If you’re struggling to conceive and frustrated by the lack of answers as to why, or if you’ve been given the diagnosis of “Unexplained Infertility,” undiagnosed or “silent” endometriosis should be on your radar. 

Why It's So Important To Diagnose Endometriosis (If You Have It)

Endometriosis is present in at least 25-40% of women struggling to conceive, and it is my opinion (and the opinion of many other thought leaders, scientists and forward-thinking medical doctors) that the longer you have been unsuccessfully trying to conceive and the more advanced fertility treatments you’ve failed, the higher your likelihood of having endometriosis is. 

In these cases, the chances of undiagnosed endometriosis could easily be 70% - 85%

Let that sink in for a minute.

And yet it isn’t even on the radar for most OB GYNs or Fertility Specialists unless it’s smack-you-in-the-face obvious. And even then it remains a challenge.

This can be a huge issue for women trying to conceive, because undiagnosed and mismanaged endometriosis can sabotage every single step of conception and pregnancy regardless of HOW you conceive. 

This means even if you are considering fertility treatments or have tried them in the past, endometriosis can negatively impact your chances of success. 

Diagnosing Endometriosis Can Be An Uphill Battle

So now you can see how important it is to diagnose endometriosis (and then treat it properly). Yet this is easier said than done. Doctors may be quick to dismiss the notion of endometriosis, and that in and of itself can be challenging, as the gold standard for diagnosing endometriosis remains diagnostic laparoscopy and histology. 

These are fancy pants words for having surgery with a very small camera to visualize or see endometriosis and then take biopsies to be sent to the lab so that they can confirm that there are changes in the cells that are consistent with endometriosis.

And last I checked, even though I love empowering women to take control of as much of their fertility as possible, do-it-yourself surgery just isn’t on the table. 

So you have to get your doctor on board.

And one of the best ways that I’ve found to do this is to do your research and prepare ahead of time. This way you’ll have personal evidence as well as scientific data (that you can swipe from below) to back up your findings and concerns.

This also helps to build your confidence, not only in your conversations with your doctor, but in yourself as you begin to really listen to your body and translate what it is saying to you.

How Do You Know If You Could Be At Risk??

So now you might be concerned (and rightfully so) that you could have undiagnosed endometriosis. But how do you know?? 

There are MANY ways to determine if you could be at risk of having undiagnosed or “silent” endometriosis, but today I want to focus on your menstrual cycle and the clues it could be giving you.

Some of these can come from general observations (like how long your cycle lasts), but others come from more detailed and advanced insight (like your core body temperature), which is why I ALWAYS recommend (and I mean strongly recommend) that my fertility clients use the OvuCore monitor. It’s really a non-negotiable.

And I’m not saying this because I’m writing a blog post for the OvuSense website. In fact, I get nothing from this post, other than the satisfaction of helping women get and stay pregnant.

I’m saying it because I’ve seen how the insight from OvuCore can change women’s lives (even when they’ve failed fertility treatments in the past).

It’s definitely food for thought.

You see, not only will it help you to gather and study the information we’re about to cover, but it will also help you prepare for those conversations with your healthcare provider that we were just talking about. 

Infertility already feels like a tornado of unanswered questions and guessing. Let’s eliminate as much of that as possible so that you can find clarity and focus, shall we? 

Ok, on with the show.

A few DISCLAIMERS before we dive in:

  • The following observations don’t automatically mean you have endometriosis, but they raise red flags for the possibility. They simply mean that these signs, symptoms and patterns seem to either be more prevalent in women with endometriosis or associated with endometriosis.
  • Conversely, if you have NONE of these “signs or symptoms,” that doesn’t mean you can cross endometriosis off the list and rule it out completely
  • All of this is part of a whole human evaluation (including history, signs, symptoms, lab findings diagnostic studies etc)
  • There’s no quick answer, BUT, what we CAN do is collect bits of intel that give more and more insight into what is happening inside our bodies and what next steps to consider.

With that being said, here are the 3 ½ clues that your menstrual cycle could be giving you that you might be at risk of having undiagnosed endometriosis.

#1: Late Decline in Basal or Core Body Temperature After The Start of Your Period 

Typically there is a direct association between the start of your period and a drop in core body temperature. However, in some cases, your period starts and your core body temperature stays elevated or lags a couple of days behind. 

This is called a late decline, and several admittedly older studies (like this [Endometriosis and basal temperature] - Abstract - Europe PMC and this Basal body temperature and endometriosis. - Abstract - Europe PMC) have shown that this could be associated with or more common in women with endometriosis. 

Specifically, core body temperature tends to remain elevated for about 3 days (starting the first day of the menstrual cycle) on average in these scenarios.

#2: Premenstrual Spotting That Lasts 2 or More Days

This is a big red flag for me that raises my suspicion of endometriosis when I’m working with women that are struggling to conceive or maintain a pregnancy. 

Not only have studies identified this pattern in women with infertility who then go on to have endometriosis confirmed with surgery (which we’ll discuss in just a moment), but I have personally and anecdotally witnessed it regularly. 

More often than not (and again, this is unofficial, unpublished good-old-fashioned paying attention type stuff), when women I work with have consistent premenstrual spotting, we will ultimately find endometriosis. 

But back to the “official” science. Studies identifying this pattern go way back like this study (Premenstrual spotting: its association with endometriosis but not luteal phase inadequacy - PubMed (nih.gov) from 1980. The group of women was somewhat small, but of the 23 patients diagnosed with endometriosis, 35% had premenstrual spotting that lasted 3 or more days.

More recently, in 2014, another study (Premenstrual spotting of ≥2 days is strongly associated with histologically confirmed endometriosis in women with infertility - PubMed (nih.gov) was conducted with women that presented to an infertility clinic and ultimately had laparoscopy (surgery) to evaluate why they weren’t able to conceive. Specifically, they were looking for the presence of endometriosis.

They then went to evaluate how prevalent premenstrual spotting was in the women who had endometriosis diagnosed via laparoscopy. 

What they discovered was that endometriosis was significantly more prevalent in subfertile women who reported premenstrual spotting for ≥2 days relative to women without this symptom (89% [34/38 women] vs 26% [11/42 women]; P < .0001). That “P < .0001” means that this was very statistically significant. Which means it was very unlikely to be the result of chance.

Translation: Women struggling to conceive who experienced 2 or more days of spotting before their period had an 89% chance of having endometriosis (confirmed with surgery).

#3: Shortened Menstrual Cycle Length (Day 1 of one cycle to day 1 of the next)

So this one is interesting. In 2016, a rather large study (Length of Menstrual Cycle and Risk of Endometriosis (nih.gov)) was published that showed that a menstrual cycle length shorter than or equal to 27 days increases the risk of endometriosis and cycle length longer than or equal to 29 days decreases the risk.

This study was a meta analysis of 11 case-controlled studies. That means that the researchers looked at all of the research that had been conducted studying correlations between menstrual cycle length and endometriosis. They took all of this info and combined and analyzed it statistically. 

Ultimately, the data of 3392 women with endometriosis and 5006 controls (without endometriosis) was used to come to their conclusions. That’s a pretty hefty amount of information!

What this doesn’t tell us is anything about the specifics: like follicular phase or luteal phase length. It’s ONLY cycle length, but it’s still quite interesting. And revealing!

But Talia, What About Luteal Phase Defect (or Insufficiency)?

Well, since you asked, I’ll go on just a tiny tangent about this one. 

It’s my opinion, and this is largely confirmed with studies like this (Endometriosis and luteal phase defect - PubMed (nih.gov)) and this Mild endometriosis and luteal function - PubMed (nih.gov)) that the incidence of LPD (luteal phase defect) is similar between women struggling to conceive with and without endometriosis. 

You can find studies that both support and refute this association (like this one [Luteal function in patients with endometriosis] - PubMed (nih.gov))..

But if I may be frank, when it comes to endometriosis, to me it’s less about the ability of the corpus luteum to make progesterone and more about the ability of progesterone to do its thing. Meaning, endometriosis impacts the ability of progesterone to do what it needs to do (specifically in the uterus) by causing progesterone resistance

THIS is the elephant in the room. THIS is why women with endometriosis can have normal luteal phase progesterone levels or use progesterone supplementation (vaginally or PIO) and STILL have symptoms of NOT having enough progesterone (like implantation failure and miscarriage). 

It’s just one of the many ways that endometriosis sabotages even the best fertility efforts. 

But I digress. Back to the menstrual cycle. 

Now I promised 3 and A HALF signs, so what about the “½?” 

I made this one a “½” because it’s less of an obvious sign and more about what isn’t happening. So here’s what I mean by this nonsense.

#3 1/2: The Lack of Any Obvious Menstrual Signs or Patterns (But Persistent Infertility or Unexplained Infertility)

If you’re trying to conceive AND:

  • You’re ovulating (confirmed with core body temperature monitoring like OvuCore)
  • You’re sexually active during your fertile window
  • You have none of these signs

But you still aren’t getting pregnant, then that alone could point INDIRECTLY to endometriosis.

But how??

Untreated and Mismanaged Endometriosis Can Sabotage Every Aspect of Your Fertility

I don’t call endometriosis the Silent Fertility Assassin for nothing. Sometimes it is so stealthy, that it evades even the best screening attempts. And yet, it can cause:

  • Damage to egg and embryo quality
  • Damage to sperm in the fallopian tubes
  • Inflammation associated with blocked fallopian tubes and adhesions
  • Changes in the uterine environment that are needed for implantation and proper pregnancy development and maintenance

The takeaway message from this is that endometriosis is SO prevalent in women struggling to conceive that it MUST be ruled out as a contributing factor for infertility and pregnancy loss. Period. 

Some Final Words

As overwhelming, frustrating and disheartening as infertility (and now this whole endometriosis possibility) can be, gathering insight and getting answers can begin to shift this experience. 

As you uncover what’s standing in the way of your ability to conceive, you gain clarity and the ability to make decisions that are informed, empowering and that actually get results. 

If you’d like to join me on a journey to uncover this and many other hidden roadblocks, so that you can reduce or eliminate them and drastically improve your chances of getting and staying pregnant, check out The Fertility Answers Workshop here (https://www.fertilityunderground.com/answers) . 

About Talia

  • Talia Lavor is a Physician Assistant and Fertility Coach 
  • She struggled for years to conceive and failed multiple aggressive fertility treatments with no clear answers or explanations (which she found slightly ironic considering she was practicing as a Women’s Health PA)
  • She was finally able to conceive naturally (twice) after discovering the root causes of infertility and how to reduce or eliminate them.
  • She has since founded The Fertility Underground, whose mission is to help women and couples reclaim their fertility freedom so that they can get and stay pregnant with a healthy baby regardless of their fertility past.
  • Check out The Fertility Underground Podcast here (The Fertility Underground Podcast • A podcast on Anchor)