Endometriosis Flare-Up Symptoms, Triggers, and Tips for Relief

If you struggle with endometriosis, you're probably all too familiar with the debilitating endometriosis flare-ups that can rock your world with excruciating pain and disrupt your daily routine.

Certain triggers, such as hormonal fluctuations, stress, increased inflammation, and fatigue, can contribute to the onset of an endometriosis flare-up. Becoming attuned to your personal triggers and having a proactive plan in place can be a game-changer in limiting the impact of these episodes.

In this article, you'll learn to recognize the telltale signs of an impending endo flare-up, identify common triggers, and arm yourself with practical strategies to alleviate discomfort and regain control over your life.

What Is an Endometriosis Flare-Up?

An endometriosis flare-up (or episode) refers to a period when the symptoms of endometriosis become more severe and difficult to manage.

Endometriosis is a condition where tissue responds to your hormones similarly as your endometrial lining grows outside the uterus—often on the ovaries, fallopian tubes, intestines, or other areas in the pelvic region. This misplaced tissue still behaves like the uterine lining, thickening and breaking down with each menstrual cycle, causing pain and inflammation in the process.

Common Endometriosis Flare-Up Symptoms:

During an endo episode, endometrial lesions can become inflamed¹, leading to increased pain and discomfort. The most common symptoms experienced during an endometriosis flare-up include:

Severe pelvic pain, often worse than your regular menstrual cramps
Heavy or irregular bleeding
Lower back pain
Pain during sex
Digestive issues like nausea, bloating, and severe bloating, also called “endo belly“
Fatigue and general feeling of being unwell

Some women find that they experience early warning signs that an endo flare-up is beginning. If you pay close attention to subtle changes in your body, you might recognize these warning signs:

Increasing pelvic pain or cramping
Abnormal pain during bowel movements or urination
Heavier menstrual bleeding than usual, sometimes with clotting
Spotting between periods
Intense fatigue or low energy levels
Mood changes or increased irritability
Headaches or migraines
Muscle aches or joint pain

How long does an endometriosis flare-up last?

It can last for several days or even up to one or two weeks. The severity can vary from person to person and from one episode to another. Each month and the menstrual cycle can be different, depending on what's going on in your life, such as how stressed, tired, or busy you've been.

Causes and Triggers of Endometriosis Flare-Ups

Endometriosis can be triggered by a number of factors, including:

Hormonal fluctuations
Inflammation in the pelvic region²
Stressful periods and chronic stress
Dietary choices
Poor gut health
Certain activities like vigorous exercise or even sex
Some medications

The menstrual cycle often plays a significant role in triggering endometriosis symptoms, considering hormonal shifts, particularly in estrogen levels³, can exacerbate endometriosis symptoms.

Here's more about some specific factors that can contribute to an endo flare-up:

Hormonal Fluctuations

Endometriosis is an estrogen-dependent condition⁴, and fluctuations in hormones during the menstrual cycle can contribute to endo symptoms. The rise and fall of estrogen and progesterone levels can cause the endometrial tissue implants to thicken, break down, and bleed, leading to inflammation and pain.

Menstrual Period

Related to the point above, many women with endometriosis experience worsening symptoms during their menstrual periods. The shedding of the endometrial lining can cause the misplaced endometrial tissue to bleed, resulting in intense cramps, inflammation, pain, and potential adhesion formation.

Ovulation

Some women report increased pelvic pain and discomfort during ovulation, as the process involves hormonal changes and the release of an egg from the ovary, which can irritate endometrial implants in the surrounding area. This doesn't occur in every woman, but it is a potential trigger.

Increased Stress

Research suggests⁵ that higher stress levels are associated with more severe endo symptoms that last for a longer duration.

Stressful periods of life and chronic stress can cause hormonal changes, including increased cortisol levels, that exacerbate inflammation in the body, potentially aggravating endometriosis symptoms. Chronic stress can also affect hormonal balance in other ways, such as by decreasing estrogen or progesterone, leading to an increased risk of flare-ups.

Diet Choices

While each woman reacts to foods differently, there are some ingredients that can contribute to gut dysfunction and inflammation, such as processed foods, red meat, dairy products, and foods high in trans fats or refined sugars.

Worsened inflammation from poor diet choices can make endometriosis symptoms more severe⁶, while a nutrient-rich diet has the opposite effect: it can provide nutrients that can help manage endo, such as magnesium and antioxidants.

Strenuous Activity

Too much exercise or lots of physical activities that put pressure on the pelvic region, such as high-impact workouts or intercourse, can sometimes trigger a flare-up by irritating endometrial tissue.

This is where it is so very important to listen to your body and provide the movement that feels best. Exercise is anti-inflammatory and can help reduce pain, but like many conditions, over exercising can increase symptoms.

Gut Microbiome Imbalance

A balanced microbiome is crucial for healthy gut function, immune response, and regulating inflammation. On the other hand, an imbalance in the gut microbiome, known as dysbiosis, is thought to worsen digestion issues that are common among people with endo, including bloating, constipation, and other gastrointestinal symptoms⁷ such as IBS or SIBO (which are common in women with endo⁸).

Factors like infections, poor diet, lack of probiotics, stress, and overuse of antibiotics can contribute to gut microbiome imbalance.

Certain Medications

Some medications, such as those containing estrogen or progesterone, can influence the growth and activity of endometrial tissue.

For example, medications containing estrogen, such as birth control pills, hormone replacement therapy, and fertility drugs, as well as medications with androgenic effects like anabolic steroids, can potentially stimulate the growth of endometrial tissue implants and exacerbate endometriosis symptoms, while some anti-inflammatory drugs may also contribute to worsening endometriosis in some women.

It is important to discuss your medications with your provider before changing the dose or discontinuing.

How to Identify Endometriosis Triggers

To effectively manage and hopefully prevent severe endometriosis episodes, you want to work on identifying and avoiding triggers whenever possible. Triggers can vary from woman to woman, and it can take time to identify your own personal triggers.

Here are tips that can help you pinpoint what's contributing to your endo symptoms:

Keep a symptom diary: Write down your symptoms to help identify patterns and factors that make your symptoms worse, whether they be stress, certain foods, or activities. Record when flare-ups occur, their duration, and the severity of your symptoms. Note any potential triggers around that time (diet, activities, stress levels, etc.)

Track your menstrual cycle: Many women experience worsening symptoms during periods or ovulation. Note any pattern with your cycle and changes that occur, which might indicate a hormonal balance that can be addressed.

Monitor your diet: Certain foods can increase inflammation (processed, high fat, high sugar), so write down what you eat and determine if your choices might be worsening or helping your symptoms. Consider trying an elimination diet to pinpoint potential food triggers, which involves the removal of potentially problematic foods from your diet, such as added sugar or flour products.

Evaluate your workouts and physical activity level: Track whether high-impact exercises and excessive activity lead to fatigue that makes your symptoms worse. You can also track the effect of sex on your symptoms.

Look for environmental factors: Exposure to toxins and chemicals can potentially affect endometriosis. Identify possible exposures at home or work, such as endocrine-disrupting chemicals found in plastics, beauty products, and household cleaners.

Work closely with your doctor. Find a provider who is knowledgeable about endo and provide detailed records to help your doctor provide guidance about the right type of treatment for your symptoms. Be sure to discuss any medications you take with your doctor, including birth control pills.

Endometriosis Pain Control

Treatment options for managing endometriosis symptoms can include:

Medications like oral contraceptive pills, Lupron, progestins, NSAIDs, and other pain medications
Anti-inflammatory diet
Natural strategies and lifestyle therapies like stress reduction, heating pads, rest, castor oil packs, exercise, and acupuncture
Supplements to manage gastrointestinal discomfort, estrogen metabolism, and inflammation, as well as those that provide antioxidants
Surgical excision of endometrial lesions

Here's a closer look at how to manage endo episodes:

Stress Reduction Techniques:

Try these remedies below to help ease stress and soothe pain and digestive issues:

Gentle exercise, such as yoga, pilates, cycling, and walking
Heat therapy, such as applying a heating pad to the abdomen while lying down to reduce pain
Acupuncture to deal with stress and discomfort
Meditation and breathing exercises to help you relax more easily
Physical therapy, especially with a therapist who is knowledgeable about pelvic pain, to help address discomfort
Therapy or counseling if you're struggling with anxiety, embarrassment, or high amounts of stress
Castor oil packs; while lacking scientific evidence, many women anecdotally report relief when using them. Here's how to use a castor oil pack.

Anti-inflammatory Diet:

An anti-inflammatory diet emphasizes vegetables, fruits, omega-3 foods, high-fiber foods, healthy fats, magnesium, zinc, and fermented foods while avoiding alcohol, caffeine, sugary drinks, refined carbs, and processed foods. A low FODMAP diet⁹ can also help reduce bloating by limiting certain carbs.

For help starting an anti-inflammatory diet, grab a copy of my Hormone Starter Kit.

Pain Relief:

You can take over-the-counter pain medications (such as ibuprofen) when your pain is bad, in addition to using natural methods like heat therapy (such as heating pads or warm baths), and gentle exercise (like walking or stretching). Remember to listen to your body and prioritize getting enough sleep and resting when necessary.

Medications and Surgery:

Medications like birth control pills, GnRH agonists, and progestins can help manage endometriosis symptoms by regulating the menstrual cycle and estrogen production. Over-the-counter pain medications provide pain relief, but NSAIDs may worsen gut issues. In severe cases, surgery to remove endometrial lesions may be recommended along with other therapies.

Supplements for Endometriosis Flare-Ups

A number of supplements can help support overall hormonal health and help reduce inflammation. Keep in mind that supplements are intended to be used as an adjunct therapy to nutrition, lifestyle, medications, and surgery to help holistically manage endometriosis.

Supplements that may help alleviate endo symptoms include:

Omega-3 fatty acids (such as Omega Plus): Found in sources like fish oil, these fats have anti-inflammatory properties that may help reduce pain and inflammation¹⁰ associated with endometriosis and alleviate painful symptoms.

Magnesium (such as Magnesium Plus): Shown to be beneficial in maintaining a healthy mood, sleep, and hormone balance and supporting the body in reducing painful symptoms¹¹ of PMS and menstrual cramps.

Probiotics (such as Women's Probiotics): May help reduce inflammation¹², modulate the immune system, and support gut health and digestion.

Vitamin B6: Aids in metabolizing estrogen into an inactive form and creating anti-inflammatory prostaglandins that may inhibit endometriosis growth.

Sulforaphane: Can help reduce inflammation, oxidative stress, and the growth of endometrial tissue outside the uterus.

Resveratrol: Acts as an antioxidant and anti-inflammatory, potentially inhibiting prostaglandin synthesis and endometriosis cell development.

DIM (Diindolylmethane): Supports the metabolism of estrogen into less potent forms, reducing estrogen's stimulatory effects on endometrial tissue.

Chaste Tree Berry (Vitex): Helps modulate estrogen levels and activity, mitigating the effects of excess estrogen in endometriosis. You’ll find a combination of chaste tree berry, vitamin B6, resveratrol, sulforaphane, selenium, DIM, and calcium d-glucarate in our Balance Women’s Hormone Support.

Polygonum: May reduce inflammation and regulate hormonal imbalances by modifying estrogen receptor activity.

Calcium d-Glucarate: Promotes the proper elimination of excess estrogens from the body.

B vitamins: Support proper cell differentiation and estrogen metabolism, which can help reduce abnormal endometrial tissue growth.
N-Acetyl Cysteine (NAC): While more research is needed, current studies¹³ show reduced pain and endometrial lesion development in those supplementing with NAC. Dosages range from 600-3,000 mg daily. You can view the Dr. Brighten Essentials NAC here.
Curcumin: The active polyphenol in turmeric, curcumin¹⁴ may help reduce inflammation and improve endometriosis through estrogen modulation. Learn more about turmeric here.
Selenium: There is an association between low levels of this trace element and chronic inflammatory conditions. In one study¹⁵, women with endometriosis who were given selenium, vitamin E, vitamin C, and zinc showed lower severity of symptoms.

When to Seek Professional Help for An Endometriosis Flare-Up

If you experience persistent, severe, or worsening endo symptoms or frequent flare-ups despite taking the steps above, then reach out to your healthcare provider for help.

Signs it's time to visit your doctor include:

Severe, debilitating pelvic pain that interferes with daily activities and causes you lots of distress
Heavy menstrual bleeding or periods lasting longer than one week
Very painful bowel movements or urination
Nausea, vomiting, or fever accompanying pelvic pain
Persistent fatigue or lack of energy
Signs of anemia, such as dizziness or paleness
Infertility or difficulty getting pregnant
Lack of relief from over-the-counter pain medications
New or concerning symptoms, such as a pelvic mass or abnormal bleeding

Your provider can assess your condition, recommend appropriate treatments, and provide personalized advice to limit your triggers and manage your symptoms.

In some cases, prescription pain medications, hormone therapy, or surgical options¹⁶ may be necessary to alleviate symptoms¹⁷ and improve your overall quality of life. You can discuss these options with your provider based on your condition and medical history.

Key Takeaways on Managing an Endometriosis Flare Up

Living with endometriosis often means facing very uncomfortable flare-ups that can impact your daily life, such as intense pain, bloating, and fatigue.
By identifying personal triggers and implementing effective relief strategies, you can achieve better symptom control and overall well-being.
To better manage endo flare-ups, consider keeping a diary to track the effects of your diet, exercise routine, stress levels, and use of medications.
Remember, you don't have to suffer in silence—seek support from knowledgeable healthcare professionals who can offer valuable guidance and resources tailored to your unique needs.

References

About The Author

Dr. Jolene Brighten

Dr. Jolene Brighten, NMD, is a women’s hormone expert and prominent leader in women’s medicine. As a licensed naturopathic physician who is board certified in naturopathic endocrinology, she takes an integrative approach in her clinical practice. A fierce patient advocate and completely dedicated to uncovering the root cause of hormonal imbalances, Dr. Brighten empowers women worldwide to take control of their health and their hormones. She is the best selling author of Beyond the Pill and Healing Your Body Naturally After Childbirth. Dr. Brighten is an international speaker, clinical educator, medical advisor within the tech community, and considered a leading authority on women’s health. She is a member of the MindBodyGreen Collective and a faculty member for the American Academy of Anti Aging Medicine. Her work has been featured in the New York Post, Forbes, Cosmopolitan, Huffington Post, Bustle, The Guardian, Sports Illustrated, Elle, and ABC News. Read more about me here.