Endometriosis can often be diagnosed without surgery now, so treatment can start sooner

Key takeaways

• European guidance from 2022 and guidance for England updated in November 2024 say imaging and a trial of treatment can come before surgery³⁴⁵.
• A normal ultrasound does not rule endometriosis out, according to England’s National Institute for Health and Care Excellence (NICE), so ongoing pain still deserves follow-up⁴.
• In company-funded trials of a newer hormone pill, 75% of women had meaningful relief from period pain, compared with 27% to 30% on a placebo⁹.
• Diet changes and acupuncture show early promise in small studies, while NICE says the evidence doesn’t support Chinese herbal medicine or supplements⁴¹²¹⁴.
• A French saliva test looks accurate in early studies, but France’s health agency said the data hadn’t yet shown that it improves care⁶⁷.

For decades, there was one accepted way to know for sure whether you had endometriosis. A surgeon made a small cut in your belly, slipped in a camera and looked.

That operation, called a laparoscopy, was the “gold standard.” Many waited years for one. Our article on frustrations with medical care tells part of that story.

In 2022, the European Society of Human Reproduction and Embryology (ESHRE) challenged that standard in a guideline with 109 recommendations². Imaging and a trial of treatment should come first, it said, with surgery held back for when those fail³.

England’s guideline agency followed. In November 2024, NICE updated its advice so that everyone with suspected endometriosis is offered an internal pelvic ultrasound, even when an exam looks normal⁴⁵. Treatment can start while tests are underway⁴.

The World Health Organization (WHO) agrees that surgery isn’t always needed before treatment begins¹. This article covers how diagnosis has changed, what treatments show in real numbers, and where self-care fits.

Endometriosis is more than bad cramps

Endometriosis happens when tissue similar to the lining of the uterus grows outside it. It usually grows in the pelvis but can appear as far away as the chest¹. WHO estimates it affects about 10% of women of reproductive age worldwide¹.

Painful periods are the best-known sign, but not the only one. WHO also lists heavy bleeding, pelvic pain that lingers after a period ends, bloating, nausea and tiredness¹. Pain during sex, bowel movements or urination can occur too¹. Some people have no symptoms at all¹.

Endometriosis can also affect fertility. Among women with infertility, as many as 25% to 50% have it, WHO says¹.

The cause is still unknown. Research points to an immune system that isn’t working as it should. People with endometriosis have higher rates of immune conditions such as lupus, multiple sclerosis and inflammatory bowel disease¹. A mother or sister with endometriosis raises your odds, NICE notes⁴.

There is no cure yet, and no known way to prevent it¹. Treatment aims to ease pain and protect fertility if you want children.

Surgery is no longer the first step to a diagnosis

Laparoscopy still lets a surgeon see growths and take a tissue sample, called a biopsy¹. But it is surgery, and WHO notes that many women can’t get it¹.

ESHRE’s 2022 guideline put imaging, such as ultrasound, ahead of the operating room³. When scans come back negative, a trial of treatment based on symptoms, called empirical treatment, is the next step. ESHRE reserves laparoscopy for people whose scans show nothing and whose trial treatment didn’t help³.

NICE’s 2024 update lays out the steps for family doctors in England⁴:

• Offer a transvaginal ultrasound, where a slim probe is placed in the vagina, to everyone with suspected endometriosis, even if the exam is normal. A scan over the belly is the fallback if someone declines.
• Use a specialist ultrasound or a pelvic MRI, planned and read by an expert, to look for deep endometriosis.
• Don’t use the CA125 blood test to diagnose it.

One catch matters a lot. A normal exam and a normal ultrasound don’t rule endometriosis out⁴. Scans are aimed at cysts on the ovaries, called endometriomas, and at deep growths⁴. If symptoms continue, NICE says laparoscopy may still make sense even after normal scans⁴.

A saliva test shows promise but hasn’t proved it helps patients

ESHRE’s 2022 guideline advised against using blood markers to diagnose endometriosis³. Since then, one new test has reached patients in France: a saliva test called Endotest, made by a company named Ziwig⁷.

The test reads a pattern of 109 tiny genetic molecules called microRNAs⁶. France’s national health assessment agency, the Haute Autorité de Santé (HAS), began reviewing it in 2023. It looked at company-funded data on 237 patients whose scans were unclear and who were headed for laparoscopy⁶. The test caught 95% of those who had endometriosis and correctly cleared 94% of those who didn’t⁶.

HAS called the test innovative. But it said the data didn’t directly show that the test improved patient care, and it asked for a study of whether it really spares people unneeded surgery⁶. It also warned that if 75% of those tested had endometriosis, about 14% of negative results would be wrong⁶.

In December 2025, Ziwig announced that a study of 971 women at 17 French hospitals had been published in the journal NEJM Evidence⁷. The company reported that the test caught 97.3% of cases and correctly cleared 94.1% of women without the disease⁷. It said the test is covered in 100 French hospitals through an early-access program for women ages 18 to 43 with pelvic pain and normal or unclear scans⁷.

By our math, using the company’s numbers, the test would miss about 27 of every 1,000 women who have endometriosis and wrongly flag about 59 of every 1,000 who don’t.

Hormone treatments ease pain for many, and the numbers are real

NICE’s first step is simple: a trial of about three months of acetaminophen (called paracetamol in Britain) or an anti-inflammatory pain reliever such as ibuprofen, alone or together⁴. Our article on period symptoms covers those basics, plus heat and exercise.

Hormone treatments come next, and NICE says they can be offered before a diagnosis is confirmed⁴. Options include combined birth control (a pill, patch or ring) and progestins, such as a hormonal IUD or a shot¹. ESHRE makes hormonal contraceptives or progestins a strong first choice for teens³. NICE says these treatments don’t permanently affect later fertility⁴.

Many natural-health readers are wary of hormones, and that’s a fair concern to raise with a clinician. The trade-off WHO describes is that symptoms can return after treatment ends¹.

A newer class of pills

In July 2018, the Food and Drug Administration (FDA) approved elagolix (Orilissa), made by AbbVie with Neurocrine Biosciences⁸. It was the first pill of its kind for moderate to severe endometriosis pain⁸. Drugs in this class, called GnRH antagonists, turn down the hormone signals that lead the ovaries to make estrogen.

Lower estrogen has a cost: bone loss. In extension studies reported by AbbVie, bone density fell an average of 0.6% to 1.1% after a year on the lower dose and 3.6% to 3.9% on the higher dose, and the loss may not fully reverse⁸. Use was capped at 24 months on the lower dose and 6 months on the higher one⁸.

A second option arrived in August 2022. The FDA approved Myfembree, a once-daily pill from Myovant Sciences and Pfizer, for endometriosis pain¹⁰. It pairs the GnRH antagonist relugolix with small doses of estrogen and a progestin. The companies say the added estrogen may reduce the risk of bone loss⁹.

In the companies’ two SPIRIT trials of more than 1,200 women, 75% of those on the drug had a meaningful drop in period pain at 24 weeks⁹. On a placebo, 27% and 30% did⁹. By our math, that’s about 45 to 48 more women out of every 100.

For pelvic pain between periods, the gains were smaller: 59% versus 40% in one trial and 66% versus 43% in the other⁹. By our math, that’s about 19 to 23 more women per 100. Average bone density dropped by less than 1% over 24 weeks⁹.

ESHRE treats GnRH antagonists as a second-line choice for adults³. In September 2025, NICE linked its drug-assessment guidance into the guideline’s section on these drugs⁵.

Surgery still matters, especially for deep disease and fertility

When surgery is needed, NICE says it should usually be done through small keyhole cuts⁴. The surgeon can cut out or destroy growths and free up scar tissue⁴. NICE suggests considering hormone treatment afterward to make the benefits last, and warns that more surgery may be needed later⁴.

Growths can come back, WHO notes¹. Even removing the uterus, usually along with the ovaries, is not a cure, though it may be an option for some people who don’t plan to have children and haven’t been helped by other treatments¹.

ESHRE also stopped recommending two older nerve-cutting operations for pain³. If a surgeon suggests one, ask why.

For fertility, the advice shifts. NICE says removing endometriosis that doesn’t involve the bowel, bladder or ureter improves the chance of getting pregnant naturally, but hormone treatment should not be used to improve natural pregnancy rates⁴. Medicine to trigger ovulation, insemination and IVF are other paths¹. Our article on fertility myths covers when to seek an evaluation.

Diet, acupuncture and self-care: what the studies show

Self-care is common. In a 2021 survey of 484 Australian women with surgically confirmed endometriosis, 76% had used some form of self-management in the previous six months¹¹. Of those, 44% had changed their diet, most often by cutting gluten, cutting dairy or trying a low-FODMAP diet¹¹.

They rated diet changes 6.4 out of 10 for easing pelvic pain, with no diet clearly better than another, and gut symptoms were what they most often said improved¹¹.

Surveys show what people try, not what works. A 2023 pilot study in the journal Human Reproduction followed 62 women for six months¹². They chose a low-FODMAP diet, a special “endometriosis diet,” or no change, and the diet groups got three months of dietitian support¹².

Women who stuck to either diet reported less pain with sex, less painful urination, less bloating and less tiredness than at the start; the no-diet group’s scores didn’t change¹². Compared directly with that group, fewer differences held up, and the authors stressed that the study was small and not randomized¹².

The gut may be part of the story. In one study of 160 women with irritable bowel syndrome (IBS), 36% also had endometriosis, and 72% of those reported gut relief on low-FODMAP eating¹³. Our guides to IBS and the low-FODMAP diet cover that overlap.

A 2024 review in the journal Nutrients rounded up other studies¹³. One trial of 60 women found less pain with vitamins C and E than with a placebo. A fish oil trial in young people found no significant pain benefit, and vitamin D trials disagreed¹³. Two of the three authors run a dietitian practice and a naturopathy clinic¹³.

NICE says the evidence doesn’t support Chinese herbal medicine or supplements for endometriosis⁴.

Acupuncture has a small but encouraging record. A 2023 review from Western Sydney University pooled six trials with 331 people¹⁴. Against “non-specific” acupuncture used as a control, real acupuncture eased overall pelvic pain and period pain more, with low to moderate certainty.

Most studies reported few side effects¹⁴. Only one to three trials fed each result¹⁴.

WHO includes physical therapy, cognitive behavioral therapy (CBT), team-based pain programs and support groups in endometriosis care¹. We didn’t find strong trials of exercise, heat or pelvic physical therapy in endometriosis alone. That makes them unproven for this disease, not proven useless.

The endometriosis care path, step by step

This table, built mainly on NICE’s steps, shows where you are and what to ask next.

Step	What happens	Typical options	Questions to ask
1. Track	A pain and symptom diary4	Paper or app	“What else could this be?”
2. First visit	History, family history, exam4	About three months of pain relievers; a hormonal pill or progestin4	“Can we start treatment while we test?”
3. Imaging	Transvaginal ultrasound; specialist scan or MRI for deep disease4	Belly scan if you decline an internal one4	“Who reads my scan? What if it’s normal?”
4. Review	Gynecology referral if treatment fails or life is disrupted; teens to adolescent specialists4	Second-line drugs such as GnRH antagonists3	“What are the bone trade-offs?”
5. Surgery, if needed	Keyhole surgery to look, sample and remove growths4	Hormone treatment afterward4	“Will you remove what you find then?”
6. Fertility	Specialist input if pregnancy is a goal4	Surgery for some; ovulation medicine, insemination or IVF14	“Should I see a fertility specialist now?”
7. Long term	Symptoms can return1	Physical therapy, CBT, support groups1	“Who coordinates my care?”

What the evidence says

Approach	What the research shows	Evidence level
Hormonal birth control or progestins for pain	Offered early by NICE; ESHRE’s first choice for teens; pain can return when stopped134	Strong evidence
GnRH antagonist pills	Two large placebo-controlled trials of one pill, run by its makers; bone loss is the main trade-off89	Strong evidence
Scans as the first diagnostic step	Endorsed by ESHRE and NICE; a normal scan can still miss endometriosis, so it’s a first step, not a final answer34	Strong evidence
Saliva microRNA test	Accurate in a company-funded analysis and a larger study the company announced; no proof yet it improves care67	Promising but early
Acupuncture	Six small trials, low to moderate certainty14	Promising but early
Low-FODMAP or other diet changes	Surveys and a small nonrandomized pilot111213	Promising but early
Vitamins C and E	One small trial13	Promising but early
Fish oil, vitamin D	One fish oil trial found no clear benefit; vitamin D trials disagree13	Not enough evidence
Exercise, heat or pelvic physical therapy	No endometriosis-specific trials turned up in our research; WHO includes physical therapy in care1	Not enough evidence
Chinese herbal medicine and other supplements	NICE says the evidence doesn’t support them4	Not enough evidence

Pain, mood and the long haul

WHO lists depression and anxiety among the effects of endometriosis, along with missed work and school and strain on sex lives¹. NICE asks clinicians to check on emotional needs and point patients to support groups and charities⁴.

If pain or worry ever leaves you feeling unable to cope, or thinking about suicide, call or text 988, the Suicide and Crisis Lifeline. It’s open 24/7¹⁵.

Listening to your body is central to natural health, and this condition rewards it. The diary NICE recommends turns “something’s wrong” into a record a clinician can act on⁴. The newer guidelines also reward speaking up: ask for a scan, ask who will read it, and ask what comes next if it’s normal.

Choosing among hormones, surgery and self-care is a real decision with trade-offs. A good clinician will treat your preferences as part of the plan, not an obstacle to it.

Questions readers ask

The bottom line

Endometriosis care no longer has to wait for an operation. Under ESHRE and NICE guidance, symptoms and imaging can lead to treatment first, with surgery kept for when answers or relief don’t come. A normal scan isn’t the end of the road if pain continues.

Hormone treatments have the strongest evidence for pain, with real trade-offs such as bone loss and returning symptoms. Diet changes and acupuncture have early support as additions. Track your symptoms, ask direct questions, and build a plan that fits your goals.

Related reading

• The frustrations that push people away from doctors are real, and you can push back
• What to say when a doctor isn’t taking you seriously
• The low-FODMAP diet is a test, not a way to eat forever
• IBS patients would trade years of life for relief, and proven help exists
• Charting your cycle can prevent or plan pregnancy, and the method makes the difference

Sources

1. World Health Organization. “Endometriosis.” WHO fact sheet, October 15, 2025. who.int
2. Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, et al. (ESHRE Endometriosis Guideline Group). “ESHRE guideline: endometriosis.” Human Reproduction Open, 2022;2022(2):hoac009 (abstract via Maastricht University research portal). cris.maastrichtuniversity.nl
3. Splete H. “Updated endometriosis guidelines emphasize less laparoscopy, more hormone therapy.” MDedge / The Hospitalist, February 9, 2022. blogs.the-hospitalist.org
4. National Institute for Health and Care Excellence. “Endometriosis: diagnosis and management” (NG73), Recommendations. NICE, 2017, last updated 2024–2026. nice.org.uk
5. National Institute for Health and Care Excellence. “Endometriosis: diagnosis and management” (NG73), Update information. NICE, 2026. nice.org.uk
6. Haute Autorité de Santé (Chambon Y, Carbonneil C). “Assessment of the Endotest saliva test in complex endometriosis diagnosis situations” (INAHTA database record). HAS, 2023–2024. database.inahta.org
7. Ziwig (company press release). “Ziwig Endotest: Scientific Validation Published in NEJM Evidence.” PR Newswire / CNW, December 2, 2025. newswire.ca
8. Healio. “FDA approves Orilissa to treat endometriosis pain.” Healio Endocrinology, July 24, 2018. cm.healio.com
9. Myovant Sciences and Pfizer (company press release). “Myovant Sciences and Pfizer Announce Publication in The Lancet of Phase 3 SPIRIT 1 and SPIRIT 2 Studies.” Pfizer, June 17, 2022. pfizer.com
10. Contemporary OB/GYN. “FDA approves Myfembree for endometriosis pain.” Contemporary OB/GYN, August 5, 2022. contemporaryobgyn.net
11. Armour M, Middleton A, Lim S, Sinclair J, Varjabedian D, Smith CA. “Dietary Practices of Women with Endometriosis: A Cross-Sectional Survey.” Journal of Alternative and Complementary Medicine, 2021;27(9). pubmed.ncbi.nlm.nih.gov
12. van Haaps AP, Wijbers JV, Schreurs AMF, et al. “The effect of dietary interventions on pain and quality of life in women diagnosed with endometriosis: a prospective study with control group.” Human Reproduction, 2023;38(12):2433–2446. pubmed.ncbi.nlm.nih.gov
13. Abulughod N, Valakas S, El-Assaad F. “Dietary and Nutritional Interventions for the Management of Endometriosis.” Nutrients, 2024;16(23):3988. pubmed.ncbi.nlm.nih.gov
14. Giese N, Kwon KK, Armour M. “Acupuncture for endometriosis: A systematic review and meta-analysis.” Integrative Medicine Research, 2023;12(4):101003 (Western Sydney University record). researchers.westernsydney.edu.au
15. Substance Abuse and Mental Health Services Administration. “In Crisis” (988 Suicide & Crisis Lifeline). SAMHSA, updated June 3, 2026. samhsa.gov