Period Pain and PCOS – it actually might be Endometriosis

By Clare Goodwin

Last updated: September 3, 2020

Do you have PCOS and Period Pain?  Severe period pain is actually not a symptom of PCOS and is more likely to be endometriosis.  Having both PCOS and endometriosis is more common than you might think, so read below to see if any of the symptoms sound like you.

I was working with a woman called Tara*. Tara had come off the pill to get pregnant. A year later and no success, she was diagnosed with PCOS. She was suffering from weight gain, severe sugar cravings and hangry attacks, fatigue and missing periods.

I sent Tara for some tests and identified that her insulin and stress hormones weren’t working optimally. After addressing these, she had some incredible results: she lost an amazing 29 pounds, and got a regular period for the first time in 16 years. She also found that her gut health improved massively, was sleeping better, was no longer getting hangry attacks and her energy improved immensely.

However, after getting her period back regularly for a few months she still wasn’t pregnant, and some other symptoms had appeared.

Her period pain was getting worse, intercourse was painful, as was trying to pass a bowel movement. After doing some of her own research, she detected that some of her symptoms sounded an awful lot like endometriosis.

Her primary care doctor agreed that she had many of the symptoms of both PCOS and endometriosis and referred her onto a gynaecologist for an internal exam. The internal exam confirmed that she had  PCOS and endometriosis and they were able to remove this scar tissue/lesions at the same time.

Then a few months post surgery, she was able to fall pregnant.

What is Endometriosis?

Unlike PCOS, endometriosis is not a hormonal condition. It’s an inflammatory condition where uterine-like lining (what sheds when you get your period), grows in other parts of your abdomen. It often grows on the ovaries and colon, and causes severe pain, scarring and infertility. Endometriosis affects up to 1 in 10 women.

How is Endometriosis Diagnosed

Diagnosis of endometriosis is quite tricky at the moment because there is no straightforward blood test (although this is very close to being available). It usually requires you to fit many of the symptoms and then a pelvic exam or ultrasound will be undertaken. If they can’t see or feel any lesions from this surgery, you may be referred for a laparoscopy. This is a surgical procedure where they make an incision near your navel for a laparoscope (camera) to fit in and find endometrial tissue. If they do find it, it can often be removed there and then so you only need the one surgery.

How is Endometriosis linked to PCOS?

Clinically, we see many women with both PCOS and endometriosis. Like Tara, I often see that endometriosis symptoms start to show after PCOS symptoms start to resolve because endometriosis is sensitive to oestrogen. If, like Tara, you haven’t had a period in a while or you’ve been on hormonal contraceptive, then your oestrogen is going to be fairly low. However, when you get your period back, or come off hormonal birth control, your oestrogen will rise and endometriosis may flare up.

What causes Endometriosis?

It would be wrong to say that we know exactly what’s going on with both PCOS and Endometriosis (especially when new research is coming out every week), however what we do know is that endometriosis is  a chronic inflammatory disease, and when inflammation is involved, so is the immune system.

There is also research to support that the immune dysfunction might be caused by bacteria.

Women with endometriosis have a high level of gram-negative bacteria and the bacterial toxin LPS (lipopolysaccharide) in their pelvis, which has been shown to contribute to endometriosis.

What are the symptoms of Endometriosis?

Two of the main symptoms of endometriosis are period pain and infertility which can often be mistaken for just PCOS.

Severe period pain

It’s a misconception that severe period pain is a symptom of PCOS. The pain I’m talking about here is the pain that makes you need to miss school, work or social events, have vomiting or nausea or take high dose painkillers to prevent the pain. This kind of pain is not caused by PCOS and is more likely caused by endometriosis.


Infertility is a symptom of both PCOS, and endometriosis. The endometrial tissue lesions can block the fallopian tubes stopping the sperm and egg meeting which can cause infertility.

I’ve compiled a file of some of the main symptoms of Endometriosis  in a download. Print the consultation questionnaire to check the symptoms you have and use this as a talking tool with your primary care doctor.

What are the treatments for Endometriosis?

I’ll split this up into conventional medical treatments and functional medical treatments. I most often see women with PCOS and endometriosis benefiting from a combination of both conventional and functional medicine treatments.

Conventional medical treatments:

  • Hormonal birth control: Hormonal birth control is generally prescribed as a treatment for endometriosis pain. Although endometriosis is not a hormonal condition, hormonal birth control stops ovulation and the production of oestrogen. This slows the growth of the endometrial tissue, but is not without side effects and the evidence for it’s effectiveness on pain is lacking. A Cochrane review concluded that there was insufficient evidence that hormonal birth control improved pain in endometriosis. Additionally, a recently released study of 1 million Danish women, found that those taking the oral contraceptive pill are 23% more likely to be diagnosed with depression and those taking the combined oral contraceptive were 34% more likely. The Mirena coil can be a great alternative for some women with endometriosis. It stops endometrial tissue growing but doesn’t shut down ovulation and oestrogen.
  • Laparoscopy (Surgery to identify and remove the lesions): Removing the lesions helps relieve the pain and improve fertility, but the research shows that they grow back within 5 years in 50% of cases. This is why surgery needs to be combined with the functional medicine treatments to address the immune/ biome component and slow/stop the tissue growth.

Functional medicine treatments:

Functional medicine focuses on treating the root cause of disease, so it focuses not the immune component of endometriosis. I have seen many cases where this works well combined with surgery. For many women, it can slow or even stop the growth of the lesions, but they most likely need to have the existing tissue removed by surgery.

  • Remove foods that may promote inflammation:
    • Gluten can promote inflammation even in non-coeliac patients. 75% of women with endometriosis reported a statistically significant reduction in pain after 12 months on a gluten free diet. This wasn’t a small study either, with 207 endometriosis patients included.
    • Dairy, especially A1 casein protein containing (conventional) dairy can also promote inflammation. While the research is not available for the effect on endometriosis symptoms, and to be fair is still in its infancy for A2 milk in general, both human rat studies have shown a higher level of inflammation with A1 milk products. Additionally dairy stimulates insulin which worsens PCOS symptoms in most women. So if you have both PCOS and Endometriosis, remove dairy entirely for at least 3-6 months and see if this helps your symptoms.
  • Try a Low FODMAP diet: As well as the above dietary recommendations, a low FODMAP diet has been found to help relieve the symptoms of endometriosis. FODMAPs are food for your bacteria, and when fed the bacteria cause the abdominal pain you might be experiencing. By removing the FODMAPs, you reduce the bacterial overgrowth and potentially improve your symptoms.
  • Take N-Acetyl Cysteine (NAC): NAC is a potent anti-inflammatory supplement as it’s the precursor to the mother of all antioxidants, glutathione. NAC is known as the master antioxidant, because it gobbles up 100 inflammatory molecules compared to the 5 other antioxidants like vitamin C do. NAC has been shown to be super effective for women with endometriosis. 50% of women in the study that were treated with NAC had such amazing improvements in their symptoms they actually cancelled their laparoscopy! The amount of NAC used in the study was 600mg 3 times a day for 3 consecutive days in the week and then 4 days without.

*Not real name to protect privacy