Endometriosis Explained: Diagnosis, Excision Surgery, and the RRM Approach

What Is Endometriosis?

Endometriosis is a chronic, systemic, inflammatory condition in which tissue that behaves like the uterine lining grows outside the uterus, in the pelvis, on the ovaries, on or in the bowel and bladder, and occasionally in sites as distant as the diaphragm and thoracic cavity. It drives pain, adhesion formation, organ dysfunction, and, in a large proportion of affected women, infertility. It is not a menstrual complaint. It is a disease.

Painful periods are not a personality trait. They are a symptom. The normalization of severe dysmenorrhea is one of the primary reasons endometriosis goes undiagnosed for nearly a decade in the average patient.

The underlying biology of endometriosis remains partially understood. John Sampson proposed the retrograde menstruation theory in 1927: that menstrual blood flows backward through the fallopian tubes and deposits endometrial cells on peritoneal surfaces. The theory has practical limits. Retrograde menstruation occurs in roughly 90% of women with patent fallopian tubes undergoing perimenstrual laparoscopy, per Halme et al. 1984, yet endometriosis develops in roughly 6 to 10% of the general female population. Something else is happening. Immune dysfunction, genetic predisposition, coelomic metaplasia (the transformation of existing peritoneal cells into endometriosis-like tissue), and stem cell involvement all appear to contribute, per Parasar et al. 2017. There is also growing evidence, challenged directly by Redwine 2002, that Sampson's theory cannot fully explain deeply infiltrating or extra-pelvic disease.

What is clear: endometriosis is not a benign cycle irregularity. It is an active disease with the capacity for invasion, adhesion, progressive destruction of anatomy, and, in rare cases, malignant transformation, particularly in ovarian endometriomas, per Nishida et al. 2000. It behaves, in several documented respects, like a low-grade malignancy, per Thomas and Campbell 2000. Treating it as a menstrual complaint is a clinical error.

Why Patients Get Missed: The Diagnostic Gap

Women with real, diagnosable conditions. Dismissed.

That is the pattern. Not occasional. Structural. The median time from first symptom presentation to diagnosis of endometriosis is 9 years, per Pugsley and Ballard 2007, a British primary-care study that found a third of patients consulted their GP six or more times before receiving the diagnosis, and 39% were referred to a gynaecologist two or more times before confirmation. Delay is not rare. It is the rule.

The reasons are multiple.

Normalized pain. Severe dysmenorrhea is often met with reassurance that menstrual pain is normal. For a subset of women, it is not. It is disease. The Agarwal et al. 2019 call to action in the American Journal of Obstetrics and Gynecology named this explicitly: symptom normalization and underrecognition are primary contributors to delay.

Imaging limitations. Standard transvaginal ultrasound (TVUS) misses most superficial peritoneal disease. Ultrasound was diagnostic in only 10.6% of patients in the Pugsley study. MRI is better for deep infiltrating endometriosis (DIE) and surgical planning, per Shenoy-Bhangle et al. 2026, but even MRI cannot reliably detect superficial peritoneal lesions. A "normal" scan does not rule out endometriosis.

Surgical technique. A laparoscopy performed without systematic mapping of the abdomen and pelvis, without near-contact inspection of peritoneal surfaces, will miss disease. Much of what passes for a "negative lap" is a non-thorough lap. The S-MAP (Systematic Mapping of the Abdomen and Pelvis) and Near-Contact Laparoscopy (NCL) techniques, described in NaProTechnology surgical literature and applied by RRM-trained surgeons, are designed to find what standard laparoscopy misses, per Whittaker NM, AAGL 2024. When a patient has been told her laparoscopy was negative, that deserves scrutiny, not acceptance.

The "unexplained infertility" problem is where the diagnostic gap becomes most costly. A 2024 study by Nezhat et al. performed diagnostic laparoscopy on 215 patients labeled "unexplained infertility" after failed reproductive technology. In this referral cohort, pathology confirmed tissue abnormalities in 98.6%, and endometriosis specifically in 90.7%. The label "unexplained" had not been earned by a complete workup. Disease was present. It had not been found.

"Unexplained infertility" is not a diagnosis. It is an incomplete workup.

Types and Stages

Endometriosis takes several anatomically distinct forms, and the form matters for surgical planning.

Superficial peritoneal endometriosis involves implants on the surface lining of the pelvic cavity. It can cause significant pain independent of lesion volume. It is the most frequently missed by surgeons using surface-level inspection.

Ovarian endometriomas are cysts filled with old blood ("chocolate cysts"). They are identifiable on TVUS. Bilateral endometriomas can meaningfully deplete ovarian reserve and affect fertility, per Valenti et al. 2026. The decision about when and how to remove them requires surgical judgment, endometrioma surgery itself can also reduce reserve, so timing and technique are consequential.

Deep infiltrating endometriosis (DIE) penetrates more than 5 mm beneath the peritoneal surface and can involve the uterosacral ligaments, rectovaginal space, bowel, bladder, and ureter. Koninckx et al. 1991 documented the association between DIE and severe pelvic pain, distinct from the surface-lesion pattern. DIE is frequently the driver of bowel symptoms, dyschezia, painful defecation with menstruation, that are routinely attributed to IBS rather than endometriosis.

Extra-pelvic endometriosis occurs in sites including the bowel, bladder, ureter, diaphragm, and in rare cases the thoracic cavity, umbilicus, and appendix. Diaphragmatic endo can cause right shoulder pain during menstruation. Thoracic endo can cause catamenial pneumothorax. These presentations are unusual, but they are documented, and they require a surgeon who thinks systematically, not just pelvically.

ASRM staging (I to IV) remains the most widely used classification. Stage I is minimal, Stage II mild, Stage III moderate, Stage IV severe. The staging correlates with anatomic extent and adhesion burden. It does not reliably predict pain level or fertility impact. A patient with Stage I can have incapacitating pain; a patient with Stage IV can present primarily with infertility and minimal pain. Staging guides surgical planning. It does not guide prognosis in isolation.

Excision vs. Ablation: The Centerpiece

This is the surgical decision that determines outcome.

Excision removes endometriosis tissue at its root. The surgeon cuts out the lesion and the underlying tissue into which it has invaded. Nothing is left behind.

Ablation destroys the surface of a visible lesion using heat, laser, or electrical energy. It burns what the surgeon can see. Disease that has grown beneath the visible surface is untouched. The architecture of the lesion is destroyed, which also destroys the specimen needed for histologic confirmation.

The outcome difference is not marginal. A prospective cohort study by Yeung et al. 2025 followed 620 patients who received optimal excision surgery at a single tertiary referral center. Only 2.5% required repeat surgery. Historical series report up to 40 to 60% repeat surgery rates after ablation. The same study found no significant association between pre-operative hormonal suppression and endometriosis stage at surgery, implying that years of hormonal suppression did not produce sustained disease regression.

That is important. It is hiding symptoms and hiding them very well. But the underlying disease is still there.

A separate long-term cohort study by McDonnell et al. 2025 followed 71 patients with confirmed endometriosis for up to 10 years after radical laparoscopic excision (88 underwent surgery; 71 had complete follow-up data). Significant improvements in menstrual pain, noncyclical pelvic pain, dyschezia, and dyspareunia were sustained across the follow-up period.

Why ablation persists: Most general gynaecologists performing laparoscopy were not trained in excision technique. Ablation is faster. It does not require the same level of surgical skill, anatomical knowledge, or willingness to operate in difficult tissue planes. It does not involve the adhesion-prevention work that follows proper excision, the reconstruction of anatomy, the barrier placement, the operative time. "Half of it is the excision and half of it is reconstructing everything and doing my adhesion prevention," as Dr. Whittaker has described it.

Surgeon selection is not a secondary consideration. It is the primary one. The quality of the operation determines the patient's next decade.

The 2011 study by Yeung et al. 2011 also showed that in teenagers who received complete laparoscopic excision, post-operative hormonal suppression was not necessary for good outcomes, challenging the common practice of prescribing combined hormonal contraception after laparoscopy as a "preventive" measure. It does not prevent. It delays recognition of recurrence.

How RRM Diagnoses Endometriosis

RRM clinicians approach endometriosis as a diagnostic question, not a symptom-management problem. The workup is designed to answer: where is the disease, how extensive is it, and what is it doing to the patient's cycle and fertility?

Clinical history. The symptom constellation matters. Dysmenorrhea requiring medication or preventing function is not normal. Deep dyspareunia, cyclical bowel or bladder symptoms, premenstrual spotting, painful bowel movements with menstruation, these are endo symptoms until proven otherwise. Premenstrual spotting of two or more days is strongly associated with histologically confirmed endometriosis in women with infertility, per Heitmann et al. 2014. Charting the cycle creates a written symptom record that carries weight in a surgical referral conversation.

Cycle charting. A Creighton Model chart, or comparable FABM chart, maps symptoms day by day. Pain location, timing, intensity, GI symptoms, the presence and character of premenstrual spotting, charted and brought to a clinical visit, this is not anecdote. It is data. It is how RRM clinicians move a conversation from "your period pain is within normal range" to "this pattern requires investigation."

Physical exam. A skilled pelvic exam can identify uterosacral nodularity, fixed retroversion of the uterus, and adnexal tenderness that are consistent with endometriosis. Routine clinical examination alone is insufficient to diagnose or locate deep infiltrating disease, per Chapron et al. 2002, but it can raise the index of suspicion that warrants imaging and surgical referral.

Imaging. TVUS by a sonographer experienced in endometriosis is valuable for identifying endometriomas and some DIE. Standard TVUS misses superficial peritoneal disease. MRI adds value in surgical planning for DIE, bowel, bladder, ureteral, and uterosacral involvement, per Shenoy-Bhangle et al. 2026. Neither modality replaces surgical confirmation.

Laparoscopy with biopsy. This remains the diagnostic gold standard. Seeing is believing, per Mak et al. 2022. The key word is systematic. A laparoscopy performed by a surgeon using S-MAP and NCL techniques is a fundamentally different procedure than a quick pelvic survey. Diagnosis is the start of care, not the end.

The RRM Treatment Pathway

Endometriosis is a surgical disease. The first and central intervention is surgical excision by a surgeon trained and credentialed in excision technique.

Pre-operative evaluation and optimization. Before surgery, RRM clinicians evaluate the full picture: cycle pattern, symptom severity, fertility goals, imaging findings, and any co-occurring diagnoses (adenomyosis, thyroid dysfunction, immune factors, male partner evaluation if fertility is a goal). Anti-inflammatory support in the pre-operative period is a reasonable clinical consideration, though specific protocols are individualized by each clinician based on the patient's full evaluation. No public dosing guidance is appropriate here; this is a conversation between the patient and her clinician.

Excision surgery. The goal is complete removal of all visible and near-visible disease, systematic mapping of the pelvis and abdomen, and reconstruction of pelvic anatomy where adhesions have distorted it. This is not a procedure that should be booked with the first available gynaecologist. Surgeon experience, technique, and comfort with difficult pelvic anatomy, DIE involving the bowel or ureter, frozen pelvis, bilateral endometriomas, are the determinants of outcome.

Adhesion prevention. Adhesion formation after pelvic surgery is a significant secondary cause of pain and infertility. RRM-trained surgeons with endometriosis expertise use adhesion-prevention barriers and technique modifications to minimize this risk. This is part of the surgical care, not an afterthought.

Post-operative cycle monitoring. After excision, cycle charting resumes. The cycle is the report card. Premenstrual spotting that persists, or returns after resolution, is clinically meaningful. If fertility is a goal, cycle-timed support and monitoring begin post-operatively with the clinician coordinating care.

On hormonal suppression. Some patients use combined hormonal contraception, progestins, or GnRH agonists before or between surgeries for symptom bridging. That is a legitimate clinical choice when the alternative is incapacitating pain with no surgical access in the near term. Suppression reduces lesion activity and symptoms while a patient is on it. It does not cure the disease, and it does not address the underlying biology. When suppression ends, symptoms return because the disease is still there. That is the difference between symptom management and disease treatment. Patients deserve to know this before accepting a prescription as the plan, per Surrey 2023.

Endometriosis and Fertility

Endometriosis is one of the most common treatable causes of infertility, and one of the most frequently overlooked.

Prevalence among infertile women is estimated between 25 and 50%, with some clinic populations showing rates higher still, per D'Hooghe et al. 2003. The mechanisms are multiple: anatomic distortion from adhesions (tubes displaced from ovaries, fimbria encased in scar tissue), an inflammatory pelvic milieu that is hostile to sperm and implantation, direct damage to oocyte quality from endometriomas and their contents, per Saridogan and Kovanci 2023, and the ovarian reserve depletion that can follow both the endometriomas themselves and, in some cases, their surgical removal.

Endometriosis is also associated with significantly elevated rates of spontaneous miscarriage, per Santulli et al. 2016, and adverse pregnancy outcomes more broadly, per Schliep et al. 2022.

Post-excision pregnancy data are encouraging. The long-term cohort study by McDonnell et al. 2025 (71 patients with complete follow-up data, up to 10 years) reported that 77.1% of patients who desired pregnancy after radical laparoscopic excision achieved it. Surgeons working in the RRM paradigm position excision as a fertility treatment in itself, not as a preparatory step before bypassing the body's own physiology. That is the central claim: treat the disease, and the body can often do the rest. For many women with surgically treated endometriosis, that is exactly what happens.

Both partners need evaluation when fertility is the goal. Male factor is solely responsible in 20 to 30% of couples and contributes in another 20 to 30%, meaning a male-factor component is involved in roughly half of infertile couples. An RRM clinician evaluates both partners from the first appointment. Treating one partner's endometriosis without reviewing the male partner's semen analysis is an incomplete workup.

Endometriosis and Adenomyosis: The Silent Twin

Adenomyosis is a related but distinct condition in which endometrial-like glands and stroma grow into the muscular wall of the uterus (the myometrium) rather than the outer peritoneal surface. It causes heavy, painful periods, uterine enlargement, and, increasingly, is recognized as a significant contributor to infertility and implantation failure.

The two conditions co-occur frequently. Endometriosis-focused laparoscopy will not identify adenomyosis, which lies within the uterine wall and requires MRI or sonographic expertise to detect pre-operatively. A patient who has had excision surgery and continues to have significant dysmenorrhea deserves evaluation for adenomyosis, not a reflexive prescription for suppression.

A dedicated guide to adenomyosis is in development. For now: if your diagnosis has focused entirely on peritoneal endometriosis and you continue to have heavy, painful cycles, ask whether adenomyosis has been evaluated.

Living with Endometriosis While You Wait for Care

Access to an excision-trained surgeon is not immediate for most patients. The wait is real. Here is what to do in the meantime.

Chart your cycle. Charting is not administrative busywork. A written symptom map, cycle length, flow character, pain timing and location, GI symptoms, premenstrual spotting, fatigue, is the most clinically useful thing you can bring to a surgical consultation. The RRM endo survey at rrmacademy.org/endo-survey/ is a structured intake tool built for exactly this purpose. Use it.

Gather your records. If you have had prior laparoscopy, request the operative report and the pathology report. Not just the summary. The operative report tells a surgeon what was seen, how the survey was conducted, and what was done. The pathology report tells you whether biopsy-proven endometriosis was confirmed. "They found nothing" and "they looked everywhere with careful technique and found nothing" are not the same statement.

Track pain patterns. Note whether pain follows a cyclical pattern (worse premenstrually or during menstruation) or is present throughout the cycle. Cyclical pain is more likely endo; persistent noncyclical pelvic pain can indicate deep infiltrating disease or co-occurring conditions. This distinction matters for surgical planning.

When to seek urgent care. Severe pain with fever, pelvic pain with urinary symptoms, sudden worsening of established pain, or signs of internal bleeding require emergency evaluation, not a scheduled appointment.

What not to do: wait on imaging. A TVUS that shows no endometrioma does not mean endometriosis is absent. An MRI that does not show DIE does not mean endometriosis is absent. These tools are not the diagnostic standard. If symptoms are consistent, the absence of imaging findings should not delay referral for surgical evaluation.

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