PCOS and Endometriosis: Decoding the Hormonal Mysteries Behind Common Women’s Health Challenges

Despite affecting millions of women, polycystic ovary syndrome (PCOS) and endometriosis remain among the most underdiagnosed, misunderstood, and mismanaged conditions in modern medicine. These aren’t just “period problems” or fertility issues—they are full-body hormonal syndromes with systemic ripple effects that often begin in adolescence with consequences that extend past menopause. PCOS is the most common hormonal problem affecting women, and endometriosis is the second most common. PCOS and endometriosis occur in approximately 6 to 10 percent of women depending on diagnostic criteria, so they are common yet also commonly missed, which leads to the ongoing normalization of women’s suffering. The era of female suffering must end.

In my practice, I see patients who have spent years—sometimes decades—being dismissed, misdiagnosed, or told their symptoms were “normal” or “in their head.” The truth is, these conditions are rooted in real, measurable hormonal imbalances. And when we understand the underlying biology, we can start to treat the root cause, not just patch symptoms.

Let’s break down what’s really happening beneath the surface in PCOS and endometriosis—and why so many women feel like they’re stuck on a hormonal roller coaster they didn’t sign up for.

PCOS: A Hormonal Web, Not Just Ovarian Cysts

Polycystic Ovary Syndrome is one of the most common endocrine disorders in women of reproductive age. Despite the name, it’s not about cysts—it’s about hormonal dysregulation, metabolic dysfunction, and a disrupted communication loop between your brain, ovaries, and pancreas.

The Root Causes of PCOS:

• Insulin Resistance: Up to 70% of women with PCOS show some degree of insulin resistance, meaning their cells don’t respond properly to insulin. This triggers the body to produce even more insulin—which fuels ovarian production of androgens like testosterone.
  
• Estrogen Dominance: With irregular or absent ovulation, progesterone remains low while estrogen continues unchecked—creating a hormonal mismatch, not necessarily excess estrogen but relative dominance.
  
• Inflammation: Chronic low-grade inflammation is common in PCOS and fans the hormonal flames—worsening insulin resistance and ovarian dysfunction.
  

Common Signs:

• Irregular periods or no periods
  
• Acne and oily skin
  
• Excess facial or body hair (hirsutism)
  
• Weight gain, especially around the abdomen
  
• Fertility struggles
  
• Fatigue, mood swings, and sugar cravings
  

And here’s the kicker: Many women don’t meet all the criteria, so they’re told, “You don’t have PCOS”—when in reality, they’re experiencing a spectrum of dysfunction that still deserves attention.

Endometriosis: When Estrogen Fuels the Fire

Endometriosis occurs when tissue similar to the uterine lining grows outside the uterus—on ovaries, intestines, bladder, or elsewhere. But this isn’t just rogue tissue. It’s inflammatory, hormonally sensitive, and chronically overlooked.

The Hormonal Landscape of Endo:

• Estrogen Overdrive: Endometriosis is an estrogen-dependent condition. High or unopposed estrogen fuels the growth of these lesions, which behave like uterine lining and bleed with each menstrual cycle.
  
• Low Progesterone: Often, estrogen isn’t balanced by adequate progesterone—either due to anovulatory cycles, perimenopause, or chronic stress disrupting ovulation.
  
• Inflammation and Immune Dysfunction: Endo is not just hormonal—it’s inflammatory and immunological. The immune system fails to clear misplaced tissue and inflammation worsens the pain.
  

Common Signs:

• Severe menstrual cramps
  
• Pain with intercourse, bowel movements, or urination
  
• Chronic pelvic pain
  
• Infertility
  
• Bloating, nausea, fatigue
  

On average, it takes 7–10 years to get a diagnosis. Why? Because these symptoms are often mistaken for IBS, UTIs, or “just bad periods.” Women are frequently told to power through with birth control, painkillers, or platitudes like “It’s just part of being a woman.”

Why Diagnoses Are Often Delayed (or Missed)

In PCOS:

• There’s no universal definition. Depending on which criteria your provider uses (NIH, Rotterdam, AE-PCOS), you might get a diagnosis—or be told you’re fine.
  
• Symptoms vary. One woman may struggle with hair growth and irregular periods, while another just can’t lose weight or gets bloated mid-cycle.
  
• It’s dismissed as “just hormonal” or “just stress” far too often.
  

In Endometriosis:

• Symptoms mimic other disorders (IBS, interstitial cystitis, pelvic inflammatory disease)
  
• Laparoscopy is still the gold standard for diagnosis, which is invasive and often delayed
  
• Hormonal treatments may mask symptoms without addressing root causes
  

The result? Women suffer in silence or get bounced from specialist to specialist without answers.

The Cortisol Connection

Here’s what we don’t talk about enough: chronic stress (and its hormonal ripple effects) can worsen both PCOS and endometriosis.

• Cortisol dysregulation impacts blood sugar balance and can fuel insulin resistance
  
• It also disrupts ovulation, reduces progesterone, and amplifies estrogen dominance
  
• In endometriosis, stress and inflammation create a feedback loop—more pain → more cortisol → more hormonal imbalance
  

If you’ve ever felt like your body is “working against you” even though you’re doing all the right things, cortisol may be behind the scenes pulling strings.

Reframing the Approach: From Symptom Control to Root-Cause Strategy

In both PCOS and endometriosis, standard care often focuses on symptom suppression: birth control, anti-inflammatories, or fertility meds. But real progress comes when we address the root hormonal imbalances and support the whole system.

What That Looks Like:

• Stabilizing cortisol through circadian rhythm support, breathwork, and adaptogens
  
• Balancing blood sugar with protein-forward meals, strength training, and insulin-sensitizing nutrients
  
• Supporting detox pathways for efficient estrogen clearance (think: fiber, liver support, movement)
  
• Enhancing progesterone production by supporting ovulation (and in some cases, using bioidentical hormones)
  
• Reducing inflammation with an anti-inflammatory diet, targeted supplements, and nervous system regulation
  

You don’t need to rely solely on hormonal birth control or accept that your pain or symptoms are “normal.” You need a map—and a method that actually honors your biology.

Final Thoughts: It’s Not Just in Your Head—It’s in Your Hormones

Whether you’re dealing with the metabolic messiness of PCOS or the inflammatory fire of endometriosis, the common thread is hormonal dysregulation. But these conditions are not life sentences. They’re signals—your body waving a flag saying, please pay attention here.

You deserve more than quick fixes and dismissive responses. You deserve more than synthetic progestins thrown at the problem. You need care that looks at the full picture—your hormones, stress load, lifestyle, hormones, values, and goals.

If you want to learn more about the root cause approach that I have used in my clinic with patients for decades, check out the chapters devoted to PCOS (androgen excess) and endometriosis (estrogen excess) in my New York Times bestselling book, The Hormone Cure.

Watch for upcoming podcasts in which we dive into the commonalities of these two diagnoses with Dr. Thais Alibadi MD, a fellow gynecologist based in Los Angeles.

PCOS and endometriosis are complex, yes. But with the right strategies, testing, and support, healing is not just possible—it’s expected. The normalization of our suffering—with pain, inflammation, cardiometabolic dysfunction, gut issues, and infertility—needs to end.

References

Bulun, Serdar E., Banu D. Yilmaz, Charles Sison, et al. 2019. “Endometriosis.” Endocrine Reviews 40 (4): 1048–1079. https://doi.org/10.1210/er.2018-00242.

Chang, Kai-Jen, Jen-Hung Chen, and Kuo-Hwa Chen. 2024. “The Pathophysiological Mechanism and Clinical Treatment of Polycystic Ovary Syndrome: A Molecular and Cellular Review of the Literature.” International Journal of Molecular Sciences 25 (16): 9037. https://doi.org/10.3390/ijms25169037.

Dilliyappan, S., A. S. Kumar, S. Venkatesalu, et al. 2024. “Polycystic Ovary Syndrome: Recent Research and Therapeutic Advancements.” Life Sciences 359: 123221. https://doi.org/10.1016/j.lfs.2024.123221.

Garvey, Maria. 2024. “Endometriosis: Future Biological Perspectives for Diagnosis and Treatment.” International Journal of Molecular Sciences 25 (22): 12242. https://doi.org/10.3390/ijms252212242.

Giudice, Linda C., Tatyana T. Oskotsky, Sofiat Falako, Josephine Opoku-Anane, and Marina Sirota. 2023. “Endometriosis in the Era of Precision Medicine and Impact on Sexual and Reproductive Health Across the Lifespan and in Diverse Populations.” FASEB Journal 37 (9): e23130. https://doi.org/10.1096/fj.202300907.

Griffiths, Megan J., Andrew W. Horne, Douglas A. Gibson, Nicola Roberts, and Philippa T. K. Saunders. 2024. “Endometriosis: Recent Advances That Could Accelerate Diagnosis and Improve Care.” Trends in Molecular Medicine30 (9): 875–889. https://doi.org/10.1016/j.molmed.2024.06.008.

Hoeger, Kathleen M., Anuja Dokras, and Terhi Piltonen. 2021. “Update on PCOS: Consequences, Challenges, and Guiding Treatment.” The Journal of Clinical Endocrinology and Metabolism 106 (3): e1071–e1083. https://doi.org/10.1210/clinem/dgaa839.

Horne, Andrew W., and Stacey A. Missmer. 2022. “Pathophysiology, Diagnosis, and Management of Endometriosis.” BMJ (Clinical Research Ed.) 379: e070750. https://doi.org/10.1136/bmj-2022-070750.

Mariadas, Hema, Jen-Hung Chen, and Kuo-Hwa Chen. 2025. “The Molecular and Cellular Mechanisms of Endometriosis: From Basic Pathophysiology to Clinical Implications.” International Journal of Molecular Sciences 26 (6): 2458. https://doi.org/10.3390/ijms26062458.

Saunders, Philippa T. K., and Andrew W. Horne. 2021. “Endometriosis: Etiology, Pathobiology, and Therapeutic Prospects.” Cell 184 (11): 2807–2824. https://doi.org/10.1016/j.cell.2021.04.041.

Shi, Jing, Xiang Tan, Guoxiang Feng, et al. 2023. “Research Advances in Drug Therapy of Endometriosis.” Frontiers in Pharmacology 14: 1199010. https://doi.org/10.3389/fphar.2023.1199010.