Fatigue: An underestimated symptom of endometriosis


Frequent fatigue affects a full half of women diagnosed with endometriosis. However, physicians are not discussing management and treatment strategies with their patients. 

Frequent fatigue affects a full half of women diagnosed with endometriosis, according to a European study. Therefore, it needs to be addressed during discussions between physicians and patients on how to manage and treat the disease.

“In my clinical work, I often heard from women diagnosed with endometriosis that doctors did not take a holistic approach in supporting them to live with endometriosis,” said principal investigator Brigitte Leeners, MD, deputy head of the Department of Reproductive Medicine at University Hospital Zürich in Switzerland. “Symptoms like fatigue were often not taken into consideration.”

Despite chronic fatigue being one of the most debilitating symptoms of endometriosis, it is not widely discussed and only a handful of large investigational studies have addressed it.

Recruitment for the study, which appeared in the journal Human Reproduction, took place at hospitals and private practices in Switzerland, Germany, and Austria between 2010 and 2016. For the multicenter, matched case-control study, data were collected from 1,120 women, 560 of whom had endometriosis. The women with endometriosis were matched to 560 controls for age (within 3 years of each other) and ethnic background.

Diagnosis of women with endometriosis was confirmed surgically and histologically, while for controls, the disease was surgically excluded or no identifying symptoms were present.

Fatigue was based on a questionnaire completed by the women that asked about various factors relating to quality of life and endometriosis, as well as medical and family histories, lifestyle and mental disorders. Fatigue and insomnia were categorized into one of five levels, ranging from 1 (never) to 5 (very often).

The majority of women diagnosed with endometriosis reported frequent fatigue: 50.7% compared to 22.4% in control women. Fatigue with endometriosis was also associated with a 7.31-fold increase in insomnia, a 4.45 increase in depression, a 2.22 increase in pain and a 1.45 increase in occupational stress. It was independent of age, time elapsed since first diagnosis of endometriosis, and disease stage.

“The percentage of women with endometriosis reporting fatigue was even higher than anticipated,” Dr. Leeners told Contemporary OB/GYN

The researchers speculated that the reason endometriosis could cause fatigue, independent of other factors, is that the endometrial lesions may be causing inflammation that activates the immune system. Cytokines involved in cell signaling when the immune system is activated have previously been shown to play a role in fatigue symptoms.

Another possible explanation for fatigue is that chronic exposure to high stress can lead to adrenal fatigue.

“We hope that our data help women receive adequate medical support when trying to integrate symptoms of endometriosis into their daily life,” Dr. Leeners said.

Dr. Leeners and her colleagues advocate improving quality of life for women suffering from endometriosis and believe that investigating and addressing fatigue should become a routine part of medical care. Women would also benefit from concrete steps to reduce insomnia, pain, depression, and occupational stress.

Two limitations of the study were that the patient questionnaire answers were subjective (and therefore at risk of bias from recollection) and the authors lacked information on the precise medication taken during the relevant period.

Moreover, women with asymptomatic endometriosis could not be excluded from the control group, thus underestimating results. The study’s design also did not allow for evaluation of casual effects.


Dr. Leeners reports no relevant financial disclosures.

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