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Many women have unexplained chronic pelvic pain for years before they are diagnosed with endometriosis. Traditional endometriosis treatments often involve the removal of the ovaries to minimize pain. At Johns Hopkins, our expert physicians use minimally-invasive techniques to help her manage endometriosis pain and also potentially save her ovaries, increasing the chances of conceiving her own child if she wishes.

What is endometriosis?
Causes of endometriosis
Symptoms of endometriosis
Diagnosis of endometriosis
Treatment options
Johns Hopkins approach to treatment
Research at Johns Hopkins

What is endometriosis?

Endometriosis is a benign disorder characterized by the presence of endometrial tissue (the tissue that lines the uterus) outside the uterine cavity where it grows on the surface of reproductive, chest, abdominal and/or pelvic organs.

Endometriosis implants are often superficial (coating the surface) but can invade surrounding structures or even grow into a mass, such as an ovarian cyst or tumor, within the uterus or abdominal wall. It is associated with inflammation which results in adhesions, scar tissue, and distorted anatomy. Cysts may range from the size of a pinhead to the size of a grapefruit; cysts, scars, and adhesions may all lead to infertility.

Endometriosis is a common disorder, most prevalent between the ages of 25 and 40. Symptoms vary and are not strictly correlated with the severity of the disease; they may worsen with time, but tend to diminish during pregnancy and cease with menopause. Many women have no symptoms at all. Treatment depends on the severity of symptoms, the age of the woman, and whether she wishes to have children.

Causes of endometriosis

The cause of endometriosis is unknown. Hereditary factors may be involved. Hormonal changes or recent pelvic surgery may promote endometriosis.

Symptoms of endometriosis include:

  • Pain in the pelvis, lower abdomen, and lower back. Pain often begins just prior to monthly periods, continues during menses, and worsens just after the cessation of blood flow.
  • Abnormal or heavy menstrual bleeding
  • Vaginal pain during sexual intercourse
  • Diarrhea, constipation, or pain during bowel movements
  • Bleeding from the rectum or blood in the urine during menses
  • Nausea and vomiting just prior to monthly periods
  • Pressure related symptoms impacting the bladder or bowels due to a large mass of endometriosis
  • Infertility or subfertility: Endometriosis is one of the most common causes of infertility.


A pelvic examination may reveal a suspicion of endometriosis. The doctor presses upon the uterus and ovaries to feel for any abnormalities. A definitive diagnosis requires:

  • Direct visualization of endometrial tissue
  • Biopsy or sampling of the extrauterine endometrial tissue. This is usually done by laparoscopy (the insertion of a thin, lighted camera into the abdomen through a small incision at the belly button). 
  • If you are diagnosed with endometriosis while undergoing laparoscopy, your doctor may remove the endometrial tissue during the procedure.

Laparoscopy has several benefits:

  1. It provides many women with symptomatic relief for a number of years
  2. Increases a patient's fertility and subsequent chance of pregnancy by minimizing scar tissue formation (adhesions)
  3. Results in minimal scarring and a speedier recovery period than a traditional open surgery

Treatment options include:

  • Your doctor may prescribe low-dose oral contraceptive pills. They work by suppressing ovulation and menstruation, thereby keeping symptoms under control. Evidence also suggests that this treatment may reduce the endometriotic implants. Over-the-counter pain relievers may be taken for mild menstrual pain.
  • Danazol, progestins, or Gn-RH (gonadotropin-releasing hormone) agonists may be administered to halt menstruation for three to six months in an effort to shrink endometrial tissue.
  • Surgical removal of the tissue may be required to relieve severe symptoms or to allow impregnation. Tissue may be destroyed by heat (electrocautery) or removed with lasers during laparoscopy (usually done on an outpatient basis under general anesthesia).  A hysterectomy, the surgical removal of the uterus (and sometimes other reproductive organs), may be advised in severe cases. Hormone replacement is required if both ovaries are removed.
  • Minimally-invasive or robotic surgery is available at Johns Hopkins for treatment of endometriosis.  Advantages of a minimally invasive approach include less bleeding, infection, less pain, faster recovery and return to normal function.

Our Approach to Endometriosis

At Johns Hopkins, we use the very latest technology to diagnose and treat endometriosis. We also rely on a team of experts that extends beyond the gynecology department to manage this and other conditions that result in chronic pelvic pain. Our multidisciplinary team includes professionals in:

  • Urogynecology
  • Reproductive endocrinology
  • Gastroenterology
  • Anesthesiology
  • Physical therapy

Whether a woman is planning to have children is the most critical question our endometriosis team at Johns Hopkins will ask. This will define future treatment options and the optimal approach to treatment.

In our physicians’ experience, too often women are offered surgery as a way to minimize their pain by removing the ovaries.  At Johns Hopkins, our physicians will always try the conservative treatment option, saving the ovaries, which can save child bearing potential and prevent menopausal symptoms.

Our physicians will operate on the ovaries conservatively and rely on experienced colon rectal surgeons who can provide assistance and guidance during the surgery.  Further, Johns Hopkins provides minimally invasive surgery for removing cysts.

While endometriosis cannot be cured, our physicians can help women learn to manage the pain without unnecessary sterilization.  Further fertility treatments are available at the Johns Hopkins Fertility Center.

Research at Johns Hopkins

Understanding the causes of pelvic pain and finding innovative treatments for endometriosis are priorities among Johns Hopkins gynecological researchers. Learn more about our endometriosis research.