Making the invisible visible: focus on endometriosis

Endometriosis is a chronic gynaecological condition that affects millions of women worldwide. Despite its high prevalence (around 10% of women), it remains a poorly understood and underdiagnosed disease. As a result, many patients experience frustration, as they must cope not only with pain but also with other debilitating symptoms that significantly disrupt their daily lives.

In this article, we will explore in detail the causes, symptoms, diagnosis and different treatment options for endometriosis. We will also highlight how complementary disciplines such as physiotherapy, osteopathy, psychology and nutrition can play a key role in its global management.

Endometriosis occurs when tissue similar to the endometrium, which normally lines the inside of the uterus, grows outside the uterine cavity. This ectopic tissue can be found in the ovaries, fallopian tubes, peritoneum and even in more distant areas such as the intestines or the bladder. During the menstrual cycle, this tissue reacts to hormones in a similar way to the uterine lining, leading to inflammation, bleeding and the formation of adhesions or cysts.

It is often said that there is not just one type of endometriosis but rather several forms of the disease, since it can appear in different locations and with varying degrees of severity:

• Superficial (peritoneal) endometriosis: implants located on the surface of the peritoneum.
• Ovarian endometriosis: the endometrioma is a cyst characterised by its thick, brownish fluid content.
• Deep pelvic endometriosis (subperitoneal): lesions that infiltrate more than 5 mm below the peritoneal surface, often affecting the uterosacral ligaments, the posterior vaginal fornix, the intestine, the bladder or even the ureters.
• Extrapelvic endometriosis: rarer, and may involve the diaphragm or even the thoracic cavity.

This diversity explains why each woman experiences the disease in a unique way.

The causes of endometriosis are not fully understood, but several theories attempt to explain its development.

• Retrograde menstruation: a phenomenon in which menstrual blood, instead of being expelled through the vagina, flows backwards through the fallopian tubes into the pelvic cavity. Endometrial cells then implant on neighbouring organs and proliferate under hormonal stimulation.
• Coelomic metaplasia: transformation of normal peritoneal cells into tissue similar to endometrium.
• Lymphatic or blood spread: which could explain extrapelvic forms of the disease.

• Genetic factors: women with a family history of endometriosis are at higher risk.
• Immune factors: a weakened or dysfunctional immune system may allow these cells to implant and survive instead of being cleared.

Ongoing studies are exploring the role of the microbiome, endocrine disruptors, genetics and epigenetics. These research avenues offer hope for a better understanding of the disease in the coming years.

Pain mainly affects the pelvic region (lower abdomen), but it can also radiate to the abdominal and lumbar areas. It may be constant, but more often it is recurrent and becomes more intense during ovulation and especially during menstruation.

Doctors consider that painful periods can be a sign of endometriosis when:

• The pain returns cyclically with each menstruation.
• It does not respond to simple painkillers such as paracetamol.
• It prevents a normal life (working, studying, moving around).

Dyspareunia refers to pain during sexual intercourse. This pain can range from mild discomfort to a complete inability to have sexual relations. It is most often described as deep dyspareunia, felt in the lower abdomen during penetration.

It may be present from the first sexual experiences or appear later in life. It frequently leads to feelings of loneliness and misunderstanding, often made worse by the lack of medical recognition. Sex therapy can help preserve intimacy and support the couple.

Bladder endometriosis may present with:

• pelvic and urinary pain,
• dysuria (difficulty urinating),
• increased urinary frequency (pollakiuria),
• occasional blood in the urine.

These symptoms are similar to those of a urinary tract infection, but urine tests are often negative.

When endometriosis affects the intestine, colon or rectum, patients often describe:

• alternating diarrhea and constipation, especially during menstruation,
• pain on defecation,
• bloating,
• and, more rarely, rectal bleeding or even bowel obstruction.

Fatigue results both from the physical burden of the disease and from its psychological impact. Lack of understanding from relatives and colleagues often increases social isolation and emotional exhaustion.

Endometriosis is diagnosed in 30–40% of women who seek medical attention for infertility. However, not all patients with endometriosis are infertile: some conceive naturally, while others become pregnant with the help of assisted reproductive techniques.

The severity of symptoms is not always proportional to the extent of lesions, which underlines the need for a personalised approach.

Diagnosis can be complex and lengthy: on average, it takes between 7 and 10 years before it is formally established.

1. Clinical assessment: a detailed interview about the nature, intensity and cyclic pattern of the pain.
2. Physical examination: particularly the pelvic exam, which may reveal masses or adhesions.
3. Imaging: transvaginal ultrasound to detect ovarian cysts (endometriomas), and MRI to visualise deep lesions.

A comprehensive and rigorous approach allows a faster and more accurate diagnosis, which is essential for appropriate treatment.

Contrary to popular belief, pregnancy does not cure endometriosis. However, it may temporarily improve symptoms due to hormonal changes. After childbirth, pain and other symptoms can reappear when the menstrual cycle resumes.

Most pregnancies in women with endometriosis evolve normally, although rare but serious complications (such as ruptures, fistulas or digestive perforations) can occur.

The treatment of endometriosis must be tailored to the individual needs of each patient, taking into account symptom intensity, age, desire for pregnancy and overall impact on quality of life. In practice, medical, surgical and complementary approaches are often combined in order to act on both symptoms and underlying mechanisms.

To reduce endometriotic lesions, which are hormone-dependent and evolve with the menstrual cycle, doctors may prescribe medications that induce amenorrhoea (absence of menstruation).

By stopping periods and therefore the bleeding from endometriotic lesions, pain often decreases or even disappears, and some lesions may regress. However, certain lesions — especially adhesions and fibrotic scars — are insensitive to hormones and do not regress with this type of treatment.

Pain is caused by inflammation, irritation of nerve endings and stiffness or loss of mobility in the affected tissues. When pain persists without effective management, the nervous system can develop central sensitisation, making the brain more reactive to pain signals.

To improve quality of life, it is crucial to start pain management as early as possible. Pain relief usually follows a progressive and individualised strategy:

• paracetamol,
• non-steroidal anti-inflammatory drugs (NSAIDs),
• or, when necessary, stronger analgesics.

NSAIDs must be used with caution: they are contraindicated in certain situations and should not be taken for long periods because of gastrointestinal and renal side effects.

In some cases, surgery is essential. It is a complex procedure, particularly when lesions involve functional organs such as the bladder, rectum or colon. Therefore, it should always be performed by surgeons with expertise in endometriosis.

Surgery is generally carried out by laparoscopy, a minimally invasive technique that facilitates postoperative recovery and reduces the risk of further adhesions.

Surgical indications are considered when:

• painful endometriosis does not respond to medical treatment,
• infertility is present and pregnancy is desired,
• and the expected benefits (pain reduction, improved fertility) outweigh potential risks (such as urinary incontinence).

Alongside medical treatments, complementary approaches also play an essential role. Lifestyle changes — such as a balanced diet, regular physical activity and stress management techniques like meditation — can help reduce symptoms and improve daily wellbeing.

In about one third of cases, endometriosis stabilises or even regresses thanks to treatment or spontaneously (especially in its superficial forms). However, some forms progress to severe disease that requires complex and multidisciplinary care. This highlights the importance of early diagnosis to prevent symptom worsening and deterioration of quality of life.

At the Aliantis Health Centre, we believe in a multidisciplinary approach that integrates physiotherapy, osteopathy, psychology and nutrition. This synergy complements conventional medical treatments and helps improve the quality of life of patients with endometriosis.

Endometriosis is a chronic and complex condition that can be better understood through the biopsychosocial model of pain. This model considers biological factors (inflammation, adhesions, nerve irritation), psychological factors (anxiety, stress, depression) and social factors (isolation, lack of understanding).

A multidimensional approach is therefore essential to help patients manage their pain more effectively and regain a better quality of life.

Physiotherapy plays a key role in relieving chronic pelvic pain and associated symptoms.

It may include:

• manual techniques to relax and mobilise the pelvic floor muscles, which are often tense,
• stretching and strengthening exercises to improve pelvic mobility and function,
• myofascial therapy and abdominal massage to reduce adhesions and improve blood and lymphatic circulation,
• postural and breathing work to reduce the functional impact of the disease on daily activities.

This personalised approach makes pelvic floor physiotherapy a valuable tool to complement medical and surgical treatment.

Osteopathy does not aim to cure endometriosis itself but to relieve symptoms and significantly improve wellbeing.

Through gentle, specific techniques, the osteopath works on:

• digestive and gynecological organs,
• the pelvis and perineum,
• the lumbar region and lower limbs.

These techniques help reduce local inflammation and relieve referred pain.

Manual lymphatic drainage is also recommended to improve circulation and reduce venous congestion in the pelvis.

Each session is tailored to the patient, as endometriosis presents differently from one woman to another. There is no standardised protocol. Follow-up is adapted to symptoms and patient experience. After surgery, osteopathy can also support recovery, always respecting appropriate healing times.

Chronic pain has a major impact on mental health. Women with endometriosis may experience anxiety, sadness, frustration and social isolation.

Psychological therapy offers tools to:

• manage emotions,
• modify negative thought patterns,
• develop resilience,
• facilitate communication with partners and family.

This global approach aims to reduce the emotional burden of the disease and provide patients with resources to better live with it.

Nutrition is a complementary pillar of care and is integrated into the pathway offered at Aliantis. An adapted diet can help reduce inflammation and support hormonal balance.

• Recommended foods include: oily fish rich in omega-3, green vegetables, berries and other antioxidant-rich fruits, whole grains and fibre-rich legumes.
• It may be helpful to limit: refined sugars, highly processed foods, excessive red meat, dairy products in case of intolerance or if they worsen digestive symptoms.

Personalised nutritional guidance helps patients understand the impact of diet on their symptoms and adopt long-term beneficial habits.

Endometriosis is a complex disease that goes far beyond the purely gynaecological sphere. It affects the body, the mind and social life.

At the Aliantis Health Centre in Sitges, we believe in a holistic and human approach. By combining physiotherapy, osteopathy, psychology and nutrition, we support each woman in managing her pain and improving her quality of life in a sustainable way.

Our commitment is to stand by your side throughout this journey, offering professionalism, empathy and dedication. Regaining your quality of life is possible, and at Aliantis, we are here to help you at every step.

This blog article is not intended to generate new knowledge; its writing is based on the review of scientific publications, blog articles, and other writings.