The Relationship Between PCOS and Endometriosis

Questions like, “Can you have PCOS and endometriosis at the same time?” and “What is the difference between PCOS and endometriosis” are common Google searches for a good reason: both of these reproductive health conditions are chronic, under-diagnosed, and not talked about nearly enough in our current healthcare system. As such, in this article we’ll be covering the signs and symptoms of endometriosis and PCOS (and yes, discussing crossover symptoms!), talking about the relationship between these disorders – according to the research – in addition to some strategies on how to treat them.

Important note: With that being said, if you suspect you have PCOS or endometriosis, it is of utmost importance you speak to your primary care physician about your symptoms. PCOS and endometriosis are serious conditions, which need to be managed with care, but sometimes they can also be indicative of other issues (such as a thyroid disorder), or something else altogether! The only way to know for sure what’s going on is to book an appointment with your doctor to investigate further.

Let’s dive in.

What is endometriosis?

Defining endometriosis

Endometriosis is a gynecological condition that affects between 2% and 10% of American women. It is characterized by uterine lining that grows in the wrong places (specifically, outside the uterus), and when it sheds, it can result in extremely unpleasant, uncomfortable, and – in the worst cases – extremely painful symptoms. In a regular menstrual cycle, it is normal for tissue to build up and consequently shed in the uterus if a woman does not conceive during ovulation, but in women with endometriosis, their bodies respond to the hormonal changes of the menstrual cycle by building up and shedding this tissue in other places, such as the ovaries, fallopian tubes, pelvic cavity, ligaments that support the uterus, and many more locations, including (less commonly) the intestines, rectum, cervix, vulva, bladder, and vagina.

According to Johns Hopkins Medicine, unfortunately, this building up and breaking down of tissue can lead to “inflammation, swelling, and scarring of the normal tissue surrounding the endometriosis implants.”

How does one develop endometriosis?

Many women with endometriosis wonder what the risk factors are for this condition, and unfortunately, any woman can develop endometriosis. Women with increased risk seem to be:

• Those who have a first-degree relative with the disease,
• Women giving birth for the first time after 30, and
• Women with an “abnormal uterus”

An abnormal uterus is simply any uterus that is different in shape or size from the average range, and usually means your uterus developed in an unusual way previous to birth. Otherwise referred to as congenital uterine anomalies, these are “malformations of the uterus that develop during embryonic life,” and are somewhat rare, accounting for 5% of all women. It’s worth noting, though, that women with uterine anomalies have been noted in up to 25% of women who experience miscarriages or deliver a premature baby.

Examples of congenital uterine anomalies can include women with didelphys (the two halves of the uterus remain separate), women with septate (a normal external uterine surface but two endometrial cavities), and women with unicornuate (meaning only half of the uterus has developed).

Symptoms of endometriosis

Common signs of endometriosis can include:

• Pain
• This can be during or after sex, as well as in the form of excessive cramps that may be felt in the pelvic area, abdomen, and lower back during and outside of menstruation
• Abnormal menstrual flow
• This can mean heavy flow during periods, or spotting between periods
• Infertility
• Research suggests 25% to 50% of women who are infertile have endometriosis and between 30% and 50% of women with endometriosis are infertile
• Painful urination during menstrual periods
• Painful bowel movements
• Diarrhea, constipation, and nausea

As a point of comparison, here are the symptoms of PCOS:

• Hirsutism (excess hair growth on areas of the body and face, such as chest, back, backs of thighs, cheeks, and neck).
• Irregular periods, absent periods, or heavy period flow
• Infertility
• Due to lack of frequent ovulation, women with PCOS can struggle getting pregnant
• Ovaries that have cysts
• Acne or oily skin
• Hair loss (this usually occurs around the crown of the head, with the hairline remaining intact on women)

As you can see from above, there are some symptoms that clearly signal PCOS that have nothing to do with endometriosis. Specifically, signs of androgen excess (an imbalance of testosterone) such as acne, hair loss, and hirsutism are all isolated to PCOS, while painful urination between periods, painful bowel movements, and pain during or after sex, are all specific to endometriosis. This is not to say that PCOS and endometriosis are unrelated, however: the crossover symptoms between PCOS and endometriosis often include heavy menstrual bleeding, painful periods, and infertility. What’s more, you can have PCOS and endometriosis at the same time, and there is increasing evidence that women with PCOS are more likely to be diagnosed with endometriosis.

Relationship between PCOS and Endometriosis

One 2015 study that examined over 2500 women hospitalized with PCOS, and over 25,000 women without PCOS, found that “women with PCOS had more hospitalizations for treatment of gynecological conditions.” The paper notes they were at higher risk for a diagnosis of endometriosis and endometrial glandular hyperplasia compared to women without PCOS who had been hospitalized. (Endometrial glandular hyperplasia is when the uterine lining is thickened, causing heavy or abnormal bleeding, and it can raise the risk of endometrial or uterine cancer).

Another smaller study that examined 40 women with PCOS compared to over 100 women without PCOS of the same age and found that “a significant association between endometriosis and women with PCOS with pelvic pain and/or infertility was found.”

Finally, a third study pointed out that high androgen levels, as well as insulin sensitivity, may elevate levels of estradiol, and “may have a major impact on endometriosis occurrence and development.”

Though not a definitive conclusion, increasing research seems to indicate that women with PCOS may be at increased risk for developing endometriosis; this is not to say that PCOS directly causes endometriosis by any means, but that potentially physiological factors that promote PCOS may indirectly contribute to the development of endometriosis. Of course, this won’t be the case for all women with PCOS, and research is still ongoing, but it is worth noting that it is possible to have both PCOS and endometriosis at the same time.

How To Treat PCOS and Endometriosis

PCOS and endometriosis may be related, but they both have different methods of treatment. For instance, when it comes to managing endometriosis, the following avenues are often explored:

• Hormone therapy
• This can include hormonal birth control or other prescriptions, but generally the goal is to halt ovulation and the hormones that precede and follow, which often prompts the development and shedding of lining outside the uterus in women with endometriosis
• This can also include Gonadotropin-releasing hormone agonists which also works to suppress ovulation and reduce estrogen levels
• Laparoscopy
• This minimally-invasive procedure involves a doctor inserting a laparoscope, a tube with a lens and light, into the abdominal wall and using this tool to see into the pelvic area and remove the endometrial growths
• Hysterectomy
• This surgery involves the removal of the uterus and potentially the ovaries as well.
• Pain relief
• Heating pads, over-the-counter pain reliever medications, and other forms of at-home self care can also be essential to protecting both your mental and physical health during painful periods of endometriosis.

Unfortunately, just like PCOS, there is no cure for endometriosis at this time; instead, physicians and specialists rely on the above treatment options to mitigate symptoms.

For PCOS, there is some crossover with the treatment options above, though for many women (and physicians) the goal is to get women with PCOS ovulating again, as opposed to preventing ovulation. Women with PCOS are generally referred to the following treatment options to combat symptoms:

• Birth control
• To help balance hormones, particularly elevated levels of estrogen and androgens, women with PCOS are often prescribed birth control pills or the hormonal IUD. This option is not for everyone, though: for women wanting to get pregnant, or for those who don’t want to (or can’t) tolerate hormonal birth control, this option is skipped over.
• Metformin
• Used to lower blood sugar levels and insulin resistance, metformin is often used in order to stimulate ovulation in women with PCOS.
• Supplements
• This is a great alternative to traditional medicine, or can be used in conjunction with it under guidance of your doctor, as supplements like zinc, magnesium, berberine, B-complex, and fish oils can all be helpful in managing symptoms. Check out our article on navigating the world of supplements to understand the roles each of these can play in helping with PCOS!
• Nutrition
• We really can’t understate the importance of a nutrient-dense, satisfying diet when it comes to managing PCOS. Honoring cravings, eating more high-fiber, high-protein meals, consuming healthy fats, and avoiding processed foods as much as possible can work wonders when it comes to: preventing sugar spikes and crashes, controlling insulin levels, and feeling full and satisfied. Learn more about what the PCOS plate looks like, here.
• Exercise
• Good for your body and mind, regular exercise helps reduce inflammation, alleviate anxiety, improve sleep, and release endorphins!

Allara Health provides personalized treatment for hormonal, metabolic & gynecological conditions that utilizes a holistic plan that merges nutrition, lifestyle, medication and supplementation, and ongoing, expert support to heal your body.