Scientists found that in some women with endometriosis, the main symptoms aren’t pelvic pain at all but migraines, anxiety and depression
Endometriosis affects roughly one in ten women of reproductive age, and it often takes years to diagnose. Doctors are taught to look for one main sign: severe pelvic or period pain. Researchers in Spain and the United States went through the health records and surveys of 22,438 women with the disease to see what it really looks like across a large population. For one group of women, the picture did not start in the pelvis.
The team found four distinct symptom patterns among women of reproductive age. One group carried a heavy load of everything: severe pain, digestive problems and low mood. Another, the largest at about 30%, had moderate symptoms centered on pain and emotional health. A third group was dominated not by pain but by anxiety, depression and migraine. Only about one in five women, 20.6%, had a low symptom burden.
That third group is the one doctors are most likely to miss. A woman whose main complaints are migraines, anxiety or depression may be sent to a neurologist or a mental health service rather than a gynecologist, and the underlying disease can go unnamed for years. Endometriosis symptoms often get explained away, a pattern that also showed up in our report on women with autoimmune diseases.
“Endometriosis does not always present the way we expect, and these symptoms may first appear in women seeking care for other physical symptoms,” senior author Dora Koller of the Sant Pau Research Institute in Barcelona told Medscape. “If we continue to focus solely on pelvic or menstrual pain, we risk overlooking many patients.”
The data came from the All of Us Research Program, a large US health database that links electronic health records with participants’ own reports. The researchers looked at 19 symptoms and conditions often tied to endometriosis, including pelvic and abdominal pain, digestive problems, migraine, anxiety, depression, chronic fatigue, infertility and irritable bowel syndrome, and used a statistical method that sorts people into groups by the symptoms they share.
To focus on active disease, the main analysis looked at 5,542 premenopausal women aged 18 to 45. Women with the most symptom-heavy patterns reported poorer quality of life.
The second finding concerns adenomyosis, a related condition in which similar tissue grows into the muscle wall of the uterus. Among women who had both conditions, the low-symptom group almost disappeared. Nearly all of them fell into high-burden patterns, which suggests the combination is especially hard on the body.
Koller also pointed to how rarely the disease is confirmed. Estimates put endometriosis at around 10% of women of reproductive age, but in the study population only 1.92% of patients had a clinically confirmed diagnosis, she told Medscape, which suggests many women live with it unrecognized.
If you have recurring migraines, digestive problems or mood symptoms alongside painful periods, it is reasonable to ask a doctor whether endometriosis could be part of the picture. The disease is still diagnosed with certainty mainly through surgery, so a full symptom history is often the first step toward a referral. Women’s health questions like this have long been understudied, as our coverage of hormone therapy and blood clots also showed.
There are limits to what this shows. The study groups women by symptoms they share; it does not prove that endometriosis causes the migraines or anxiety. Some diagnoses came from self-reports rather than medical records, and the All of Us population is American, so the patterns may differ elsewhere.
Source
Goroshchuk O, et al. “Characterizing endometriosis and adenomyosis symptom clusters and their impact on quality of life in the All of Us Research Program.” Human Reproduction, 2026.
DOI: 10.1093/humrep/deag101
