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April 9, 2026
Christine Bürg & Marianne Waldenfels
Endometriosis often goes undiagnosed for years. An expert explains the symptoms, causes and which treatments can help.
© PMC
An interview with
Dr. med. Uta Emmerich
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10 to 15 percent of women of reproductive age are affected by endometriosis – yet many don’t know for years what is causing their pain. Diagnosis often takes a long time. Gynecologist Dr. Uta Emmerich explains why, what symptoms to look out for, and which treatments can help.
Endometriosis is one of the most common – and at the same time most underdiagnosed – gynecological conditions. Symptoms can range from severe menstrual pain to infertility, yet they are often not properly recognized for years. On average, it takes around seven and a half years for a diagnosis to be made.
What exactly is endometriosis – and how can you recognize it?
Endometriosis is a chronic inflammatory, estrogen-dependent condition in which tissue similar to the lining of the uterus grows outside the uterine cavity – for example on the ovaries or the peritoneum. In more severe cases, known as deeply infiltrating endometriosis, organs such as the bladder or bowel can also be affected. A related condition is adenomyosis, where this tissue is found within the muscular wall of the uterus.
Common symptoms at a glance:
Many people live with these symptoms for years or dismiss them as “normal period pain.” But it’s important to know: Severe pain is not normal – and should always be medically evaluated.
We spoke with gynecologist Dr. Uta Emmerich about why endometriosis is so often diagnosed late – and what needs to change for those affected.
On average, it takes about seven and a half years for the diagnosis to be made. Why is that?
There are several reasons for this. On one hand, the symptoms are often nonspecific and overlap with other gynecological and non-gynecological conditions, which can initially lead to misdiagnoses. On the other hand, severe menstrual pain was long normalized or trivialized – and this sometimes still happens today. Additionally, there is still an overall insufficient awareness, both among patients and in the medical field.
Many doctors still refer to laparoscopy as the gold standard of diagnosis. It is a surgical procedure. What do you see as the advantages and disadvantages?
Laparoscopy is no longer considered the gold standard without reservations today. For several years, we have had good clinical and imaging techniques available. The method of first choice is transvaginal ultrasound, possibly supplemented by an MRI of the pelvis. This allows a well-founded suspected diagnosis in many cases.
Surgery is usually the next step and is used selectively – such as when there is suspicion of organ involvement, deep infiltrating endometriosis, noticeable or large cysts, or for patients wishing to have children.
What do you look for when examining a patient suspected of having endometriosis?
The gynecological examination often reveals typical pain points, such as in the area of the posterior vaginal wall. Such findings may indicate deep infiltrating endometriosis. Pain during mobilization of the uterus is also a possible sign – these patients often additionally report pain during intercourse.
Ultrasonography often reveals characteristic changes, such as endometriosis cysts on the ovaries, which have a typical appearance. In the case of adenomyosis, an irregular structure of the uterine wall is often noticeable, such as thickening, small cavities, or an overall inhomogeneous appearance.
In addition, the mobility of the uterus relative to the bladder and bowel can be assessed, which can also provide diagnostic clues. In advanced stages, nodular changes in the pelvis may also be visible. Even subtler changes are now considered important diagnostic criteria.
Let's talk about treatment options. Where do you usually start?
Once the diagnosis is confirmed, treatment usually begins with hormonal therapy – especially for patients with symptoms who currently do not wish to conceive. The first choice is usually a progestin, which is taken continuously and leads to suppression of estrogen production. The goal is to Menstruation auszusetzen und so die Beschwerden zu reduzieren.
Diese Therapie ist in der Regel gut wirksam, vergleichsweise nebenwirkungsarm und kostengünstig. Allerdings sprechen etwa 10 bis 20 Prozent der Patientinnen nicht ausreichend darauf an.
Als zweite Option kommen sogenannte GnRH-Analoga oder -Antagonisten infrage. Diese sind ebenfalls wirksam, gehen jedoch häufiger mit Nebenwirkungen einher, die an Wechseljahresbeschwerden erinnern, wie Hitzewallungen oder Knochenschmerzen, und sind zudem kostenintensiver.
Operative Maßnahmen bleiben eine wichtige Option, insbesondere bei Therapieversagen, bei großen Zysten oder bei bestehendem Kinderwunsch.
Welche zusätzlichen Therapien helfen, die Beschwerden zu lindern? Ich denke da an Osteopathie, Akupunktur oder Ernährung – was würden Sie empfehlen?
Ein zentraler Baustein ist zunächst die Pain therapy. In addition, there is quite good data for some complementary approaches. For acupuncture, for example, there are larger meta-analyses that show significant pain reduction.
Osteopathy can also be helpful, especially after surgical procedures – for example, to alleviate symptoms and prevent adhesions in the small pelvis.
Another important factor is diet. An anti-inflammatory, i.e., anti-inflammatory diet can have positive effects. This includes, for example, an omega-3-rich diet, an overall balanced and possibly calorie-reduced diet, and in some cases, a low-gluten or gluten-free diet. Studies show improvements in both quality of life and pain symptoms.
Also not to be underestimated is exercise: sports in general and especially gentle forms such as yoga can also alleviate the symptoms.
What exactly is the cause of endometriosis?
The exact cause has not been definitively clarified to this day. The most widespread theory is the so-called retrograde menstruation. In this process, cells of the uterine lining reach the abdominal cavity via the fallopian tubes during menstruation and settle there. In addition, genetic factors play an important role – about 50 percent of the risk of disease is associated with this. However, it is not "the one" endometriosis gene, but a complex interplay of various genetic and regulatory influences.
And what role does genetics play?
Genetics indeed plays a significant role – it is assumed to be involved in about half of the development. We also see familial clusters, which further underscores this connection.
There are studies suggesting that bacteria could also be triggers. What is the current status?
Bacteria are probably not the sole cause, but they can play an important role. The current state of research shows that patients with endometriosis often have a disturbed microbiome – in the endometrium, in the vaginal mucosa, in the intestines, or even in the peritoneum. These changes can promote inflammatory processes and immune disorders, which in turn can contribute to the development or worsening of the disease.
Chronic pain is indeed a common consequence. Does that mean the disease lasts a lifetime?
Unfortunately, endometriosis is a chronic condition that cannot be completely cured at present. The primary goal of therapy is therefore to alleviate symptoms and improve quality of life.
In 40 to 50 percent of women with unfulfilled desire for children, endometriosis is the cause. Does that mean, conversely, that about half of all affected women cannot have children?
It cannot be said so generally. The fertility rate in endometriosis is about 30 to 50 percent. However, many patients with a desire for children need support - whether through surgical measures, medication therapies, or assisted reproduction techniques.
There is a new diagnostic method from Australia that can detect endometriosis in menstrual blood. There are also reports of a saliva test. How promising are these approaches - and what is a reliable method at present?
Currently, according to studies, there is no established method to reliably diagnose endometriosis via menstrual blood. There are initial studies showing that menstrual blood could be a promising approach for non-invasive diagnostics – however, these methods are clearly still in the research stage. In the long term, this is certainly exciting, but it has not yet reached clinical routine.
Indeed, a saliva test is now available, also in Germany. The so-called Endo-Test can be conducted through specialized centers or professionals. It has a relatively high accuracy of about 96.6 percent, but it is a self-pay service and quite costly at around 750 euros. Despite these promising data, it has not yet become so established that it is routinely used to secure diagnosis.
So, you have to pay for it yourself?
Yes, currently it is a self-pay service.
Does the health insurance cover the classic treatment?
The established treatment forms are covered. These include both surgical interventions and hormonal therapies, including modern and costly medications – at least within the framework of approved therapies. However, there are differences depending on insurance status: statutory health insurances cover standard treatments, whereas privately insured individuals often have additional benefits covered depending on their tariff.
What advice would you give to women who have these symptoms?
I think it is very important to openly discuss your own complaints and also actively ask: Could it be that I have endometriosis? Many women today come to the consultation already well-informed – they have researched their symptoms and developed a suspicion themselves. That is fundamentally positive.
However, it is crucial to recognize the disease as early as possible to avoid long-term consequences such as an unfulfilled desire to have children. The earlier action is taken, the better it can be counteracted.
Once the diagnosis has been made, I believe it is important for patients to take the disease seriously and actively engage with it. This includes accepting recommended therapies and also independently informing oneself.
There are now many supportive offerings, such as digital health applications. An example is the Endo-App, which provides information, instructions for pain therapies, breathing exercises, and physiotherapy exercises that can also be performed independently.
What is important is: Treatment does not only consist of hormonal therapy. There are many ways to contribute to improving quality of life oneself – however, this also requires initiative and a conscious engagement with the disease.
The good news: With the right therapy, the symptoms can be significantly alleviated in many cases.
