Severe period pain is not something patients should be told to simply tolerate. Endometriosis is a common cause of chronic pelvic pain, painful periods, pain with sex, bowel or bladder symptoms during periods, and difficulty conceiving. It can be difficult to diagnose because it does not show up on a routine blood test and may be missed on standard imaging, especially when disease is superficial.
At Women’s Health Group Chicago, Dr. Michael Awad and our clinical team evaluate pelvic pain with a structured approach. The goal is to identify patterns early, rule out other causes, and create a treatment plan based on symptoms, exam findings, imaging, fertility goals, and response to treatment.
What Is Endometriosis?
Endometriosis is a condition in which tissue similar to the lining of the uterus grows outside the uterus. These implants can cause inflammation, pain, scarring, adhesions, ovarian cysts called endometriomas, and fertility problems in some patients.
Endometriosis most commonly affects pelvic structures, including:
- Ovaries
- Fallopian tubes
- Pelvic lining
- Tissue behind the uterus
- Uterosacral ligaments
- Bowel or bladder surfaces in more advanced cases
Some patients have symptoms mainly during their period. Others have pain throughout the month.
Why Endometriosis Is Often Missed
Endometriosis can be delayed or missed because symptoms vary widely and can overlap with other conditions.
Common reasons for delayed diagnosis include:
- Ultrasound may appear normal
- There is no single blood test that confirms endometriosis
- Pain is sometimes dismissed as “normal cramps”
- Symptoms may overlap with IBS, bladder pain, pelvic floor dysfunction, ovarian cysts, fibroids, adenomyosis, or pelvic infection
- Some patients have severe pain with minimal visible disease
- Some patients have significant disease with fewer symptoms
A normal ultrasound does not rule out endometriosis. Ultrasound is still useful because it can identify ovarian endometriomas, some signs of deep endometriosis, fibroids, ovarian cysts, and other possible causes of pelvic pain.
Symptoms That May Suggest Endometriosis
Endometriosis can present differently from patient to patient. Several patterns raise clinical suspicion.
Severe Period Pain
Period pain that interferes with work, school, sleep, exercise, or normal daily activities should be evaluated. Pain that worsens over time is also concerning.
Chronic Pelvic Pain
Pain may occur before the period, during the period, after the period, or throughout the month.
Pain With Sex
Deep pelvic pain during or after intercourse can be associated with endometriosis, especially when lesions or scarring involve areas behind the uterus.
Bowel Symptoms During Periods
Some patients experience painful bowel movements, constipation, diarrhea, bloating, rectal pressure, or cyclical bowel discomfort.
Bladder Symptoms During Periods
Urinary urgency, bladder pressure, painful urination, or cyclical bladder pain may occur in some patients.
Difficulty Conceiving
Endometriosis can affect fertility in some patients. Not every patient with endometriosis has infertility, and not every patient with infertility has endometriosis, but the connection is important.
Heavy or Irregular Bleeding
Heavy bleeding is not the classic defining symptom of endometriosis, but some patients have overlapping conditions such as adenomyosis, fibroids, polyps, or hormonal bleeding patterns.
Conditions That Can Mimic or Overlap With Endometriosis
A complete pelvic pain evaluation should not focus on endometriosis alone. Other possible causes may include:
- Adenomyosis
- Fibroids
- Ovarian cysts
- Pelvic inflammatory disease
- Scar tissue or adhesions
- IBS or bowel disorders
- Interstitial cystitis or bladder pain syndrome
- Pelvic floor muscle dysfunction
- Nerve-related pain
- Musculoskeletal pain
- Prior surgical scarring
- Primary dysmenorrhea
Some patients have more than one condition at the same time. This is why a structured evaluation matters.
How We Evaluate Pelvic Pain in Our Chicago Office
At Women’s Health Group Chicago, evaluation is designed to move beyond guessing and toward clinical clarity.
A pelvic pain evaluation may include:
Detailed Symptom History
We review when pain occurs, how severe it is, whether it is related to the menstrual cycle, whether it occurs with sex, urination, or bowel movements, and whether symptoms are worsening over time.
Review of Prior Treatment
We review previous birth control use, pain medications, antibiotics, prior imaging, prior surgeries, fertility history, and what treatments have or have not helped.
Pelvic Examination
A focused pelvic exam may identify tenderness, pelvic floor muscle pain, uterine tenderness, adnexal tenderness, nodularity, reduced mobility, or other findings that guide the next steps.
In-Office Ultrasound
Ultrasound can evaluate the uterus, ovaries, ovarian cysts, fibroids, adenomyosis patterns, endometriomas, and other visible abnormalities.
A normal ultrasound does not rule out endometriosis, but it helps identify conditions that may change the treatment plan.
Additional Testing When Appropriate
Depending on symptoms, additional testing may include pregnancy testing, STI testing, urine testing, blood work for anemia or inflammation when clinically indicated, or referral for bowel or bladder evaluation.
MRI or Specialist Imaging for Suspected Deep Endometriosis
If symptoms or exam findings suggest deep endometriosis involving the bowel, bladder, ureters, or deeper pelvic structures, pelvic MRI or specialist ultrasound may be recommended.
Clinical Diagnosis and Treatment Response
Endometriosis may be suspected based on symptoms, exam findings, imaging, and response to treatment. In some patients, treatment can begin before surgical confirmation.
Laparoscopy When Needed
Laparoscopy may be recommended when symptoms persist, imaging is negative but suspicion remains high, medical treatment fails or is not appropriate, fertility goals require more direct evaluation, or surgical treatment is being considered.
During laparoscopy, suspected endometriosis lesions may be removed or treated when appropriate, and tissue may be sent for pathology.
Treatment Options for Endometriosis and Pelvic Pain
Treatment depends on symptom severity, age, medical history, fertility goals, imaging findings, prior treatment response, and patient preference.
NSAIDs and Pain Control
Anti-inflammatory medication may help reduce period-related pain in some patients. If pain remains severe or disruptive, further evaluation is needed.
Hormonal Birth Control
Combined hormonal birth control may reduce painful periods, cyclical pain, and non-menstrual pelvic pain in some patients.
Progestin Therapy
Progestin options may include pills, injections, implants, or a levonorgestrel-releasing IUD. These treatments may reduce stimulation of endometriosis-related tissue and improve pain.
GnRH Medications
GnRH agonists or antagonists may be considered when first-line hormonal options are not effective or are not appropriate. These medications require careful counseling about side effects and, in some cases, add-back therapy.
Pelvic Floor Therapy
Some patients with chronic pelvic pain develop pelvic floor muscle dysfunction. Pelvic floor physical therapy may be helpful when exam findings suggest muscle-related pain.
Fertility-Focused Planning
For patients trying to conceive, treatment is adjusted to avoid suppressing ovulation when pregnancy is the goal. Fertility evaluation, surgical planning, or referral to reproductive endocrinology may be appropriate depending on the case.
Minimally Invasive Surgery
Laparoscopic surgery may be used to diagnose and treat endometriosis. Surgical planning depends on suspected disease location, severity, fertility goals, prior surgery, and whether deep endometriosis is suspected.
What to Expect at Your First Visit
Many patients arrive after months or years of uncertainty. The first visit is focused on understanding the pattern of symptoms and creating a plan.
You can expect:
- A detailed discussion of your pain history
- Review of menstrual, sexual, bowel, bladder, and fertility symptoms
- Review of prior imaging, medications, and surgeries
- Focused pelvic examination when appropriate
- In-office ultrasound when indicated
- Discussion of likely causes
- A clear plan for treatment, further testing, imaging, or surgical evaluation if needed
The goal is to leave with direction, not dismissal.
Why Ongoing Gynecologic Care Matters
Endometriosis and chronic pelvic pain often require ongoing care. Symptoms may change over time, and treatment may need adjustment.
A relationship-based gynecology approach allows for:
- Continuity of care
- Earlier recognition of symptom patterns
- Better tracking of treatment response
- Coordination with fertility goals
- Timely escalation when symptoms do not improve
- More individualized decisions about medication, imaging, or surgery
Why Chicago Patients Choose Women’s Health Group Chicago
Women’s Health Group Chicago offers structured evaluation for pelvic pain and suspected endometriosis with:
- Physician-led evaluation by Dr. Michael Awad
- In-office ultrasound
- Careful symptom pattern review
- Evaluation for overlapping gynecologic conditions
- Medical treatment options
- Minimally invasive surgical evaluation when appropriate
- Fertility-conscious treatment planning
- Clear communication about next steps
Patients are not asked to accept severe pain as normal. Persistent pelvic pain deserves a careful evaluation.
Take the Next Step
If you have severe period pain, chronic pelvic pain, pain with sex, bowel or bladder symptoms during your cycle, or difficulty conceiving, schedule a consultation with Women’s Health Group Chicago.
A structured evaluation can help identify the most likely cause of your symptoms and guide the right next step.
Frequently Asked Questions
Can you have endometriosis with a normal ultrasound?
Yes. A normal ultrasound does not rule out endometriosis. Ultrasound can detect some endometriomas and signs of deep disease, but superficial endometriosis may not be visible.
Is there a blood test for endometriosis?
No routine blood test can reliably diagnose endometriosis. Diagnosis is based on symptoms, exam findings, imaging, response to treatment, and sometimes laparoscopy.
What does endometriosis pain feel like?
Endometriosis pain may feel like severe cramping, deep pelvic pain, pain during sex, pain with bowel movements, bladder pain, or pelvic pain that worsens around menstruation.
Is painful sex a sign of endometriosis?
Deep pelvic pain during or after sex can be associated with endometriosis, but other causes are also possible. It should be evaluated.
Does endometriosis always affect fertility?
No. Some patients with endometriosis conceive without difficulty. Others may need fertility evaluation, surgery, or reproductive support.
Can endometriosis get worse over time?
It can progress in some patients, but progression varies. Symptom severity does not always match the amount of visible disease.
Do I need surgery to diagnose endometriosis?
Not always as the first step. Some patients are treated based on clinical suspicion, imaging, and symptoms. Laparoscopy may be recommended when symptoms persist, medical treatment fails, fertility goals require direct evaluation, or surgical treatment is being considered.
What is the first step if I suspect endometriosis?
The first step is a gynecologic evaluation focused on symptom timing, pelvic exam findings, ultrasound, prior treatment response, and fertility goals.
