Silent Symptoms of Endometriosis: What Most Women Dismiss as Normal Pain

Chronic bloating. Lower back pain. Fatigue that lingers even after rest. These are symptoms many women know all too well, but usually blame on a stressful week, hormonal shifts, or poor sleep. Over time, they become part of the background noise of everyday life. Familiar, manageable, and often dismissed. 

But sometimes, these ordinary discomforts aren’t so ordinary. They are the early signs of a chronic condition that is frequently misunderstood, even by healthcare professionals.

Endometriosis is typically associated with severe pelvic pain especially during periods. Yet for some women, the condition doesn’t follow that script. Instead, it shows up as vague (and sometimes) cyclical symptoms: gastrointestinal issues, urinary discomfort, persistent fatigue, back pain, or difficulties with fertility. These are the silent symptoms of endometriosis – symptoms that are present, yet subtle enough to be overlooked or misattributed to other causes like irritable bowel syndrome, urinary tract infections, or simply stress.

This is one of the reasons endometriosis remains underdiagnosed. While the condition affects around 1 in 10 women of reproductive age, research shows that 20–25% of patients may not present with classic pelvic pain, and many more experience symptoms that are mistakenly normalised or minimised [1], and some remain completely asymptomatic. 

The result is a diagnostic delay that often spans years—years during which inflammation progresses, fertility may decline, and quality of life quietly erodes. Early recognition of these symptoms is hence critical. It allows for earlier investigation, more accurate diagnosis, and timely care that can protect long-term health and well-being (both in and out of the gynaecological realm).

In this blog, we explore the lesser-known, often overlooked signs of endometriosis, the ones many women dismiss as normal. We break down what these silent symptoms look like, why they are so commonly misdiagnosed, and how recognising them early can make a significant difference in long-term health outcomes. Whether you are experiencing symptoms yourself or supporting someone who is, understanding what endometriosis can look like beyond pelvic pain is a crucial step toward better awareness and care. 

Why Symptoms Are Dismissed as “Normal”

Many women with endometriosis spend years coping with symptoms that are often misunderstood or attributed to common hormonal changes. Because many of the early signs are vague, cyclical, or overlap with other conditions, they are frequently seen as part of the normal menstrual experience and not immediately recognised as indicators of an underlying condition.

Here are some of the key reasons why symptoms are often overlooked:

• Cultural conditioning around menstrual pain — From adolescence, women are often taught that pain is simply part of having a period. Menstrual cramps, bloating, or exhaustion are brushed off as hormonal or expected. This normalisation leads many to tolerate symptoms that should raise concern, assuming they are part of the “female experience.”

• Misdiagnosis due to overlapping symptoms — Endometriosis can affect multiple systems and mimic conditions such as irritable bowel syndrome (IBS), urinary tract infections (UTIs), or even sciatica. Bloating may be blamed on improper diet, back pain due to inappropriate posture, and urinary symptoms on mild urinary tract infection, while the underlying cause remains unaddressed.

• Prolonged diagnostic delay — Because of these patterns, diagnosis is rarely prompt. A 2024 review published in the Health Care for Women International journal reports that the average delay ranges from 4 to 11 years, with a mean of 6.6 years globally, and even longer in some countries (7.96 years in the UK; 11.7 years in the US) [2]. During this time, the condition may quietly worsen, leading to chronic inflammation, scarring, and potential fertility issues.

Silent symptoms are not truly silent all the time – they are simply unheard. Raising awareness of these patterns is crucial to shifting the current diagnostic gap and ensuring that subtle but persistent symptoms are taken seriously.

What are the Less-Obvious (Silent) Symptoms of Endometriosis 

While severe pelvic pain is the symptom most commonly associated with endometriosis, many women experience a broader range of subtler symptoms that are often misattributed to other conditions. These signs may follow a cyclical pattern, worsening around menstruation, but without awareness of the underlying link to endometriosis, they are frequently dismissed or mistreated.

• Gastrointestinal symptoms — Bloating, constipation, diarrhoea, and nausea are common complaints in women with endometriosis. These are often assumed to be signs of irritable bowel syndrome (IBS) or dietary issues. However, unlike typical IBS, endometriosis-related bowel symptoms may worsen around menstruation and fail to respond to standard gastrointestinal treatments.

• Endo belly — A term commonly used to describe the severe bloating and abdominal distension experienced by many women with endometriosis. This inflammatory swelling can become so pronounced that it is frequently mistaken for pregnancy or weight gain, particularly during flare-ups around the menstrual cycle.

• Urinary and bladder issues — Symptoms such as urinary urgency, frequency, or pain during urination can resemble urinary tract infections (UTIs) but often return repeatedly without any actual infection. In many cases, these symptoms follow a hormonal pattern, intensifying during the menstrual cycle.

• Musculoskeletal and nerve-related pain — Endometriosis can affect pelvic nerves and surrounding structures, leading to chronic lower back pain, pelvic discomfort, or (uncommonly) radiating pain down the legs [3]. These symptoms may be misinterpreted as sciatica or general musculoskeletal strain, delaying appropriate investigation.

• Fatigue and mental health effects — Persistent low energy, brain fog, anxiety, and depressive symptoms are increasingly recognised as part of the inflammatory burden of endometriosis. Chronic pain and hormonal disruption contribute to emotional distress and fatigue, significantly impacting daily functioning.

• Reproductive challenges — Many women may first learn that they have endometriosis when they struggle to conceive. Endometriosis can interfere with egg quality/reserve, tubal function, and implantation, even in women who have never experienced pain. In some cases, it may also be associated with pregnancy complications.

• Uncommon physical signs — Less typical but still important symptoms include the presence of small, painful nodules in the abdominal wall, known as cutaneous endometriosis. These usually manifest in cyclical pain during menstruation, but the link may not be made easily as the pain is not located in the pelvis. These may appear in surgical scars, such as those from a caesarean section, and are often misdiagnosed as unrelated.

Recognising these less-obvious symptoms is essential to reducing diagnostic delays. When recurring discomforts are viewed in isolation, they may appear minor. But when seen together, especially with a cyclical pattern, they can form a clearer picture of underlying endometriosis.

The Science Behind the Silent Symptoms of Endometriosis 

Endometriosis is a complex condition that extends far beyond the uterus. Its symptoms can appear in multiple systems of the body due to the way endometrial-like tissue behaves when it is located where it shouldn’t. Understanding the underlying biology helps explain why the symptoms are so varied, and why they are often misinterpreted.

• Ectopic lesion spread — In endometriosis, tissue similar to the uterine lining implants outside the uterus, on the ovaries, fallopian tubes, bowel, bladder, and even at distant sites such as the diaphragm or lungs. These lesions respond to hormonal cycles in much the same way as the endometrium, leading to bleeding, inflammation, and scarring in areas not equipped to handle it. This widespread implantation can create gastrointestinal, urinary, respiratory, or musculoskeletal symptoms depending on the location of the lesions.

• Nerve involvement and pain signalling — In some cases, endometrial lesions can involve pelvic nerves or stimulate surrounding nerve fibres. This contributes to chronic pain and referred sensations such as sciatica-like leg pain or hip discomfort. Research also suggests that endometriosis may be linked to heightened nerve sensitivity and inflammatory signalling through CGRP (calcitonin gene-related peptide) pathways, which are associated with migraine-like symptoms and widespread body pain [4].

• Inflammatory response — The body treats endometrial lesions as injury or invasion, triggering a constant inflammatory response. This systemic inflammation contributes to bloating, fatigue, and swelling, symptoms that are often cyclical and easily confused with dietary issues or hormonal changes. The inflammatory environment also affects immunity, hormone regulation, and energy levels, adding to the broad spectrum of symptoms experienced by many women.

Together, these biological mechanisms explain why endometriosis doesn’t always manifest in a predictable or localised way. Instead, it behaves as a multisystem inflammatory condition, one whose impact depends heavily on where lesions are located and how the body responds to them.

What You Can Do If You Suspect Endometriosis

If you have been experiencing recurring symptoms, whether it’s bloating, fatigue, back pain, or unusual bowel or urinary changes, it’s important not to dismiss them. While these signs may seem minor in isolation, recognising patterns over time can provide valuable clues. Here are practical steps you can take to advocate for your health:

• Track your symptoms — Use a symptom diary or mobile app to document how your body feels throughout your cycle. Pay attention to when symptoms appear, how long they last, and whether they worsen around menstruation. This record can be a useful reference during medical consultations.

• Notice and report cyclical patterns — If your urinary, bowel, or musculoskeletal discomforts seem to follow a monthly rhythm, raise this with your GP or gynaecologist. Many endometriosis symptoms go unrecognised because they are discussed in isolation rather than as part of a hormonal pattern.

• Ask for targeted investigations — If symptoms persist or disrupt your daily life, request appropriate imaging such as a pelvic ultrasound or MRI. In some cases, a diagnostic laparoscopy may be required to confirm endometriosis. Seek out a provider experienced in diagnosing and managing the condition.

• Explore treatment options — Depending on the severity and your personal goals (e.g. managing pain or preserving fertility), treatment may include non-steroidal anti-inflammatory drugs (NSAIDs), hormonal therapies (like the pill or IUD), anti-inflammatory dietary changes, pelvic physiotherapy, or surgical intervention.

• Reach out for support — Endometriosis can affect mental health, relationships, and quality of life. Consider connecting with support groups, counselling services, or fertility specialists. Speaking with others who understand your experience can reduce isolation and help you make informed decisions.

Listening to your body and recognising what feels out of sync is the first step. You don’t need to have every symptom to seek help and you don’t need to wait until things get worse. Early attention can change the trajectory of your health.

Conclusion 

Endometriosis does not always appear in obvious ways. While severe pelvic pain is often highlighted, many women in Singapore experience quieter symptoms—bloating, fatigue, back pain, digestive issues, urinary discomfort, or unexplained infertility—that are easily mistaken for something else. 

In most cases, societal norms around menstruation, overlapping symptoms with other conditions, and medical bias contribute to delayed diagnosis. Meanwhile, the disease can continue to progress, affecting quality of life and reproductive health. Understanding how endometriosis works, including its inflammatory and neurological effects, can help explain why its symptoms are so widespread and varied.

If you’ve noticed a recurring pattern in your symptoms, especially if they tend to worsen around your period, it’s important not to dismiss them. Track your cycle, monitor your symptoms, and consult a doctor to explore the possibility of endometriosis and discuss appropriate next steps.

An early consultation with your gynaecologist can make all the difference, helping to confirm or rule out the condition, initiate appropriate endometriosis treatment, and prevent further complications. If symptoms are persistent, cyclical, or affecting your daily life, it’s time to take them seriously.

References

1. Bulletti, C., Coccia, M. E., Battistoni, S., & Borini, A. (2010). Endometriosis and infertility. Journal of Assisted Reproduction and Genetics, 27(8), 441–447. https://doi.org/10.1007/s10815-010-9436-1 
2. Fryer, J., Mason-Jones, A. J., & Woodward, A. (2025). Understanding diagnostic delay for endometriosis: A scoping review using the social-ecological framework. Health Care for Women International, 46(3), 335–351. https://doi.org/10.1080/07399332.2024.2413056 
3. Colak, C., Chamie, L. P., Youngner, J., Forney, M. C., Luna Russo, M. A., Gubbels, A., VanBuren, W. M., & Feldman, M. (2024). Mri features of pelvic nerve involvement in endometriosis. RadioGraphics, 44(1), e230106. https://doi.org/10.1148/rg.230106 
4. Chaichian, S., Firoozabadi, Z. D., Rokhgireh, S., Tahermanesh, K., Kashi, A. M., Govahi, A., Minaeian, S., Mehdizadeh, M., & Ajdary, M. (2024). CGRP neuropeptide levels in patients with endometriosis-related pain treated with dienogest: A comparative study. BMC Women’s Health, 24, 257. https://doi.org/10.1186/s12905-024-03095-y