Endometriosis - a prevalent but often underestimated condition

EDITORIAL Irish Journal of Medical Science (1971 -) (2026) 195:223–224 https://doi.org/10.1007/s11845-025-04143-8 often have mild-moderate disease while some women with severe disease have few or no symptoms. Infertility can be the main manifestation of disease for some women and up to 50% of women with infertility have endometriosis [ 2]. Some of these women are asymptomatic or do not recognise their symptoms as abnormal until they receive a diagnosis of endometriosis during their infertility workup. Endometriosis may be suspected clinically based on symptom history and physical examination findings. Ultra - sound and MRI may also support a diagnosis of disease where ovarian involvement (endometriomas) or deep nod - ular disease are detected. Definitive diagnosis is based on laparoscopic visualisation and histological confirmation of disease. Women should be informed that laparoscopy has surgical and anaesthetic risks, and that surgery may be avoidable with successful empiric treatment. Empiric treat- ment can sufficiently manage endometriosis symptoms for many women, and it should be initiated in primary care. The choice of empiric therapy depends on the severity of symptoms and the woman’s reproductive aspirations. Non- steroidal anti-inflammatory drugs (NSAIDs) are frequently used to manage pain, but they do not address the underly - ing disease. Hormonal treatments including combined oral contraceptives, progestin-only contraceptives and gonado - tropin-releasing hormone (GnRH) analogues aim to reduce or suppress oestrogen levels, thus suppressing the disease process. Surgery is typically recommended for women with persistent symptoms despite medical therapy, for women who cannot tolerate medical therapies due to side effects, or for women with infertility where endometriosis may be a contributing factor. Laparoscopy is the gold standard for diagnosis and for the removal of endometriotic lesions for symptomatic relief - this may involve excising or ablating lesions, removing scar tissue, and, in severe cases, address- ing organ involvement with the input of colorectal surgeons and urologists. Additional supportive therapies play a cru - cial role in addressing the multifaceted nature of endome - triosis. Pain management clinics and pelvic physiotherapy can help manage chronic pain, while counselling and cogni- tive behavioural therapy can improve the mental health of Endometriosis is a challenging chronic disease that deserves increased recognition, not least because the diagnosis is often delayed, and the implications can be life altering. The systematic review and meta-analysis published by Özcan et al. in this journal highlights the importance of support for people with endometriosis to help manage the symptoms of their disease and deserves recognition for the work that con- tinues to advocate for high quality and holistic assessment and care [1]. Endometriosis is characterised by the growth of endome- trial-like tissue outside the uterus. It is a hormone-mediated condition driven by oestrogen from the onset of menstrua - tion (menarche). The endometrial-like tissue causes a chronic inflammatory response that can lead to scar tissue formation in the pelvis and in rare cases elsewhere in the body. Various causes have been postulated but none proven. Endometriosis symptoms are highly variable – for some women these symptoms can be debilitating and can severely impact on quality of life. Classically women report lower abdominal/pelvic pain symptoms such as painful periods (dysmenorrhoea), pain during or after sexual intercourse (dyspareunia) and/or pain on defaecation (dyschezia). Some women may report chronic non-cyclical pelvic pain (i.e. not related to their menstrual cycle) while others have no pain symptoms. Additionally, women may present with non-specific symptoms that overlap with other medical con- ditions, such as bloating, nausea and fatigue, while others may experience depression or anxiety. Various classification systems have been developed to categorise disease severity based on the anatomy of endometriotic lesions, however the anatomical severity of disease often does not correlate with clinical symptoms. Many women with severe symptoms David James Rooney [email protected] 1 Specialist Registrar in Obstetrics and Gynaecology, National Maternity Hospital, Dublin, Ireland 2 Consultant Gynaecologist, National Maternity Hospital, St Vincents University Hospital, Dublin, Ireland Published online: 11 November 2025 © The Author(s), under exclusive licence to Royal Academy of Medicine in Ireland 2025 Endometriosis – a prevalent but often underestimated condition David James Rooney1 · Zara Fonseca-Kelly2 1 3 Irish Journal of Medical Science (1971 -) (2026) 195:223–224 those suffering from anxiety or depression related to their condition. It is thought that up to 10% of women and girls are affected by endometriosis globally, but for many a diagno - sis is delayed or remains elusive [ 2]. Barriers to diagnosis and effective treatment include: a lack of education and awareness of endometriosis symptoms amongst the gen - eral public; a lack of training and guidance in endometrio - sis diagnosis and management among healthcare providers including general practitioners and general gynaecologists; challenges for both patients and clinicians in recognising endometriosis due to the heterogeneity of symptom presen- tation – these symptoms often overlap with other medical conditions that may actually be causing or contributing to the patients symptomatology; a lack of access to diagnostic imaging such as ultrasound and MRI; a lack of experience/ training amongst gynaecologists in laparoscopic diagnosis and treatment of endometriosis; a lack of access to specialist endometriosis services with multidisciplinary teams to man- age complex disease; and a lack of access to surgery due to operating theatre waiting lists. The National Framework for Endometriosis Care in Ireland developed by the Health Service Executive (HSE) and the National Women and Infants Health Programme (NWIHP) aims to improve access to endometriosis care through the establishment of five regional endometriosis hubs and two supra-regional specialist centres in Dublin and Cork [3]. The continued implementation of this frame - work (announced in 2023) is of paramount importance for Irish women suffering from endometriosis symptoms and for clinicians who want to provide the highest standards of care in a timely manner. Barriers to the implementation of the framework remain, particularly in the areas of training, recruitment and retention of specialists and in terms of wait- ing lists for access to specialist clinics, diagnostic imaging and theatre. The HSE National Clinical Practice Guide - line on the Assessment and Management of Endometriosis (March 2025) will further improve standards of care for Irish patients as it provides a comprehensive standardised template for the assessment and management of women with endometriosis symptoms and endometriosis-associated infertility [4]. References 1. Özcan H, Çuvadar A, Uzun S (2025) The effect of psychothera - peutic interventions on pain and quality of life in endometrio - sis: a systematic review and meta-analysis study. Ir J Med Sci 194(4):1391–1400. h t t p s : / / d o i . o r g / 1 0 . 1 0 0 7 / s 1 1 8 4 5 - 0 2 5 - 0 3 9 8 5 - 6 2. World Health Organization (2023) Endometriosis [Fact Sheet]. Available at: h t t p s : / / w w w . w h o . i n t / n e w s - r o o m / f a c t - s h e e t s / d e t a i l / e n d o m e t r i o s i s. Accessed 16 Jun 2025 3. Department of Health (2023) Minister for Health announces development of the National Endometriosis Framework [Press Release]. Available at: h t t p s : / / w w w . g o v . i e / e n / d e p a r t m e n t - o f - h e a l t h / p r e s s - r e l e a s e s / m i n i s t e r - f o r - h e a l t h - a n n o u n c e s - d e v e l o p m e n t - o f - t h e - n a t i o n a l - e n d o m e t r i o s i s - f r a m e w o r k /. Accessed 16 Jun 2025 4. DeMaio A, McTiernan A, Durand O, Connor A et al (2025) National Clinical Practice Guideline: Assessment and Manage - ment of Endometriosis. National Women and Infants Health Pro- gramme and The Institute of Obstetricians and Gynaecologists. h t t p s : / / w w w . h s e . i e / e n g / a b o u t / w h o / a c u t e - h o s p i t a l s - d i v i s i o n / w o m a n - i n f a n t s / c l i n i c a l - g u i d e l i n e s / a s s e s s m e n t - a n d - m a n a g e m e n t - o f - e n d o m e t r i o s i s - 2 0 2 5 - . p d f. Accessed 17 Jun 2025 Publisher’s Note Springer Nature remains neutral with regard to juris- dictional claims in published maps and institutional affiliations. 1 3 224