Editing Endometriosis (section)

==Signs and symptoms==
Pain and infertility are common symptoms, although 20–25% of affected women are asymptomatic.<ref name=Bulletti2010/> The presence of pain symptoms is associated with the type of endometrial lesions, as 50% of women with typical lesions, 10% of women with cystic ovarian lesions, and 5% of women with deep endometriosis do not have pain.<ref name="Koninckx Ussia Mashiach Vilos 2021 pp. 1035–1036">{{cite journal | vauthors = Koninckx PR, Ussia A, Mashiach R, Vilos G, Martin DC | title = Endometriosis Can Cause Pain at a Distance | journal = Journal of Obstetrics and Gynaecology Canada | volume = 43 | issue = 9 | pages = 1035–1036 | date = September 2021 | pmid = 34481578 | doi = 10.1016/j.jogc.2021.06.002 | publisher = Elsevier BV | s2cid = 237422801 | doi-access = free | title-link = doi }}</ref>

===Pelvic pain===
A major symptom of endometriosis is recurring pelvic pain. The pain can range from mild to severe cramping or stabbing pain that occurs on both sides of the [[pelvis]], in the lower back and rectal area, and even down the legs. The amount of pain a person feels correlates weakly with the extent or stage (1 through 4) of endometriosis, with some individuals having little or no pain despite having extensive endometriosis or endometriosis with scarring, while others may have severe pain even though they have only a few small areas of endometriosis.<ref name="Stratton2011">{{cite journal | vauthors = Stratton P, Berkley KJ | title = Chronic pelvic pain and endometriosis: translational evidence of the relationship and implications | journal = Human Reproduction Update | volume = 17 | issue = 3 | pages = 327–46 | year = 2011 | pmid = 21106492 | pmc = 3072022 | doi = 10.1093/humupd/dmq050 }}</ref> The most severe pain is typically associated with menstruation. Pain can also start a week before a menstrual period, during, and even a week after a menstrual period, or it can be constant. The pain can be debilitating and result in emotional stress.<ref>{{cite journal|vauthors=Colette S, Donnez J|date=July 2011|title=Are aromatase inhibitors effective in endometriosis treatment?|journal=Expert Opinion on Investigational Drugs|volume=20|issue=7|pages=917–31|doi=10.1517/13543784.2011.581226|pmid=21529311|s2cid=19463907}}</ref> Symptoms of endometriosis-related pain may include:
* [[Dysmenorrhea]] (64%)<ref name="ovarianendo">{{cite journal | vauthors = Gałczyński K, Jóźwik M, Lewkowicz D, Semczuk-Sikora A, Semczuk A | title = Ovarian endometrioma - a possible finding in adolescent girls and young women: a mini-review | journal = Journal of Ovarian Research | volume = 12 | issue = 1 | page = 104 | date = November 2019 | pmid = 31699129 | pmc = 6839067 | doi = 10.1186/s13048-019-0582-5 | doi-access = free | title-link = doi }}[[File:CC-BY icon.svg|50px]] Text was copied from this source, which is available under a [https://creativecommons.org/licenses/by/4.0/ Creative Commons Attribution 4.0 International License] {{Webarchive|url=https://web.archive.org/web/20171016050101/https://creativecommons.org/licenses/by/4.0/ |date=16 October 2017 }}.</ref> – painful, sometimes disabling cramps during the menstrual period; pain may get worse over time (progressive pain), also lower back pains linked to the pelvis
* Chronic pelvic pain – typically accompanied by lower back pain or abdominal pain
* Dyspareunia – painful [[sexual intercourse]]
* [[Dysuria]] – urinary urgency, frequency, and sometimes painful voiding<ref name="NIH">{{cite web|url=https://www.nichd.nih.gov/health/topics/endometri/conditioninfo/symptoms|title=What are the symptoms of endometriosis?|author=<!--Not stated-->|website=National Institutes of Health|access-date=4 October 2018|archive-date=27 January 2021|archive-url=https://web.archive.org/web/20210127204323/https://www.nichd.nih.gov/health/topics/endometri/conditioninfo/symptoms|url-status=live}}</ref>{{Failed verification|date=December 2024|reason=The reference mentions neither urgency nor frequency, only painful voiding}}
* [[Mittelschmerz]] – pain associated with ovulation<ref>{{cite journal | vauthors = Brown J, Farquhar C | title = Endometriosis: an overview of Cochrane Reviews | journal = The Cochrane Database of Systematic Reviews | issue = 3 | pages = CD009590 | date = March 2014 | volume = 2014 | pmid = 24610050 | doi = 10.1002/14651858.cd009590.pub2 | pmc = 6984415 }}</ref>
* Bodily movement pain – present during exercise, standing, or walking<ref name="NIH" />

Compared with patients with superficial endometriosis, those with deep disease appear to be more likely to report shooting rectal pain and a sense of their insides being pulled down.<ref name="Ballard">{{cite journal | vauthors = Ballard K, Lane H, Hudelist G, Banerjee S, Wright J | title = Can specific pain symptoms help in the diagnosis of endometriosis? A cohort study of women with chronic pelvic pain | journal = Fertility and Sterility | volume = 94 | issue = 1 | pages = 20–7 | date = June 2010 | pmid = 19342028 | doi = 10.1016/j.fertnstert.2009.01.164 | doi-access = free | title-link = doi }}</ref> Individual pain areas and intensity appear to be unrelated to the surgical diagnosis, and the area of pain is unrelated to the area of endometriosis.<ref name=Ballard/>

There are multiple causes of pain. Endometriosis lesions react to hormonal stimulation and may "bleed" during menstruation. The blood accumulates locally if not cleared shortly by the immune, circulatory, and lymphatic systems. This accumulation can lead to swelling, which triggers inflammation via [[cytokines]], resulting in pain. Another source of pain is organ dislocation that arises from [[Adhesion (medicine)|adhesion]] binding internal organs together. The ovaries, the uterus, the oviducts, the peritoneum, and the bladder can all be bound together. Pain triggered in this way can last throughout the menstrual cycle, not just during menstrual periods.<ref>{{page needed|date=April 2015}}{{cite book|vauthors=Murray MT, Pizzorno J |title=The Encyclopedia of Natural Medicine|date=2012|publisher=Simon and Schuster|location=New York, NY|edition=3rd}}</ref>

Additionally, endometriotic lesions can develop an independent nerve supply, creating a direct and two-way interaction between lesions and the [[central nervous system]]. This interaction can produce a variety of individual differences in pain that, in some cases, become independent of the disease itself.<ref name=Stratton2011/> Nerve fibers and blood vessels are thought to grow into endometriosis lesions by a process known as [[neuroangiogenesis]].<ref>{{cite journal | vauthors = Asante A, Taylor RN | title = Endometriosis: the role of neuroangiogenesis | journal = Annual Review of Physiology | volume = 73 | pages = 163–82 | date = 2011 | pmid = 21054165 | doi = 10.1146/annurev-physiol-012110-142158 }}</ref>

===Infertility===
{{Main|Endometriosis and infertility}}
About a third of women with infertility have endometriosis.<ref name=Bulletti2010/> Among those with endometriosis, about 40% are infertile.<ref name=Bulletti2010/> The [[pathogenesis]] of infertility varies by disease stage: in early-stage disease, it is hypothesised to result from an inflammatory response that impairs various aspects of conception, whereas in later stages, distorted pelvic anatomy and adhesions contribute to impaired fertilisation.<ref>{{cite web|url=https://www.uptodate.com/contents/treatment-of-infertility-in-women-with-endometriosis|title=Treatment of infertility in women with endometriosis|website=uptodate.com|access-date=18 December 2017|archive-date=8 August 2020|archive-url=https://web.archive.org/web/20200808155241/https://www.uptodate.com/contents/treatment-of-infertility-in-women-with-endometriosis|url-status=live}}</ref>

===Other===
Bowel endometriosis may include symptoms like [[diarrhea]], [[constipation]], [[Rectal tenesmus|tenesmus]], [[dyschezia]], and, rarely, [[rectal bleeding]]. Other symptoms include [[Fatigue#Chronic|chronic fatigue]], [[nausea]] and [[vomiting]], [[migraines]], low-grade [[fevers]], [[Heavy menstrual bleeding|heavy]] (44%) and/or [[irregular periods]] (60%), and [[hypoglycemia]].<ref name="ovarianendo"/><ref>{{cite journal | vauthors = Wolthuis AM, Meuleman C, Tomassetti C, D'Hooghe T, de Buck van Overstraeten A, D'Hoore A | title = Bowel endometriosis: colorectal surgeon's perspective in a multidisciplinary surgical team | journal = World Journal of Gastroenterology | volume = 20 | issue = 42 | pages = 15616–23 | date = November 2014 | pmid = 25400445 | pmc = 4229526 | doi = 10.3748/wjg.v20.i42.15616 | doi-access = free | title-link = doi }}</ref><ref name="NIH" /> Endometriosis is associated with certain types of cancers, notably some types of [[ovarian cancer]],<ref name="pmid22361336">{{cite journal | vauthors = Pearce CL, Templeman C, Rossing MA, Lee A, Near AM, Webb PM, Nagle CM, Doherty JA, Cushing-Haugen KL, Wicklund KG, Chang-Claude J, Hein R, Lurie G, Wilkens LR, Carney ME, Goodman MT, Moysich K, Kjaer SK, Hogdall E, Jensen A, Goode EL, Fridley BL, Larson MC, Schildkraut JM, Palmieri RT, Cramer DW, Terry KL, Vitonis AF, Titus LJ, Ziogas A, Brewster W, Anton-Culver H, Gentry-Maharaj A, Ramus SJ, Anderson AR, Brueggmann D, Fasching PA, Gayther SA, Huntsman DG, Menon U, Ness RB, Pike MC, Risch H, Wu AH, Berchuck A | title = Association between endometriosis and risk of histological subtypes of ovarian cancer: a pooled analysis of case-control studies | journal = The Lancet. Oncology | volume = 13 | issue = 4 | pages = 385–94 | date = April 2012 | pmid = 22361336 | pmc = 3664011 | doi = 10.1016/S1470-2045(11)70404-1 }}</ref> [[non-Hodgkin's lymphoma]] and [[brain cancer]].<ref>{{cite journal | vauthors = Audebert A | title = [Women with endometriosis: are they different from others?] | language = fr | journal = Gynécologie, Obstétrique & Fertilité | volume = 33 | issue = 4 | pages = 239–46 | date = April 2005 | pmid = 15894210 | doi = 10.1016/j.gyobfe.2005.03.010 | trans-title = Women with endometriosis: are they different from others? }}</ref> Endometriosis is however unrelated to [[endometrial cancer]].<ref name="pmid21925719">{{cite journal | vauthors = Rowlands IJ, Nagle CM, Spurdle AB, Webb PM | title = Gynecological conditions and the risk of endometrial cancer | journal = Gynecologic Oncology | volume = 123 | issue = 3 | pages = 537–41 | date = December 2011 | pmid = 21925719 | doi = 10.1016/j.ygyno.2011.08.022 }}</ref>

Rarely, endometriosis can cause endometrium-like tissue to be found in other parts of the body. [[Thoracic endometriosis]] occurs when endometrium-like tissue implants in the [[lung]]s or pleura. Manifestations of this include [[hemoptysis|coughing up blood]], a [[pneumothorax|collapsed lung]], or [[hemothorax|bleeding into the pleural space]].<ref name=zondervan32212520/><ref>{{cite journal | vauthors = Rousset P, Rousset-Jablonski C, Alifano M, Mansuet-Lupo A, Buy JN, Revel MP | title = Thoracic endometriosis syndrome: CT and MRI features | journal = Clinical Radiology | volume = 69 | issue = 3 | pages = 323–330 | date = March 2014 | pmid = 24331768 | doi = 10.1016/j.crad.2013.10.014 }}</ref> Endometriosis may also affect the nearby colon, which in rare situations may progress to partial [[Bowel obstruction|obstruction]], requiring emergency surgery.<ref>{{cite journal | vauthors = Sarofim M, Attwell-Heap A, Trautman J, Kwok A, Still A | title = Unusual case of acute large bowel obstruction: endometriosis mimicking sigmoid malignancy | journal = ANZ Journal of Surgery | volume = 89 | issue = 11 | pages = E542–E543 | date = November 2019 | pmid = 30277298 | doi = 10.1111/ans.14869 | s2cid = 52902719 }}</ref>

Stress may be a contributing factor or a consequence of endometriosis.<ref name=stress>{{cite journal |vauthors=Reis FM, Coutinho LM, Vannuccini S, Luisi S, Petraglia F |title=Is Stress a Cause or a Consequence of Endometriosis? |journal=Reproductive Sciences |volume=27 |issue=1 |pages=39–45 |date=January 2020 |pmid=32046437 |doi=10.1007/s43032-019-00053-0 |s2cid=209896867}}</ref>

===Complications===

==== Physical health ====
Complications of endometriosis include internal scarring, adhesions, pelvic [[cyst]]s, ovarian [[Endometrioma|chocolate cysts]], ruptured cysts, and [[Gastrointestinal tract|bowel]] and ureter obstruction resulting from pelvic adhesions.<ref>{{cite journal |vauthors=Acosta S, Leandersson U, Svensson SE, Johnsen J |title=Fallbeskrivning. Endometrios orsakade kolonileus, uretärobstruktion och hypertoni |language=sv |journal=Läkartidningen |volume=98 |issue=18 |pages=2208–2212 |date=May 2001 |pmid=11402601 |url=https://lup.lub.lu.se/search/publication/1121619 |trans-title=A case report. Endometriosis caused colonic ileus, ureteral obstruction and hypertension}}</ref> [[Endometriosis-associated infertility]] may result from scar formation and anatomical distortions caused by the condition.<ref name="WH2014" />

Ovarian endometriosis may complicate [[pregnancy]] through [[decidualization]], abscess formation, and/or rupture.<ref name="Ueda">{{cite journal | vauthors = Ueda Y, Enomoto T, Miyatake T, Fujita M, Yamamoto R, Kanagawa T, Shimizu H, Kimura T |date=June 2010 |title=A retrospective analysis of ovarian endometriosis during pregnancy |journal=Fertility and Sterility |volume=94 |issue=1 |pages=78–84 |pmid=19356751 |doi=10.1016/j.fertnstert.2009.02.092 |doi-access=free |title-link=doi}}</ref>

[[Thoracic endometriosis]] can be associated with recurrent [[Hemothorax#Nontraumatic|thoracic endometriosis syndrome]] which manifests during menstrual periods. It includes [[Uterine cycle|catamenial]] pneumothorax in 73% of women, catamenial [[hemothorax]] in 14%, catamenial hemoptysis in 7%, and pulmonary [[Nodule (medicine)|nodules]] in 6%.<ref>{{cite journal | vauthors = Visouli AN, Zarogoulidis K, Kougioumtzi I, Huang H, Li Q, Dryllis G, Kioumis I, Pitsiou G, Machairiotis N, Katsikogiannis N, Papaiwannou A, Lampaki S, Zaric B, Branislav P, Porpodis K, Zarogoulidis P | title = Catamenial pneumothorax | journal = Journal of Thoracic Disease | volume = 6 | issue = Suppl 4 | pages = S448-60 | date = October 2014 | pmid = 25337402 | pmc = 4203986 | doi = 10.3978/j.issn.2072-1439.2014.08.49 }}</ref><ref name=McCann2020p1419/>

A 20-year study involving 12,000 women with endometriosis found that individuals under 40 are three times more likely to develop heart problems compared to their healthy peers.<ref>{{cite journal |vauthors=Wise J |title=Women with endometriosis show higher risk for heart disease |journal=BMJ |volume=353 |pages=i1851 |date=April 2016 |pmid=27036948 |doi=10.1136/bmj.i1851 |s2cid=28699291}}</ref>

A study indicated that 39% of women with surgically confirmed non-graded endometriosis had a 270% higher risk for [[ectopic pregnancy]] and a 76% higher risk for [[miscarriage]] compared to their peers. For women with deep endometriosis (>5&nbsp;mm invasion, ASRM Stage II and higher), the risk of miscarriage increased by 298%.<ref name="PMC9588543">{{cite journal | vauthors = Schliep KC, Farland LV, Pollack AZ, Buck Louis G, Stanford JB, Allen-Brady K, Varner MW, Kah K, Peterson CM | title = Endometriosis diagnosis, staging and typology and adverse pregnancy outcome history | journal = Paediatric and Perinatal Epidemiology | volume = 36 | issue = 6 | pages = 771–781 | date = November 2022 | pmid = 35570746 | pmc = 9588543 | doi = 10.1111/ppe.12887 }}</ref><ref name="ESHRE2015">{{cite web |date=2015 |title=ESHRE2015: Endometriosis associated with a greater risk of complications in pregnancy |url=https://endometriosis.org/news/congress-highlights/eshre2015-endometriosis-associated-with-a-greater-risk-of-complications-in-pregnancy/#:~:text=After%20adjustments%20for%20age%20and%20previous%20pregnancy%2C%20results,three%20times%20higher%20for%20ectopic%20pregnancy%20%28OR%202.7%29 |url-status=live |archive-url=https://web.archive.org/web/20240213213247/https://endometriosis.org/news/congress-highlights/eshre2015-endometriosis-associated-with-a-greater-risk-of-complications-in-pregnancy/#:~:text=After%20adjustments%20for%20age%20and%20previous%20pregnancy%2C%20results,three%20times%20higher%20for%20ectopic%20pregnancy%20%28OR%202.7%29 |archive-date=13 February 2024 |access-date=14 February 2024 |website=endometriosis.org |publisher=European Society of Human Reproduction and Embryology |vauthors=Saraswat L}}</ref>

Women with endometriosis also face a significantly increased risk of experiencing [[Antepartum bleeding|ante-]] and [[Postpartum bleeding|postpartum hemorrhage]]<ref name="ESHRE2015" />  as well as a 170% increased risk of severe [[pre-eclampsia]]<ref name="PMID28181672" /> during pregnancy.

Endometriosis slightly increases the risk (about 1% or less) of developing ovarian, breast, and thyroid cancers compared to women without the condition.<ref name="Kvaskoff Mahamat-Saleh Farland Shigesi pp. 393–420">{{cite journal | vauthors = Kvaskoff M, Mahamat-Saleh Y, Farland LV, Shigesi N, Terry KL, Harris HR, Roman H, Becker CM, As-Sanie S, Zondervan KT, Horne AW, Missmer SA | title = Endometriosis and cancer: a systematic review and meta-analysis | journal = Human Reproduction Update | volume = 27 | issue = 2 | pages = 393–420 | date = February 2021 | pmid = 33202017 | doi = 10.1093/humupd/dmaa045 | publisher = Oxford University Press (OUP) | hdl = 20.500.11820/fa3c779d-3cc7-4d0d-b93a-d7176fd8244d | hdl-access = free }}</ref>

The mortality rates associated with endometriosis are low, with unadjusted and age-standardized death rates of 0.1 and 0.0 per 100,000, respectively.<ref name="GBD2015Pre">{{cite journal | vauthors =  Vos T, Allen C, Arora M, Barber RM, Bhutta ZA, Brown A, Carter A, Casey DC, Charlson FJ, Chen AZ, Coggeshall M, Cornaby L, Dandona L, Dicker DJ, Dilegge T, Erskine HE, Ferrari AJ, Fitzmaurice C, Fleming T, Forouzanfar MH, Fullman N, Gething PW, Goldberg EM, Graetz N, Haagsma JA, Hay SI, Johnson CO, Kassebaum NJ, Kawashima T, Kemmer L | title = Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015 | journal = Lancet | volume = 388 | issue = 10053 | pages = 1545–1602 | date = October 2016 | pmid = 27733282 | pmc = 5055577 | doi = 10.1016/S0140-6736(16)31678-6 | title-link = doi | doi-access = free }}</ref>

Sciatic endometriosis, also called catamenial or cyclical sciatica, is a rare form where endometriosis affects the sciatic nerve. Diagnosis is usually confirmed through [[Magnetic resonance imaging|MRI]] or [[CT-myelography]].<ref name="Gandhi Wilson Liang Weissbart pp. 3–9">{{cite journal | vauthors = Gandhi J, Wilson AL, Liang R, Weissbart SJ, Khan SA | title=Sciatic endometriosis: A narrative review of an unusual neurogynecologic condition | journal=Journal of Endometriosis and Pelvic Pain Disorders | publisher=SAGE Publications | volume=13 | issue=1 | date=11 November 2020 | issn=2284-0265 | doi=10.1177/2284026520970813 | pages=3–9| s2cid=228834273 }}</ref>

Endometriosis can also impact a woman's [[fetus]] or [[neonate]], increasing the risks for [[congenital malformations]], [[Preterm birth|preterm delivery]], and higher [[Perinatal mortality|neonatal death]] rates.<ref name="PMID28181672">{{cite journal | vauthors = Berlac JF, Hartwell D, Skovlund CW, Langhoff-Roos J, Lidegaard Ø | title = Endometriosis increases the risk of obstetrical and neonatal complications | journal = Acta Obstetricia et Gynecologica Scandinavica | volume = 96 | issue = 6 | pages = 751–760 | date = June 2017 | pmid = 28181672 | doi = 10.1111/aogs.13111 }}</ref>

Endometriosis can lead to ovarian cysts (endometriomas), adhesions, and damage to the fallopian tubes or ovaries, all of which can interfere with ovulation and fertilization. Treatment for endometriosis often includes hormonal therapies, pain management, and in some cases, surgery to remove the endometrial tissue. For women who struggle with infertility due to endometriosis, assisted reproductive technologies such as in vitro fertilization (IVF) may be recommended, sometimes in combination with surgical treatment to improve fertility outcomes.

==== Mental health ====
"Endometriosis is associated with an elevated risk of developing depression and anxiety disorders".<ref>{{cite journal | vauthors = Jia SZ, Leng JH, Shi JH, Sun PR, Lang JH | title = Health-related quality of life in women with endometriosis: a systematic review | journal = Journal of Ovarian Research | volume = 5 | issue = 1 | pages = 29 | date = October 2012 | pmid = 23078813 | pmc = 3507705 | doi = 10.1186/1757-2215-5-29 | title-link = doi | doi-access = free }}</ref> Studies suggest this is partially due to the pelvic pain experienced by endometriosis patients. {{blockquote| "It has been demonstrated that pelvic pain has significant negative effects on women's mental health and quality of life; in particular, women who suffer from pelvic pain report high levels of anxiety and depression, loss of working ability, limitations in social activities and a poor quality of life" <ref>{{cite journal | vauthors = Low WY, Edelmann RJ, Sutton C | title = A psychological profile of endometriosis patients in comparison to patients with pelvic pain of other origins | journal = Journal of Psychosomatic Research | volume = 37 | issue = 2 | pages = 111–116 | date = February 1993 | pmid = 8463987 | doi = 10.1016/0022-3999(93)90077-S }}</ref>
}}
Mental health concerns like depression and anxiety can also result due to poor diagnostic procedures related to cultural norms where women's concerns are devalued or ignored, especially by medical professionals.<ref>Culley L, Law C, Hudson N, Denny E, Mitchell H, Baumgarten M, et al. (1 November 2013). "The social and psychological impact of endometriosis on women's lives: a critical narrative review". Human Reproduction Update. 19 (6): 625–39. doi:10.1093/humupd/dmt027. hdl:2086/8845. PMID 23884896.</ref><ref>Nnoaham KE, Hummelshoj L, Webster P, d'Hooghe T, de Cicco Nardone F, de Cicco Nardone C, et al. (August 2011). "Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries". Fertility and Sterility. 96 (2): 366–373.e8. doi:10.1016/j.fertnstert.2011.05.090. PMC 3679489. PMID 21718982.</ref>