Endometriosis: An Internist's View of Inflammation, Diagnosis, and Care

Endometriosis is a chronic, estrogen-dependent inflammatory condition in which tissue similar to the uterine lining grows outside the uterus, causing pain, fatigue and, for some, infertility. It affects roughly one in ten women of reproductive age, and diagnosis is often delayed by years. As an internist, I see it as more than a pelvic problem: it involves the immune system, local hormone production and the nervous system, and it deserves coordinated, whole-person care.

More than "misplaced tissue"

The simplest description of endometriosis is endometrial-like tissue growing in the wrong place, commonly on the ovaries, the pelvic lining and the ligaments around the uterus, and sometimes on the bowel or bladder. That description is accurate but incomplete.

Research over the past two decades shows that these lesions actively shape their environment:

• Immune changes. Studies have found reduced activity of natural killer cells, which normally help clear abnormal cells, in many people with endometriosis.
• Altered macrophages. Immune cells called macrophages in the pelvis can shift toward a repair-and-growth mode that supports lesion survival.
• Inflammatory signals. Lesions and surrounding cells produce prostaglandins and cytokines that drive inflammation and pain.
• New blood vessel growth and fibrosis. Growth factors such as VEGF help lesions build a blood supply, while repeated inflammation leads to scarring and adhesions.

These findings help explain why endometriosis can be persistent and why symptoms are not always proportional to the amount of visible disease.

Local estrogen production and progesterone resistance

Endometriosis depends on estrogen, which is why many treatments lower estrogen exposure or counter it with progestins. But lesions add a twist. Many express aromatase, the enzyme that converts androgens into estrogen, allowing them to produce some estrogen locally. Many also show progesterone resistance, meaning they respond less to progesterone's normally calming effect on endometrial tissue.

This helps explain why some people continue to have symptoms despite hormonal therapy. It does not mean hormonal treatments are futile. Progestins, combined hormonal contraceptives and GnRH-pathway medications help many people substantially, and they remain first-line options. For difficult cases, specialists sometimes add other strategies, including aromatase inhibitors.

How endometriosis is diagnosed today

For many years, laparoscopic surgery was considered necessary to confirm endometriosis. The 2022 guideline from the European Society of Human Reproduction and Embryology (ESHRE) changed that emphasis. Diagnosis can now begin with:

• A detailed symptom history: painful periods, pain with intercourse, pain with bowel movements or urination, chronic pelvic pain, and infertility
• Physical examination
• Imaging: transvaginal ultrasound or MRI, which can identify ovarian endometriomas and deep disease

Importantly, normal imaging does not rule out endometriosis, because superficial lesions are often not visible. Treatment with hormonal therapy can be started on clinical grounds, and surgery is considered when imaging is unclear, symptoms persist, or fertility is a concern.

The role of surgery, and its limits

Surgical excision of lesions can reduce pain and may improve fertility for some patients. Symptoms can return over time, though, and how often that happens varies widely between studies, surgeons and types of disease. Hysterectomy can help selected patients, particularly those who also have adenomyosis, but it does not always resolve pain, especially if endometriosis outside the uterus remains or if pain pathways have become sensitized.

These are decisions to make with an experienced gynecologic surgeon who can explain the expected benefits and the realistic risk of recurrence for your situation.

Why endometriosis is a whole-body condition

Many people with endometriosis describe symptoms well beyond the pelvis. That makes sense given what we know:

• Fatigue is common and may relate to chronic inflammation, poor sleep, pain and, frequently, iron deficiency from heavy bleeding.
• Digestive symptoms, such as bloating, cramping and altered bowel habits, often overlap with irritable bowel syndrome.
• Bladder pain and urinary urgency may occur.
• Central sensitization, in which the nervous system amplifies pain signals, can develop with long-standing pain.
• Mood and sleep are often affected, and both influence pain in turn.

Emerging research is also examining links between endometriosis and metabolic and cardiovascular health. These associations are still being studied, but they reinforce the value of looking at the whole person.

An internist's role in endometriosis care

Gynecologists lead the diagnosis and specific treatment of endometriosis. An internist can add value by coordinating care and addressing the rest of the picture:

• Checking for iron deficiency and anemia, which are common with heavy periods (see iron overload and ferritin optimization)
• Reviewing inflammatory and metabolic labs in context (inflammation biomarkers)
• Evaluating digestive symptoms and overlapping conditions (gut health and systemic inflammation)
• Monitoring bone health when long-term estrogen-lowering medications are used
• Supporting sleep, mood and pain management, including referral to pelvic floor physical therapy and pain specialists
• Reviewing medications and supplements for interactions

Lifestyle measures, such as regular exercise, an anti-inflammatory, fiber-rich diet and good sleep, are reasonable supportive steps, though the evidence that diet changes alter the disease itself is limited.

How I approach endometriosis at Laeeq M.D.

At Laeeq M.D., I work alongside a patient's gynecologist rather than in place of one. We review the full history, check for anemia and other contributors to fatigue, look at sleep, digestion, mood and metabolic health, and make sure the overall plan fits together. For patients in Reston, VA and across the states we serve, that coordination can make a long-term condition easier to live with.

Sources

• Becker CM, et al. ESHRE guideline: endometriosis. Human Reproduction Open, 2022. https://pubmed.ncbi.nlm.nih.gov/35350465/

Book a Consultation

If you live with endometriosis and want a physician to look at the whole picture, including fatigue, labs, digestion and long-term health, we can help. You can book a consultation for a 60-minute visit with Dr. Laeeq, virtually or in Reston, to review your history and coordinate a plan with your gynecologic care.

This article is for educational purposes and is not medical advice. Discuss any treatment with a licensed physician who knows your history.