that only surgery can determine the “extent” of the disease.

  • Staging is 1 through 4.  Stage 1 is minimal, Stage 4 is extensive
  • Treatment is through surgical “EXCISION” of the disease, or removal. Ablation or “burning” of the disease is not acceptable for treatment since it does not remove all disease.
  • For more information on the Treatment of Endometriosis and CIGC Hyper-Specialists, please go to Treatment Options and review Endometriosis.


The BEST option for diagnosis and treatment since CGIC Hyperspecialists are GYN Oncology trained and have the highest level of training in surgery.

  • OBGYNs are NOT HyperSpecialists – they focus on Obstetrics, not Endometriosis care.
  • “Specialists” online are often OBGYNs who do not have extensive surgical training and are more specialists in Obstetrics, not surgery.


  • Do not pay cash, use your insurance.
  • CIGC surgeons are in network with your insurance and provide equal and often superior care than “cash-based endometriosis specialists.”
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Endometriosis Symptoms and Complications 

When endometriosis is not diagnosed quickly and treated properly, symptoms become worse and complications occur. The following is a more detailed discussion of the summary above.

The Top 5 Symptoms and Complications of Endometriosis

1. Infertility is a common result of endometriosis, even when it is treated properly. Delay in the diagnosis, improper surgical removal, and advanced stage disease are common with endometriosis, leading to severe infertility.

2. Pain can become “debilitating,” meaning that many women cannot go to work or function normally when their cycle occurs. Improper and untimely treatment leads to severe pain, emotional and mental health issues, as well as narcotic use. Pain with intercourse, pelvic pressure and back pain, sharp stabbing pain, and eventually constant pain can occur as the disease progresses.

3. Ovarian cysts and Endometriomas can develop with delay in care and late diagnosis.

4. Bowel, Bladder, and other organ involvement can cause problems with pain during bowel movements, urination, and obstruction of the ureters, causing kidney swelling.

5. Inflammation of endometriosis has been linked to immunosuppression, heart disease, and many other negative conditions.

The Top 5 Explained

1. Infertility

This can happen at any stage of the disease due to chronic inflammation. In fact, up to 50% of women with endometriosis suffer from infertility. This occurs because the endometrial cells have “mini periods” outside the uterus each month, causing inflammation, pain, and scarring. Inflammation and scarring from endometriosis results in infertility.

2. Inflammation

    • Impairs fertilization between egg and sperm
    • Impairs transport through the tubes
    • Impairs implantation of the embryo into the uterine lining for pregnancy

In the following diagram, red “X”s indicate where endometriosis can block fertility.

Step 1 – Fertilization
Step 2 – Transport of the Embryo down the tube
Step 3 – Implantation of the embryo into the uterine lining

Diagram showing a woman's reproductive system with endometriosis

  • Tubal Scarring – preventing transport of the egg down the tube to the uterus by blocking the tubes

Illustration of a female reproductive system with endometriosis

  • Endometriomas, or the formation of large cysts of endometriosis in the ovaries, can destroy ovarian tissue and can decrease ovarian reserve — the number of eggs remaining in the ovaries — as well as decrease egg quality
Endometrioma in the right ovary. Endometrioma in the left ovary with normal right ovary. Picture from JAM

Endometrioma in the right ovary. Endometrioma in the left ovary with normal right ovary.

3. Pain

With endometriosis comes pain from two main causes: Invasion into the peritoneal lining and Adhesions.  Delay in treatment creates more pain from this disease, and more complications.

  • The Peritoneal Lining. The peritoneum covers all organs of the pelvis and abdomen,  as well as the diaphragm, and it is where endometriosis grows.
    • Delay in care and more time allows deeper growth into the lining causing more pain and inflammation.
    • Inflammation is a localized reaction to endometriosis growing into the peritoneal lining – swelling, redness, and movement of white blood cells to the implant site causes pain.
    •  Inflammation can affect the organ on which the endometriosis is growing by impairing its function.
Endometriosis of the peritoneal lining – black and brown implants of disease

Endometriosis of the peritoneal lining – black and brown implants of disease

Endometriosis involving the base of the uterus, the pelvis (culdesac) and the peritoneum of the right uterine sidewall

Endometriosis involving the base of the uterus, the pelvis (culdesac) and the peritoneum of the right uterine sidewall

  • Adhesions. The peritoneal lining usually has a shiny and slippery surface so that no other organs will attach to it. The bladder and bowel, for example, sit above and below the uterus, and the ovaries are on the side.
    • Endometriosis involvement of bladder or bowel will cause the slippery surface to become “rough”, allowing it to “stick” to the uterus causing pain. Any organ can develop this rough surface due to endometriosis and stick to another organ causing severe adhesions.
    • The longer endometriosis is not treated, the more it is allowed to grow with more adhesions and more pain.
    • Adhesions to the tubes and ovaries will not only cause pain, but also infertility since their normal function is affected.
Adhesions between endometriosis, the fallopian tube, and the uterus

Adhesions between endometriosis, the fallopian tube, and the uterus

  • The Result. Organs “stuck” together hurt and can cause pain either with the cycle or constantly. Pain with intercourse is an example of the bowel stuck to the back of the uterus, or the bladder stuck to the front of the uterus. Intercourse “moves” the uterus, which is fixed in position and causes pain.

4. Ovarian Cysts/Endometriomas

In its later stages, endometriosis can lead to the development of endometriomas – large cystic collections of endometriosis in the ovary. This can destroy and replace normal ovarian tissue, and can lead to decreased ovarian reserve and infertility.  

  • Ultrasound CAN detect larger endometrimoas in the ovary, which should be removed immediately with minimally invasive laparoscopic surgery.
  • Endometriomas often “stick” to the structures in the pelvis such as the sidewall, the bowel, bladder, ureters and cause extensive adhesions and pain.
  • Laparoscopic specialists can remove endometriomas without removing ovarian tissue, allowing preservation of the ovary. The ovary does NOT NEED TO BE REMOVED for those patients who want fertility.  
  • OBGYN’s often remove the ENTIRE OVARY, and this must be avoided since it will decrease ovarian reserve by 50% (loss of one ovary).
Large endometrioma in the left ovary

Large endometrioma in the left ovary


5. Bowel Problems- Urinary Problems

Endometriosis can affect the bowel in two ways: it can develop on the outside of the organ (called superficial bowel endometriosis) or penetrate the bowel wall in more severe cases.

  • If endometriosis spreads to the outside of the bowel, it may cause the bowel to become stuck to other organs in the pelvis, such as the uterus or ovaries, causing chronic pelvic pain.
  • Adhesions on the bowel can also cause constipation and diarrhea, as well as pain with bowel movements.

In severe cases, deep endometriosis can infiltrate the bowel wall, causing rectal bleeding.

Endometriosis on the bowel

Endometriosis on the bowel

Endometriosis can affect the bladder by growing around and into the bladder wall, causing problems with urination and even blood in the urine.  Obstruction of the ureters can result from advanced disease causing kidney swelling and dysfunction.

Endometriosis involving the bowel – left- and the bladder – right.

Endometriosis involving the bowel – left- and the bladder – right.

Inflammation – Increased Risk of Heart Problems

Studies have shown an increased risk for high cholesterol and coronary heart disease among women with laparoscopically confirmed endometriosis. Due to chronic inflammation and high levels of cholesterol, women, especially young women, with endometriosis may be more likely to develop chest pain, have a heart attack or undergo heart surgery.

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Getting a Diagnosis

An endometriosis specialist can diagnose, stage, and treat the disease through minimally invasive laparoscopic surgery. If you have painful symptoms that you suspect may be caused by endometriosis, early diagnosis will bring you closer to relief

How to Diagnose Endometriosis

Endometriosis is a condition in which cells similar to those in the endometrium, the layer of tissue that normally covers the inside of the uterus, grow outside it.  Important points:

  • Cells outside the uterus that grow in “clusters” are often called “implants.”  
  • Implants are too small to be seen by imaging studies such as MRI, Ultrasound or CT scan since they are much less than half a centimeter – or 0.2 inches.  The best imaging requires at least one half to one centimeter in size to see.
  • Endometriosis is a complex condition. Its symptoms are easily mistaken for other medical conditions such as fibroids, ovarian cysts, adenomyosis, bladder and bowel conditions.
  • Ultrasound and MRI are often performed.  However, a NORMAL ultrasound or MRI does  NOT mean endometriosis is NOT present.
    • These studies help rule out large collections of endometriosis on the ovary, called Endometriomas which are seen, and will also identify fibroids and ovarian cysts.
  • Visual laparoscopy, a minimally invasive procedure during which a small camera is inserted through the belly button to examine the pelvic area, is the ONLY way to confirm and treat endometriosis.
    • Visual laparoscopy can SEE very tiny implants, less than 1 mm, STAGES the disease, and EXCISES or removes the disease all at the same time.
    • Recovery is very fast.  CIGC Hyper-Specialist results are usually 2 – 4 days back to work with minimal pain and very low complications.
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Endometriosis Types

Endometriosis is the lining of the uterus – the endometrial lining – going outside the uterus and growing on the peritoneal lining. The peritoneal lining covers all organs of the pelvis and abdomen, and it is where endometriosis grows. The lining has many nerve endings, which sense the growth of endometriosis and its irritation, causing pain

There are three primary types of endometriosis that all start with growth on the peritoneal lining, and then “invade” or penetrate deeper into the lining with time. Delay in treatment allows endometriosis to grow, so this is why a diagnosis should be made sooner rather than later. All three types of endometriosis can cause pain and infertility. 

  • Superficial Peritoneal Lesions: These are thin, flat lesions that do not grow extensively into the lining and deeper. While these lesions are typically associated with mild cases of endometriosis, they can still be responsible for severe pain.
  • Ovarian Endometriomas (also known as Chocolate Cysts): Endometriomas are cysts that are commonly found on the ovaries and sometimes filled with brown fluid (chocolate cysts). Ovarian endometriomas are usually associated with more severe stages of endometriosis.
  • Deep Infiltrating Endometriosis (DIE): These lesions penetrate deep into the surface of the peritoneum, often causing severe pain. The presence of multiple deep implants indicates a later stage of endometriosis.
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Endometriosis Stages

Endometriosis is classified into four stages — minimal, mild, moderate or severe — depending on where the endometriosis is, and how deep it has penetrated into the peritoneal lining.  

  • A stage does not mean more pain. Patients with stage 4 endometriosis may experience little or no symptoms, while patients with stage 1 endometriosis may be in severe pain.
  • A stage is determined by laparoscopic surgery. This procedure uses a small thin camera through the belly button to look at the pelvis, determine the stage, and then “excise” or remove the disease. 
  • A stage will help to determine what “medical therapy” is to be used after surgical removal.  
    • Surgery can remove almost all disease present, and can do what it takes medical therapy months to achieve.  
    • However, with advanced stage disease, medical therapy is used to “suppress” or control disease AFTER surgery, and it is important to know what the stage is so that the right medical suppression can be given. 
Stage 1 Endometriosis

Stage 1 endometriosis is classified as minimal. In this stage, there are few superficial implants and no significant adhesions or scar tissue. It is still possible to have severe symptoms in this stage despite the light spread of the disease.

Stage 1 minimal

Stage 2 Endometriosis

Stage 2 endometriosis is classified as mild. In this stage, there can be both superficial and deeper implants, but still without any significant adhesions. 

Stage 2 mild

Stage 3 Endometriosis

Stage 3 endometriosis is classified as moderate. In this stage, there are multiple deep implants, small cysts on one or both ovaries and filmy adhesions. Adhesions are made up of scar tissue that causes organs to stick together. Adhesions can cause pain and nausea in some cases.

Stage 3 moderate

Stage 4 Endometriosis

Stage 4 endometriosis is classified as severe. In this stage, there are multiple implants, large cysts on one or both ovaries and dense adhesions. Patients in this stage are at the highest risk of infertility and other complications, so treatment should be considered urgent. 

Stage 4 severe

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Treatment and Specialists

CIGC Hyper-Specialists are NOT OBGYN’s, but are GYN oncology-trained specialists using the powerful DualportGYN RetroPeritoneal Excision method for the surgical removal of endometriosis. The techniques and procedures used by CIGC provide the highest quality of care at the lowest possible cost. Outcomes have shown the fastest recovery and lowest complications. 

For more information, please go to the section on Treatment Options, Endometriosis. 

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Endometriosis Causes & Risk Factors

The cause of endometriosis is still widely unknown, but there are ongoing studies to determine it, and several likely theories exist on the subject (the most common is a phenomenon called retrograde menstruation). There are also several risk factors that indicate a higher likelihood of endometriosis developing, including short menstrual cycles and never having given birth. It is important to understand these causes and risk factors to understand whether you might be at risk.  

Endometriosis Causes

While researchers are not sure what definitively causes endometriosis, they have identified several possible causes, including:

  • Genetic factors: Endometriosis can often be inherited through genes.
  • Hormones: Endometriosis is dependent on estrogen for growth. Researchers are studying whether endometriosis is the result of a problem with the female endocrine system.
  • Surgical scar implementation: A surgeon may accidentally pick up and misplace tissue from the endometrium during surgery to the uterus or the abdominal area, such as a cesarean section (C-section) or hysterectomy.
  • Retrograde menstruation: Cells from the endometrium that are shed into the uterus during a period are carried backward through the tubes and into the pelvis, where they can implant.
  • Transport by circulation: Endometrial cells are carried from the uterus to other areas of the body via the lymphatic system and blood vessels.
  • Embryonic cell growth: Cells within the abdomen and pelvis turn into endometrial cells.
  • The immune system: Problems with the immune system may lead to failure in detecting and destroying endometrial tissue outside of the uterus.
  • Induction of peritoneal cells: Hormones cause peritoneal cells, which line the inside of your abdomen, to transform into cells that resemble endometrial cells.

Endometriosis Risk Factors

Certain factors may place you at higher risk for developing endometriosis. The following are risk factors for endometriosis2:

  • One or more relatives with endometriosis
  • Abnormalities in the reproductive and menstrual tracts
  • Short menstrual cycles, i.e., less than 27 days
  • Heavy menstrual periods that last longer than seven days
  • Never having given birth
  • Starting your period at an early age
  • Going through menopause at an older age
  • Having a history of high estrogen production
  • Low body mass index
  • Medical conditions that prevent menstrual flow
  • Infertility
  • Ovarian Cancer
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Endometriosis Specialists at CIGC

Choosing the right specialist for endometriosis removal is an essential part of managing the condition. If removed incorrectly or incompletely, endometriosis can continue to cause pain and impact fertility. Our specialists understand what women with endometriosis suffer through, and we put the needs of our patients first. Many women spend tens of thousands of dollars out of pocket for specialist care. At CIGC, we accept most major insurance plans, ensuring our patients can focus on getting healthy.


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Schedule a Consultation

If you suspect you may have endometriosis, our specialists are ready to evaluate your symptoms and recommend an appropriate solution.

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