157. Could Silent Endometriosis Be Behind Your Infertility?

Most people think endometriosis means debilitating period pain. But what if you had no pain at all — and endometriosis was still quietly damaging your fertility? Silent endometriosis is real, it is more common than anyone is told, and infertility is often the first and sometimes the only sign that it even exists.

In this episode of Cycle Wisdom, Dr. Monica Minjeur walks through exactly what silent endometriosis is, why it is so consistently missed, and what a thorough clinical evaluation looks like for women with unexplained infertility and no pain. Through Brooke's story — a 30-year-old with regular cycles, no period pain, and 14 months of unexplained infertility — you will see how a complete evaluation can find what standard workups routinely miss, and what becomes possible when it does.

You will learn:

• Why pain severity does not correlate with disease severity — and why up to 50% of women with infertility and NO PAIN have endometriosis when thoroughly evaluated
• What silent endometriosis actually looks like on a cycle chart and in subtle symptoms that are almost never connected to endometriosis in conventional care
• Why surgical excision — not ablation, not birth control, and not IVF — is the treatment that changes outcomes for most women with endometriosis and infertility

If you have been labeled with unexplained infertility and endometriosis has never been considered — this episode will change how you think about your next step. Learn more or schedule a free discovery call at radiantclinic.com.

Transcript

Speaker 0:02

Most people think endometriosis means debilitating period pain or even heavy periods. But what if you had no pain at all and endometriosis is still quietly damaging your fertility? Silent endometriosis is real. It is more common than anyone is told, and infertility is often the first and sometimes the only sign that it even exists. I'm Dr. Monica Minjeur, the host of Cycle Wisdom, where we help women and couples restore hormonal balance and reclaim their well-being through personalized healthcare grounded in clinical excellence. Let's meet Brooke. Brooke is a patient of mine, and she came to us at 30 years of age, having regular cycles, no significant period pain, but she and her partner had been trying to conceive for the last 14 months without success. She was honestly confused more than anything. She had no symptoms she could point to, no history of pain, had regular cycles, and both she and her husband were very healthy. She felt like something was missing and started to doubt herself. Her OB had done a standard fertility workup that was all normal. She was then referred on to a reproductive endocrinologist who recommended moving to IUI without any additional investigation, but something still didn't feel right. A coworker of hers mentioned our podcast, and Brooke actually came in looking for deeper dive before she started IUI treatment. As always, we got her started with cycle charting and targeted lab evaluation, and that started to tell a more complete story. Her charting revealed that although she had adequate ovulation, her cervical mucus quality was low, and she had a shortened luteal phase. A repeat pelvic ultrasound actually showed a small endometrioma on her right ovary that had not been previously identified. We referred her on for additional evaluation with one of our endometriosis specialists, and a diagnostic laparoscopy confirmed stage two endometriosis with lesions that affected her right tube and throughout her peritoneum or the pelvic cavity. None of these had caused a single symptom. We worked on balancing Brooke's hormones prior to surgery and after surgery. While we worked on decreasing the inflammation, improving ovulation quality, and improving her luteal phase, Brooke began to feel better, and she recognized that there were actually symptoms she had had that she hadn't identified previously. She told us she felt less inflamed, less abdominal bloating, and more importantly for her, within six months after surgery, she had conceived naturally. Brooke had been living with endometriosis for years without ever knowing it was there. So let's back up a step and talk just a bit more about endometriosis. What is it? How common is it? And why is this so important? Worldwide, endometriosis is estimated to impact about 190 million women. This is approximately 10% of all women of reproductive age. However, many of our specialist surgeons s- think that this is grossly underestimated. The average time from symptom onset to diagnosis can be 7 to 10 years, and for women with silent endometriosis, it can be much longer because there are no symptoms to report. One of our expert surgeons, Dr. Patrick Yeung, who is a colleague and friend down in St. Louis, has done extensive research on the topic of endometriosis, and his practice center is focused on the treatment of endometriosis and improving fertility. And in his studies, he sees that women that have infertility and no pain, approximately 50% of the time will have endometriosis present when a thorough surgical evaluation is performed. In women with infertility and pain that was not improved by hormone treatment or birth control, over 80% of those women have endometriosis. And in women that have both pain and infertility, over 90% have endometriosis. This is why it's so important is that we know when we think about when I have pain, do I need to consider endometriosis? But again, go back to that first statistic. In women that have no pain and have only infertility as their primary symptom, up to 50% of them have endometriosis, and that is significant. And most importantly, it is treatable, and it is correctable. Silent endometriosis does not mean that it is mild or inconsequential. Minimal and mild endometriosis stages are independently associated with infertility, implantation failure, and increased miscarriage risk. So even a little bit of endometriosis can cause problems in some women Now, some of the common things that we hear as myths or things that just aren't true is that if you don't have severe period pain, you can't have endometriosis. And again, as I had just mentioned, the severity of pain does not correlate with the disease severity, and some of the most extensive endometriosis sometimes can cause no pain at all, and we'll talk about that a little bit later in the episode here. Another very common question we get is, "Well, I've had a normal ultrasound, so I don't have endometriosis, right?" Although an ultrasound can detect endometriomas, which are cysts or larger lesions of endometriosis, it oftentimes misses the majority of lesions, including lesions throughout the peritoneum, adhesions, scar tissue, superficial implants, and this is why the only way currently that is the gold standard for diagnosis is going to be a laparoscopy, which is a surgical procedure So what is endometriosis? Endometriosis is a growth of endometrial-like tissue outside of the uterus. So the endometrium is tissue that grows on the inside lining of the uterine wall, but endometriosis happens when that tissue grows outside of the uterus. So it can be anywhere throughout the abdomen and the pelvis. Oftentimes, we'll find it on the ovaries, the fallopian tubes, the peritoneum, which is kind of like a lining that covers the abdominal cavity. It can be on the bowel, on the bladder, on any of your intestines or other pelvic structures, and it can even be found outside of the abdomen and pelvis extending up into the chest cavity, so the lungs or the heart and beyond. This tissue, because it has the same receptors as what's going on in the uterus, does respond to hormonal cycling. It will increase when estrogen is exposed, and so we can have sometimes bleeding even of this tissue when a woman has a menstrual cycle. It creates scar tissue, it can create inflammation on any place that it implants, and it is responsive to other hormones that the body is exposed to. When women have pain with endometriosis, it typically is occurring when lesions are irritating pain-sensitive tissue. However, not all pelvic areas are equally pain sensitive, and lesions in certain locations can cause pain while others do not, regardless of their extent or inflammatory activity. We also know that different women have different pain receptors and different levels of pain tolerance. Depending upon the location of those lesions, pain may not be the primary symptom that we notice. And so we're gonna talk a little bit about silent endometriosis, because silent endometriosis is not rare. It is a recognized clinical entity, and if we dig a little bit deeper, we oftentimes discover that it wasn't actually silent. So oftentimes, silent endometriosis is still producing signals that are oftentimes normalized or dismissed. So if a doctor is screening and just asking about pain, we can oftentimes miss those subtle symptoms that oftentimes will actually be present with endometriosis. So things to consider and things that may be related to endometriosis include abdominal bloating that worsens with your cycle, especially if it's worse in the cycle week leading up to your menstrual cycle These mild changes can also be attributed to other bowel changes. Constipation or loose stools or feeling like you need to go to the bathroom suddenly. Many women will chalk it up to irritable bowel syndrome or, "I ate something unusual," or, "I was increasingly stressed." And until we start tracking and seeing when are these symptoms happening, it can be really hard to pick up the patterns at times. Other symptoms that we see that women can sometimes attribute to something different include fatigue, especially before your menstrual cycle begins. Slight discomfort or pressure with intercourse, not necessarily always pain, but sometimes a sensation that feels different, especially if it's a particular location, can also be a cause of what we would otherwise say is silent endometriosis. Even recurrent unexplained low back pain, hip discomfort, tightness throughout your pelvis, those can also be signs of endometriosis. And finally, spotting or irregular bleeding. Most frequently, we're going to see this happening before the period happens, but in some cases, we can see it around the time of ovulation or even at the end of a period, and these can also be possible signs of endometriosis that can impact the uterine environment and contribute to a luteal phase defect or hormone imbalance after ovulation has occurred. Now, none of these symptoms alone can confirm endometriosis, and they aren't specific enough that we need to do a deeper dive. But if we have any of these symptoms in combination with unexplained infertility, it should raise the index of suspicion that we need to at least consider, is there something else that's going on? Subtle clinical symptoms, especially when they are cyclical, are rarely connected to endometriosis in conventional evaluation unless pain is a part of the problem. In the world of restorative reproductive medicine, we're looking at this full clinical picture, inclusive of charting data and identifying other pattern symptoms that are worth investigating. This is why we always want to be thinking about endometriosis and why it's something that I always consider from the very first evaluation I have with any patient So how does endometriosis cause infertility, or how might it be impacting miscarriage? The environment of the peritoneum, the entire abdominal and pelvic cavity, can be filled with endometriosis, and what that does is it creates these inflammatory cytokines or proteins that increase the activity of inflammation. What this does is it adds prostaglandins, and these can be toxic to sperm, eggs, and embryos even without any structural damage. So even if you have endometriosis that's on your small intestine, for example, the inflammatory cytokines and prostaglandins that are released can be causing problems to all of the other DNA structures of sperm and egg that can be present in the uterine environment. We also know that these inflammatory mediators from these peritoneal lesions can directly impair the development of a follicle or kind of that shell that forms around the egg and the maturation of the egg throughout the follicular process. This is further added to, from a problematic standpoint, when fertilization occurs. The peritoneal fluid in the uterus can have direct implications on fertilization rates, and this explains why some couples that don't have any structural barriers still don't conceive. Endometriosis creates a hostile uterine environment as well through progesterone resistance and altered immune tolerance, which are both critical for successful implantation. Now, even though women with endometriosis can conceive, they do have significantly higher rates of early pregnancy loss and miscarriage, both from impaired implantation and from the systemic inflammatory environment that's present. So how do I know if I have endometriosis? And really, the gold standard is still going to be diagnostic laparoscopy, so going into the abdominal and pelvic cavity with a camera, with a laparoscopy under anesthetic during surgery with biopsies. And this is the only method that definitively diagnoses these lesions and minimal disease. Now, ultrasound can be useful for detecting endometriomas or these large ovarian cysts, but they oftentimes miss peritoneal lesions or superficial disease entirely. An MRI has high sensitivity for endometriomas, and they are better than an ultrasound looking for deep infiltrating endometriosis, but it still is insufficient for minimal disease. So even an MRI can miss endometriosis. There are some blood markers that we can look at. They're nonspecific though, and they're, again, not sensitive enough to pick up early disease and not a reliable screening tool. And there are other technologies that are emerging, one of which is a salivary test. So a saliva test is a spit test that we look for RNA signatures. It is showing promising diagnostic accuracy in research settings, and we're hopeful that that's going to become more mainstream in practice in the coming years. But as of the time of this recording in 2026, it is just not something that is mainstream enough. Furthermore, if that salivary test shows that yes, indeed, you have a high predictive value as far as having endometriosis, you still need the surgical procedure in order to remove it. So part of the way that we manage things in our practice is that women with unexplained infertility and a clinical picture that raises suspicion, we oftentimes start discussing diagnostic laparoscopy as a reasonable and oftentimes revealing next step, not as a last resort. From a practical standpoint, for us, we look at it from a standpoint of saying, "Let's get the hormones balanced. Let's make sure your charting looks great." And if we've got six really good cycles that show the hormones are well-balanced, we've evaluated male factor, charting looks great, then we say, "Let's get you sent to a surgeon to evaluate for the possibility of endometriosis." And again, I would say in clinical practice, I would mirror at least what Dr. Young had mentioned as far as 50% endometriosis, and quite frankly, I would say a much larger percentage of those patients when we've got good hormone balance, and even if they don't have symptoms, we do find endometriosis at least 70% to 80% of the time, if not more Now, when it comes to treatment, again, we're always looking at treatment through a restorative lens. So many women come to us having been put on birth control to suppress their symptoms of endometriosis. And while some women do feel better with this temporarily, it does not stop the growth of endometriosis, and it does not make it go away. The only current treatment for endometriosis that we have is surgical excision. And I say excision on purpose because many surgeons, many gynecologists are taught to remove endometriosis with ablation, which is just burning of those lesions. The choice of surgeon and the choice in technique matters immensely. I talk about this a lot more in episode number 109, where I talk all about endometriosis treatment. But really kind of the nuts and bolts of it is that in general practice with gynecology, with ablation treatment, 40 to 60% of women will have a recurrence of their endometriosis within two to five years. This frequently means that if she is wanting to have another child, have another pregnancy, she is needing to go through a repeat surgery every two to three years in order to remove the endometriosis that has grown back. And for me, that's just completely unacceptable Instead, what we do is, is that we send our patients to see our highly skilled and trained endometriosis specialists. And what they find with their studies is that they have a less than 5% recurrence rate when we methodically remove those lesions of endometriosis, stitch them back together so that we can use plastic surgery techniques to avoid scarring and adhesions. And over the course of my practice in the last 15 years and multiple, multiple patients that I have sent for surgery, I have seen only about four patients in my practice that have ever had a recurrence of their endometriosis. And this is far, far, far better than what the general standard is currently here in the United States. Now, I will add on here that both pre-surgical and post-surgical restorative hormone support is essential. Many patients find significant relief when we can balance their hormones prior to surgery. We treat the thyroid dysfunction, we treat the adrenal dysfunction, and surgery is needed to remove those lesions. Now, removing those lesions doesn't always completely get rid of the underlying inflammatory environment, the progesterone imbalance, or nutritional drivers that can contribute to recurrence. So this is why it's important that we keep everything well-balanced going into surgery as well as after surgery. Talking through with patients anti-inflammatory diet as well as anti-inflammatory supplements and maintaining good hormone balance, especially with progesterone support, oftentimes will help make measurable differences with the luteal phase as well as a good balance of the hormones in order to improve conception rates. Addressing all of this is important part of a complete multifactorial and multifaceted approach So let's wrap up with just a few common questions that we get frequently. I have no pain. Surgery sounds really intense. Is it really worth investigating the endometriosis? And in our world, we say yes, especially if you have unexplained infertility, recurrent miscarriage, or not even having any pain. Pain, again, is not a prerequisite for endometriosis, and waiting for pain to appear before investigating means the disease can be impacting your fertility quietly for years. And I get it, surgery sounds scary, and especially if you've never had a surgery before, you can be really concerned about that surgical risk. And what I would say to that is laparoscopy done in experienced hands of endometriosis specialists that do this every day, hundreds of thousands of cases over their lifetime, carry very, very low complication rates. For a woman who has been trying to conceive without success and has received an unexplained infertility label, the information that's provided with a laparoscopy oftentimes can confirm the diagnosis and treat the disease, is clinically meaningful. And in our practice, we say after endometriosis surgery is completed, it's a fresh slate. We get to start from scratch as far as our evaluation process, as far as balancing the hormones, getting rid of the inflammation. And for many couples, it is the fresh start they need in order to be able to conceive Many women are told that they have endometriosis, and so they're referred directly to IVF. And I would say this is absolutely not the default next step for every diagnosis of endometriosis. Many women with endometriosis, including even stage II or III disease, can go on to conceive naturally or with minimal intervention after surgical excision and restorative hormone support. Again, this is why it's so important to understand that underlying cause of why. Why is it problematic to get pregnant? Why am I having a recurrent miscarriage? Do I perhaps have any of these subtle signs of endometriosis? And especially if you have any infertility and pain, we absolutely, positively want to get evaluated right away. But again, no pain does not equal no disease. Imagine if the absence of pain wasn't automatically linked to the absence of endometriosis, and every woman with unexplained infertility was offered a clinical evaluation thorough enough to find what ultrasound and blood work alone cannot see. Imagine if silent endometriosis was identified years earlier, before it had spent that time quietly shaping the peritoneal environment, impacting egg quality, and creating the conditions for implantation to fail. That investigation can come before the diagnosis of unexplained infertility is handed over as a final answer, because for many couples, the explanation was there all along, just waiting for someone to look in the right place. That is what thorough care looks like, and the care that you deserve to improve health and promote fertility

Speaker 2 21:43

If you're ready to work with our elite team of healthcare professionals, go to our website radiantclinic.com to schedule a free discovery call and learn more about our package-based pricing for comprehensive care. We are currently able to see people for in-person appointments in our Cedar Rapids, Iowa clinic or can arrange for a telehealth visit if you live in many different states across the US. Check out our website for current states that we can serve medical clients, and let us know if your state is not listed to see if we can still cover you there as we are constantly expanding our reach. Please note that our fertility educators are able to take care of clients no matter where they live. Thank you so much for listening to this episode. Please share this podcast with someone in your life who would benefit from our services. Remember to subscribe to this podcast for more empowering content that I look forward to sharing with you on our next episode of Cycle Wisdom