Understanding endometriosis: What the evidence tells us

Endometriosis occurs when tissue similar to the lining of the uterus grows outside it — most commonly in the pelvis, but sometimes involving the bowel, bladder, or other organs. It affects women primarily during their reproductive years, with peak prevalence between 25 and 35 years of age. Despite how common it is, the path to diagnosis remains unacceptably slow. A 2020 parliamentary inquiry in the UK found an average time-to-diagnosis of eight years, during which 85 percent of patients visited their GP at least ten times before receiving a diagnosis (All-Party Parliamentary Group on Endometriosis, 2020). At Dr. Schmid's Robina, Gold Coast practice, reaching a diagnosis efficiently — and without dismissing a patient's symptoms — is a priority.

What symptoms does it cause?

The most common symptoms are chronic pelvic pain, severe period pain, pain during intercourse, and difficulty conceiving. Bowel and bladder symptoms — including pain with defecation, urgency, and bloating — are also frequently reported and are often mistakenly attributed to irritable bowel syndrome. A cohort study found that women with endometriosis were ten times more likely to report five or more of these overlapping visceral symptoms compared with unaffected women (Hansen et al., European Journal of Obstetrics & Gynecology and Reproductive Biology, 2014). Importantly, the severity of symptoms does not reliably reflect the extent of disease — women with minimal visible disease can have debilitating pain, and vice versa.

How is it diagnosed?

Transvaginal ultrasound is the first-line imaging investigation and can reliably identify ovarian endometriomas and deeply infiltrating lesions. MRI provides additional detail when bowel, bladder, or ureteral involvement is suspected. Definitive diagnosis requires laparoscopy with tissue biopsy, though international guidelines now support a presumptive clinical diagnosis as sufficient to begin low-risk treatments such as hormonal contraceptives or anti-inflammatory medications, avoiding unnecessary surgical delay.

Treatment: What the evidence supports

Treatment is tailored to whether pain management or fertility is the primary concern — these goals require different approaches, and hormonal suppression used for pain relief is not compatible with trying to conceive.

For pain management, current guidelines from the European Society of Human Reproduction and Embryology (ESHRE, 2022) support a stepwise approach beginning with NSAIDs and continuous hormonal contraceptives. A randomised controlled trial of 405 women following conservative endometriosis surgery found that both combined hormonal contraceptives and long-acting progestins (depot medroxyprogesterone or levonorgestrel IUD) reduced pain scores by 40 percent at three years compared with pre-operative levels (Cooper et al., BMJ, 2024). For women who do not respond adequately, GnRH antagonists represent the next step. Two phase-three trials of elagolix reported meaningful reductions in dysmenorrhea in 44 to 74 percent of patients, and two phase-three SPIRIT trials of relugolix combination therapy reported dysmenorrhea response in 75 to 85 percent at six to twelve months (Taylor et al., New England Journal of Medicine, 2017; Giudice et al., The Lancet, 2022).

For surgical management, laparoscopy remains both the gold standard for diagnosis and the primary treatment for removing implants, endometriomas, and adhesions. A 2014 Cochrane systematic review found that women who underwent operative laparoscopy were three times more likely to report improvement in pain at twelve months compared with those who had diagnostic laparoscopy alone (Duffy et al., Cochrane Database of Systematic Reviews, 2014). However, conservative surgery is not a cure — recurrence rates reach approximately 40 percent at ten years, and around 20 percent of patients require further surgery within two years. Post-operative hormonal suppression is recommended by both ASRM and ESHRE guidelines to delay recurrence and reduce the need for repeat procedures.

For women who have completed childbearing and whose symptoms have not responded to other treatments, hysterectomy with excision of all visible disease offers the most durable outcome, with significantly lower reoperation rates than conservative surgery alone.

Dr. Schmid's approach

Dr. Schmid has extensive laparoscopic surgical experience in endometriosis management, including excision of deeply infiltrating disease and ovarian endometriomas due to his experience with pelvic sidewall dissection. His approach integrates thorough pre-operative assessment — including transvaginal ultrasound and MRI where indicated — with post-operative medical management to protect the outcome of surgery long-term. Consultations at his Robina practice address both the immediate symptom burden and the long-term management plan, which for many women spans decades.

Clinical content informed by ESHRE Endometriosis Guideline (2022), Cooper et al. (BMJ, 2024), Taylor et al. (NEJM, 2017), Giudice et al. (The Lancet, 2022), and Duffy et al. (Cochrane, 2014).