Endometriosis begins with a retrograde flushing of endometrial tissue that backs up into the fallopian tubes and then sprays into the abdominal cavity. The endometrial cells can then implant themselves on any organ—ovaries, fallopian tubes, bladder, bowel—and grow with each monthly cycle. One would guess that the endometrial tissue somehow gravitates toward its source, the uterus, and implants itself only there. This is not true. In a recent study by a team of endocrinologists and infertility specialists, led by Dr. Susan Jenkins at Duke University Medical Center in North Carolina, it was found that the ovaries were the most likely site of endometrial implants (nearly 60 percent of the cases). For unknown reasons, the left ovary was a more common site than the right by 20 percent. The uterus was the host organ in only 11 percent of the cases. The cul-de-sac, the cavity between the uterus and the rectum, also ranked high as a nesting location for these renegade cells. Endometriosis in the cul-de-sac can be responsible for lower back pain during menstruation. Cases are commonly found in which the bladder and kidney are involved. Soil more surprising, but much more rare, has been the discovery of endometriosis in the lung, armpits, and brain. No women in this study were found to have implants on the cervix or in the vagina—in fact, implants in these two sites are nearly unknown.

Imagine now what happens every month when endometrial tissue, existing outside its normal environment, responds according to its nature. The vulnerable endometrial implants outside the uterus react to the surge of estrogen and progesterone. The tissue thickens and bleeds, as if it were growing in the uterus, but, unlike menstrual blood, it has no way to exit the body. The implants can enlarge and then ding to organs.

If the endometrial masses are not located near nerve endings, they may not cause pain. Endometriosis has been found in women who were pain-free and functioning normally, but who were suffering from other problems, such as uterine fibroids or infertility. About 30 percent of women with endometriosis have no oven symptoms and find out only incidentally that they have the disease. If the implants grow near nerve endings, however, a woman life can be made miserable. Seventy percent of endometriosis victims may begin feeling pain about two weeks prior to and continuing into menstruation. Overwhelming damage can be done to organs bound with endometrial masses in both symptomatic and asymptomatic sufferers.

The most frequent complaint that leads me to suspect endometriosis in a patient is dysmenorrhea, or painful menstruation. Many women with endometriosis tell of long histories of menstrual distress, most specifically heavy menstrual flow accompanied by severe cramping. Backache and/or deep abdominal pain on either side of the body may indicate engorgement of blood in exiled endometrial tissue on the bowels or ovaries.

Dyspareunia, or painful intercourse, is yet another serious problem. Endometrial lesions, especially when they are trapped and growing in the cul-de-sac, can push the uterus into a retroverted position. Retroversion is a tilting back of the uterus. When the uterus is thus pulled out of its normal position, deep vaginal penetration during intercourse can be extremely painful.

Rectal bleeding, the need to urinate frequently, or blood in the urine during menstruation can also indicate endometriosis. Furthermore, if a woman feels pain radiating from her buttocks to the outside of her legs, her sciatic nerve may be affected. Vomiting and abdominal swelling may implicate the involvement of the small intestine. Finally, infertility, which may strike up to 75 percent of all women who have endometriosis, is directly linked to this disease.

Because endometriosis is so variable in nature, a small implant may cause greater suffering than a larger mass. In either case, physical pain from endometriosis does not exist in a Vacuum. This physical pain generally results in a life-changing state of emotional distress, a devastating side effect made worse by the belief among others—doctors, family, friends—that the pain does not, in fact, exist.

Pelvic pain can become an overwhelming entity in itself.

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