The uterus is lined by the endometrium, which thickens each month in response to female hormones so a fertilized egg can implant; if pregnancy does not occur, it is shed as the period. In endometriosis, tissue similar to the endometrium grows outside the uterus: on the ovaries, the pelvic lining, the bowel, the bladder, the vagina and, rarely, more distant sites. This tissue also responds to the monthly hormones. Normally the shed lining leaves the body as menstrual blood, but in endometriosis the bleeding is trapped inside the body, causing inflammation and adhesions in the affected area.
Endometriosis may appear as dark or bluish spots on the pelvic surfaces, or as a cyst in the ovary filled with old dark blood, known as an endometrioma or “chocolate cyst”. It affects about 1 in 10 women of reproductive age and is found in up to half of women with infertility.
The exact cause is unknown. The best-known theory is retrograde menstruation, in which menstrual blood flows backwards through the fallopian tubes into the pelvis, but immune, genetic and hormonal factors also play a role.
Symptoms
Some women have no symptoms. Others have painful periods, typically starting before the period and continuing or worsening during it, pelvic pain through the month, pain during intercourse, and sometimes pain with bowel movements or urination around the period. Endometriosis can cause infertility through adhesions that stop the tube from picking up the egg, and indirectly through effects on egg quality, fertilization and implantation.
Diagnosis
Symptoms alone are not specific. An experienced transvaginal ultrasound can identify endometriomas and deep endometriosis, and MRI can map more extensive disease. Current ESHRE guidance allows diagnosis and treatment to start on the basis of symptoms and imaging, without needing laparoscopy. Laparoscopy remains useful when imaging is normal but symptoms persist, or when surgery is planned anyway, as it allows diagnosis and treatment at the same time.
Treatment
Medical treatment
Endometriosis responds to estrogen and progesterone. Hormonal treatments suppress the disease and relieve pain in women who are not trying to conceive: the combined contraceptive pill taken continuously, progestogens such as dienogest, GnRH agonists or newer oral GnRH antagonists (with “add-back” hormones to protect the bones). Danazol, used in the past, has largely been abandoned because of its male-hormone side effects. Painkillers are used for pain alone. Hormonal treatments prevent pregnancy while taken and do not improve fertility afterwards, so they are not used to treat endometriosis-related infertility.
Surgical treatment
In women trying to conceive, laparoscopic removal of endometriosis from the pelvis can improve natural pregnancy rates in mild to moderate disease. Surgery for ovarian endometriomas needs careful judgement, because removing a cyst can also remove healthy ovarian tissue and lower the egg reserve (AMH); the decision depends on cyst size, symptoms, age and ovarian reserve, and draining the cyst under ultrasound guidance is an option in selected cases.
IVF
IVF (with or without ICSI) is recommended for moderate to severe endometriosis, when the tubes are damaged, when other factors are present, when the woman is older, or when surgery has not led to pregnancy.
Learn more on our endometriosis treatment page.
International Guidelines
In line with global standards, Dr. Sabry follows the latest recommendations from the American Society for Reproductive Medicine (ASRM), European Society of Human Reproduction and Embryology (ESHRE), and Royal College of Obstetricians and Gynaecologists (RCOG). Thus, patients receive care that is safe, ethical, and evidence-based.
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Why Choose Dr. Ashraf Sabry?
Dr. Ashraf Sabry, consultant in obstetrics, gynecology, fertility, and aesthetic gynecology, is recognized among the best OBGYN and fertility specialists in Cairo. With over 20 years of experience, he combines science and compassion to provide world-class care. Book your appointment through the contact page, WhatsApp, or call +201022224442.