Endometriosis and Uterine Fibroids (Leiomyomas): The Co-Existing Pelvic Pain Puzzle

If you suffer from chronic pelvic pain, heavy menstrual bleeding, and profound abdominal pressure, you want a single, definitive answer. You want your doctor to point to one specific cause so you can treat it and move on with your life.

Unfortunately, the female pelvis is rarely that simple.

When patients arrive at Endometriosis Surgical Specialists International (ESSI) after years of dismissed symptoms and failed treatments, we frequently discover that they are not fighting just one disease. They are fighting a combination of conditions. One of the most common—and most frequently mismanaged—combinations is the co-existence of endometriosis and uterine fibroids (leiomyomas).

Can they co-exist? Absolutely. In fact, they share common biological drivers. But because standard gynecology often stops looking as soon as it finds one problem, patients with both conditions are routinely under-diagnosed and improperly treated.

Here is the biological reality behind these co-existing conditions and how our multidisciplinary team evaluates the entire pelvic puzzle.

Understanding the Anatomy: Two Different Diseases

While they often occur at the same time and feed on the same hormones, endometriosis and fibroids are entirely different structural conditions.

• Endometriosis: An inflammatory, systemic immune disease where tissue similar to the uterine lining implants outside the uterus (on the ovaries, bowel, bladder, and pelvic nerves). These lesions create dense, sticky scar tissue and microscopic pain generators.

• Uterine Fibroids (Leiomyomas): Benign (non-cancerous) tumors made of smooth muscle cells and fibrous connective tissue that grow in or on the wall of the uterus. They can range in size from a small seed to larger than a grapefruit.

The Common Thread: Estrogen Dominance

Why do these two conditions so frequently show up together? Both endometriosis and uterine fibroids are estrogen-dependent.

They rely on estrogen to grow and thrive. If your body has a high level of circulating estrogen, or if you have a localized inflammatory environment that promotes estrogen dominance, it creates the perfect storm for both ectopic endometriosis lesions and uterine fibroids to flourish simultaneously.

The Diagnostic Trap: The “Distraction” of Fibroids

The co-existence of these two conditions creates a massive diagnostic trap for standard OBGYNs, primarily because of how they appear on imaging.

Fibroids are dense, solid masses. They are very easy to see on a standard transvaginal ultrasound or MRI. Endometriosis, however, can be clear, flat, or microscopic, making it notoriously difficult to spot on standard imaging.

The result is incomplete care. A patient will come in complaining of severe pelvic pain, heavy bleeding, and back pain. The doctor performs an ultrasound, easily spots a 5-centimeter fibroid, and says, “Aha! We found the problem.” The doctor surgically removes the fibroid (a myomectomy) but never inspects the bowel, the pelvic sidewalls, or the deep pelvic cavity.

The patient wakes up, recovers from surgery, and is devastated to find that her sharp, radiating pelvic pain is still there. The fibroid was removed, but the deep infiltrating endometriosis was completely missed.

Deciphering the Symptoms: Which is Causing What?

Because the symptoms overlap so heavily, it requires a true pelvic pain specialist to untangle them. While every patient is unique, the symptoms generally lean in specific directions:

• Symptoms Driven Primarily by Fibroids: Extremely heavy menstrual bleeding, passing large blood clots, a sensation of intense pelvic “heaviness” or bearing down, frequent urination (if the fibroid presses on the bladder), and an enlarged, protruding lower abdomen.

• Symptoms Driven Primarily by Endometriosis: Sharp, stabbing, or “electric” pelvic pain, pain that radiates down the legs (sciatica), severe pain during bowel movements or urination, and deep, sharp pain during intercourse.

(Note: It is also highly common to find a third condition—Adenomyosis, which is endometriosis inside the uterine muscle—co-existing alongside fibroids and external endometriosis).

The ESSI Approach: Total Pelvic Evaluation and Preservation

At ESSI, our East Coast and West Coast surgical hubs do not put on blinders. We know that finding a fibroid is often just the beginning of the diagnostic journey, not the end.

1. Comprehensive Diagnostic Mapping: We utilize specialized imaging protocols and expert clinical evaluation to map your entire pelvic anatomy. We do not just look at the uterus; we evaluate the ureters, the bowel, and the pelvic nerves to see the complete picture of your disease burden.

2. One Surgery, Complete Resolution: If you require surgery, our goal is to address every pathology in a single operation. Our elite surgeons are equipped to meticulously excise the deep infiltrating endometriosis while simultaneously performing a delicate myomectomy to remove the fibroids.

3. Fierce Uterine Preservation: When standard gynecologists encounter a pelvis full of endometriosis and multiple fibroids, their default solution is often to recommend a hysterectomy. We believe your organs are not disposable. Our surgical philosophy is rooted in uterine and fertility-sparing techniques. We meticulously reconstruct the uterus and preserve your reproductive anatomy whenever biologically possible.

Stop Settling for Partial Answers

If you have been diagnosed with fibroids but your pain feels deeper, sharper, and more systemic than what a single uterine tumor should cause, your body is telling you that the puzzle is incomplete.

You deserve a surgical and diagnostic team that understands the complex, overlapping nature of pelvic disease.