Both polycystic ovarian syndrome (PCOS) and endometriosis are complex conditions that can have a devastating impact on women’s lives, physically and emotionally. Many women will receive their diagnosis of PCOS when they are having fertility issues, and along with PCOS, endometriosis is also a leading cause of infertility. These conditions are quite different from each other, but it is possible to have both.
There haven’t been a large number of studies on the overlap of PCOS and endometriosis, but a few have shown some crossover, mostly in studies on women with infertility. A report published in 1989 showed endometriosis in 16.5% of women with confirmed PCOS in a study of 91 women. (1) In 1994 a study reported that 10% of an infertile group of women had both endometriosis and PCOS, which was 58% of all the PCOS patients in that study. (2) In 1996 a study was done on the combination of PCOS and endometriosis in 274 infertile women. Almost 50% were diagnosed with PCOS, and coexisting endometriosis was found in 11.83% of those. (3)
What is PCOS?
PCOS is a hormone imbalance disorder characterized by inflammation and insulin resistance and an overproduction of male (or androgenic) hormones. PCOS is typically diagnosed when a woman has a combination of the following conditions:
- Irregular or no periods and failure to ovulate;
- Tests showing high androgens or symptoms of high androgens
- Enlarged ovaries containing multiple small follicles (polycystic ovaries).
Some of the symptoms of PCOS include:
- Weight gain
- Irregular or missing periods
- Unwanted hair growth
- Thinning hair on the head
What is Endometriosis?
Endometriosis is a condition where tissue very similar to the lining of the uterus is found throughout the pelvic cavity, including on the ovaries, ligaments, bladder and bowel and the peritoneum (a continuous membrane lining the abdominal cavity and covering the abdominal organs). In some cases, endometriosis has been found to spread to other parts of the body as remote as the gastrointestinal tract or the respiratory tract. This tissue creates a chronic, inflammatory reaction that can cause major pain and scarring.
- Endometriosis affects approximately 1 in 10 women of reproductive age
- An estimated 176,000,000 women worldwide have endometriosis
- Up to 50% of women who are experiencing infertility have endometriosis
- From time of symptom onset to diagnosis patients with endometriosis experience a delay in diagnosis of nearly a decade
How is Endometriosis Diagnosed?
The only certain way to diagnose endometriosis is through a surgery called a laparoscopy where the tissue can be biopsied. Usually, a diagnostic laparoscopy will be combined with the surgical removal of any endometriosis lesions and adhesions.
- Pelvic pain with cycle or throughout cycle
- Heavy/irregular bleeding
- Gastrointestinal symptoms, like IBS
- Pain during bowel movements or urination
- Pain with intercourse
There are currently multiple theories of the causes of endometriosis. Influences on the development of endometriosis may include hormones, inflammation, genetics, immunological process disruption, and environmental toxins.|
What do PCOS and endometriosis have in common?
The causes and symptoms of PCOS and endometriosis may be quite different, but there are some contributing factors that impact on both conditions, including inflammation, hormones, blood sugar, and toxic exposures.
- Inflammation – Women with endometriosis have been found to have higher inflammation markers and higher amounts of prostaglandin E2 (hormone-like substances involved in pain and inflammation) than women without endo. Women with PCOS have also been shown to have higher levels of some markers of inflammation, which may reflect a state of chronic low-grade inflammation. (4)
- Hormone imbalance – Endometriosis symptoms are fueled by estrogen, in fact endometriosis implants can actually make their own estrogen. This is why some of the hormonal treatments prescribed act to suppress estrogen levels in the body. Women with PCOS may not always ovulate, and this creates an environment of estrogen with a lack of counterbalancing progesterone. These conditions could aggravate symptoms in women with PCOS and endometriosis.
- Blood sugar – High blood sugar levels cause more insulin hormone to be released and that results in an excess of prostaglandins which increases the inflammation and pain of endo. Women with PCOS often struggle with maintaining balanced blood sugar due to insulin resistance. When insulin increases this can lead to lower levels of sex hormone binding globulin (SHBG), a protein that binds excess estrogen and testosterone in the blood. When SHBG is low, that allows higher levels of these hormones to circulate. Insulin resistance can also cause the ovaries to produce higher levels of testosterone. You can see how regulating blood sugar can be an important player in reducing symptoms of both conditions.
- Toxins – Links to exposure to many everyday chemicals (called endocrine disruptors) that can interfere with hormones have been made for both endometriosis and PCOS.(5) You can read more about this in detail on my blog.
Although these 2 conditions are distinct, the fact that they can overlap makes being aware of the different symptoms and patterns and getting a clear diagnosis important. Kristin J. Hoch et al, in the Journal of Endometriosis and Pelvic Pain Disorders stated, “our findings support the hypothesis that PCOS and endometriosis coexist in a population of women with infertility, painful periods and chronic pelvic pain.” Symptoms of PCOS and endometriosis can be misdiagnosed and that may contribute to women going through unnecessary years of frustration and struggle without knowing exactly what they’re dealing with. If you have PCOS but are experiencing significant and chronic pelvic pain, you need to pursue finding out the cause.
Excision surgery is considered the gold standard surgical treatment for endometriosis, by removing the implants from the body. But not everyone may have access to the limited number of experienced endometriosis excision surgeons worldwide, and many women also may experience recurrent symptoms or have co-existing conditions that surgery will not deal with.
Hormonal drug therapies, including the birth control pill, may be offered to women with endometriosis with the intent to stop menstrual cycles, change hormone levels and reduce the impact of estrogen. They might temporarily relieve symptoms, but don’t correct the underlying problem, and often can create uncomfortable side effects. After my diagnosis with endometriosis, I was given Provera, a synthetic form of progesterone, and in a couple of months gained 8-10 pounds, had skin breakouts, bloating and digestive issues, and terrible mood swings – I was angry, weepy and miserable! I couldn’t take it by the 9-month mark and decided to end this treatment, and that’s when I really dove into researching natural approaches to manage my health.
It’s been my experience that a whole-body approach using multiple strategies to support your health at every level can put the body in the best position to heal. Depending on your individual situation, this may include some combination of surgery, hormonal and/or pain medications, and specific nutrition and lifestyle changes to support the immune system, improve hormone and blood sugar balances, detoxify the body and reduce inflammation. Using therapies like pelvic floor physical therapy, acupuncture, stress management, and mind/body practices were also crucial in my personal healing path with endometriosis.
Trying to put all this together may seem overwhelming – I know I was feeling that way in my first year after diagnosis. One of the most important things I learned from my journey with endometriosis is that you have to put yourself in charge of your own health; the more knowledgeable you are about your condition, the more you’ll be aware of all the options available, and the incredible healing your body is capable of doing with the right support.
Susan Tessman is a Certified Women’s Health and Nutrition Coach specializing in supporting women suffering with endometriosis and other chronic pelvic pain conditions using a holistic approach. As a woman with endometriosis she understands the pain and frustration that can be part of the condition and is passionate about supporting women with the information and tools they need to heal. For more resources on natural solutions for endometriosis and pelvic pain please visit www.susantessman.com
(1) Singh KB et al, “Coexistence of polycystic ovary syndrome and pelvic endometriosis”, 1989, Oct; 74(4): 650-2
(2) Kristin J. Hoch et al, “Coexistence of polycystic ovary syndrome and endometriosis in women with infertility”, Journal of Endometriosis and Pelvic Pain Disorders, 2014; 6(2): 78-83
(3) Kichuova D, “Polycystic ovaries in association with pelvic endometriosis in infertile women diagnosed by laparoscopy”, 1996, Folia Med (Plovdiv); 38(3-4):71-3
(4) Antoni J. Duleba, M.D. and Anuja Dokras, MD., PhD, “Is PCOS an inflammatory process?”, 2012, Fertil Steril. Jan; 97(1): 7–12
(5) Palioura E, Diamanti-Kandarakis E, “Polycystic ovary syndrome (PCOS) and endocrine disrupting chemicals (EDCs)”, 2015, Rev Endocr Metab Disord. Dec;16(4):365-71
Felice L. Gersh, MD, “Uterine Fibroids, Endometriosis, Adenomyosis and PCOS: Common themes-etiologies and therapies”, Web
Onofrio Trioloa et al, “Chronic Pelvic Pain in Endometriosis: An Overview”, J Clin Med Res, 2013;5(3):153-163
Sajal Gupta, Avi Harlel and Ashok Agarwal, “Endometriosis and PCOS: Two major pathologies linked to oxidative stress in women”, www.clevelandclinic.org/reproductiveresearchcenter
Wu MH, Shoji Y, Chuang PC, “Endometriosis: Disease pathophysiology and the role of prostaglandins”, 2007, Expert Rev Mol Med, 1 Jan; 9 (2) 1-20
Xue-ya Qian et al, “Is there a relationship between Polycystic Ovary Syndrome and Endometriosis?”, September 2011, Journal of Reproduction and Contraception, Volume 22, Issue 3, PP 177-182