Women’s health is often under-researched, underfunded, and misunderstood. And many times, the symptoms women experience are too easily dismissed as “just part of being a woman” without ever being diagnosed or treated.
Endometriosis is one such condition.
It’s a chronic disease that impacts at least 1 in 7 women of reproductive age in Australia alone, making it a significant public health issue. The condition is also a leading cause of infertility.
That’s why understanding the stages of endometriosis is essential for diagnosis, treatment planning, and managing symptoms effectively.
What is Endometriosis?
Endometriosis occurs when endometrial tissue, which is similar to the lining of the uterus, grows outside the uterus, often in the pelvic cavity.
This misplaced tissue responds to the menstrual cycle, thickening, breaking down, and bleeding each month, but unlike the endometrial lining, it has no way to exit the body. This leads to inflammation, scar tissue, and adhesions that can bind pelvic organs together.
Endometriosis Symptoms
Common endometriosis symptoms include:
- Pelvic pain (often cyclical, but sometimes chronic)
- Painful periods and pain during intercourse
- Bloating, fatigue, and bowel or urinary discomfort, especially during menstruation
- Fertility challenges
How is Endometriosis Diagnosed?
A definitive diagnosis of endometriosis is made via laparoscopy, which is a minimally invasive surgical procedure. This allows direct visualisation and biopsy of endometrial implants.
While imaging, such as ultrasound or MRI, also helps identify ovarian cysts (commonly known as chocolate cysts or ovarian endometriomas) and scar tissue, it can often miss smaller or superficial lesions.
Unfortunately, for most women, endometriosis diagnoses are often delayed, sometimes for years. This is mostly due to the variable nature of symptoms and the normalisation of menstrual pain. Tragically, though, the delay can impact treatment outcomes, particularly where fertility preservation is a concern.
The Four Stages of Endometriosis
Endometriosis is classified into four stages (I–IV) based on a point system developed by the American Society for Reproductive Medicine.
The staging considers the number, size, depth, and location of endometrial implants, the presence of dense adhesions or filmy adhesions; and whether reproductive organs are involved.
Stage I: Minimal Endometriosis or Peritoneal Endometriosis
- Few, small, superficial lesions
- Little or no scar tissue
- Mild pelvic pain or no symptoms at all
Treatment: Laparoscopy is often recommended to remove endometriosis tissue; hormone therapy to suppress recurrence
Stage II: Mild Endometriosis
- Stage II endometriosis has more lesions than Stage I and deeper infiltration
- Possible mild adhesions
- Common symptoms: more consistent pelvic pain, painful periods
Treatment: Laparoscopy is often recommended to remove endometriosis tissue; hormone therapy to suppress recurrence
Stage III: Moderate Endometriosis
- Multiple deep implants
- Small ovarian endometriomas or cysts may be present
- Adhesions may begin to bind organs such as the ovaries, uterus, or fallopian tubes
Treatment: Laparoscopy is often recommended to remove endometriosis tissue; hormone therapy to suppress recurrence
Stage IV: Severe Endometriosis
- Extensive deep implants
- Large cysts and thick adhesions throughout the pelvic cavity
- May involve the bladder, bowel, or ureters
- Severe Symptoms: Chronic pelvic pain, infertility, pain during bowel movements or urination.
Treatment: Treatment typically includes complex endometriosis surgery by a multidisciplinary team, with emphasis on preserving fertility where possible
Do Symptoms Always Match the Stage?
Interestingly, one of the most challenging aspects of endometriosis is that symptom severity does not always correlate with disease stage.
Women with Stage I minimal endometriosis may experience debilitating endometriosis pain, while those with Stage IV may have minimal discomfort.
This disconnect underscores the importance of individualised treatment plans and comprehensive pain management.
Common Symptoms of Endometriosis
Endometriosis encompasses a spectrum of disease severity, from minimal to severe endometriosis, and each stage presents with its clinical challenges and implications for treatment and fertility.
The common symptoms of endometriosis are
- Pelvic pain and cramping
- Painful periods (dysmenorrhea) and pain during intercourse (dyspareunia)
- Painful urination or bowel movements during menstruation
- Fatigue and mild pelvic pain outside of menstruation
- Bloating, constipation, or diarrhoea
- Fertility issues due to distorted pelvic anatomy, scar tissue, or blocked fallopian tubes
It’s important to note that endometriosis symptoms vary significantly depending on the location of the endometrial tissue.
Complications Linked to Endometriosis
Endometriosis can lead to several complications, with infertility or subfertility affecting up to 50% of women who struggle to conceive.
The condition may also cause the development of ovarian cysts known as endometriomas, as well as dense adhesions that bind pelvic organs, sometimes resulting in a “frozen pelvis.”
In severe cases, endometriosis can lead to bowel or bladder obstruction, and although rare, there is also an increased risk of ovarian cancer.
Treatment Options Based on Stage
Medical Management
Treatment for endometriosis is typically guided by the severity of the condition, symptom burden, and the individual’s fertility goals.
In mild or early-stage endometriosis, medical management is often the first line of treatment. Hormonal therapies such as oral contraceptives, progestins, or gonadotropin-releasing hormone (GnRH) analogues are used to suppress the menstrual cycle, thereby slowing the growth of endometriosis tissue and alleviating symptoms.
Pain relief is commonly managed with nonsteroidal anti-inflammatory drugs (NSAIDs) or, in more persistent cases, medications that target nerve pain.
Surgical Options
For moderate to severe endometriosis, particularly when endometrial implants deeply invade pelvic organs or fertility is impacted, surgical intervention may be required.
Laparoscopic surgery allows for the removal of lesions, ovarian cysts (such as endometriomas), and scar tissue that may be distorting the pelvic anatomy. This minimally invasive surgical approach not only helps relieve pain but can also improve the chances of conception.
In advanced cases, a multidisciplinary team including colorectal or urological specialists may be involved to manage complex diseases that are linked to the bowel, bladder, or other reproductive organs.
Managing Endometriosis
Managing endometriosis often involves regular check-ins with a healthcare provider or specialist, tracking symptoms across the menstrual cycle, and making lifestyle changes like following an anti-inflammatory diet, exercising regularly, and managing stress.
Getting a Endometriosis Diagnosis
The four stages of endometriosis provide a useful guide for treatment, but they don’t always reflect the severity of symptoms. If you’ve received an endometriosis diagnosis, are struggling to conceive, or are experiencing ongoing symptoms, it’s important to book a consultation with a specialist to figure out your next steps.
As a fertility specialist, I have seen firsthand how complex and often frustrating this condition can be.
Fortunately, support and advanced reproductive medicine are available today to help women manage symptoms and improve outcomes. And with the right care, it is possible to relieve pain, preserve fertility, and reclaim your quality of life.
