7 Silent Signs of PCOS and Endometriosis That Ruin Fertility

Identify the hidden signs of PCOS and Endometriosis before it’s too late. Learn expert strategies to reclaim your fertility and hormone health.

7 Silent Signs of PCOS and Endometriosis That Ruin Fertility

If you went to an ophthalmologist complaining of clouded vision, and you had a cataract—the most common cause of blindness—it would be exceedingly rare for the doctor to miss it. It is a standard diagnosis. Yet, when it comes to PCOS and Endometriosis, the leading causes of infertility on the planet, up to 90% of women go undiagnosed.

Women’s health is often treated as a different beast entirely. It is the only field of medicine where a patient can see ten different specialists, complaining of debilitating pain or irregularity, only to be told, “You are crazy,” or “It’s all in your head.”

This article dives deep into the groundbreaking insights from Dr. Thais Aliabadi, a leading OB/GYN and surgeon. We will explore why PCOS and Endometriosis are missed, how to identify them, and the actionable steps you can take to advocate for your health, fertility, and life.

The “Average” Woman and the Myth of Fertility

We often hear that fertility rates are dropping and sperm counts are declining. Is this a modern phenomenon, or are we simply failing to detect underlying issues?

The standard textbook trajectory of fertility suggests a gradual decline as women age. However, for women suffering from PCOS and Endometriosis, this trajectory is false. These conditions do not just affect your ability to conceive in the moment; they actively degrade egg quality and ovarian reserve over time.

Dr. Aliabadi argues that if every 20-year-old were screened properly for these conditions, fertility clinics would be nearly empty. Instead, women end up in these clinics in their late 30s, having lost valuable years to dismissal and misdiagnosis.

Why You Can’t Ignore Your Symptoms

Pain is not a lifestyle. Irregularity is not a quirk. These are biological signals.

• The Cost of Silence: Women often bounce from doctor to doctor, spending years in pain.
• The Egg Count Reality: A woman is born with millions of eggs, but by menopause, only about 1,000 remain. PCOS and Endometriosis can accelerate this loss or destroy the quality of the remaining eggs.
• Early Intervention is Key: Diagnosing a girl at 14 can save her fertility at 30.

Part 1: Polycystic Ovary Syndrome (PCOS)

PCOS and Endometriosis are often discussed separately, but they are the twin pillars of female infertility. PCOS is the most common hormone disorder in women of reproductive age, affecting at least 15% of women in the US, though likely far more.

What is PCOS Really?

Despite the name, Polycystic Ovary Syndrome does not necessarily mean you have cysts. It refers to a specific look of the ovary on an ultrasound—a “string of pearls” appearance where many small follicles are frozen in growth, unable to ovulate.

To be diagnosed with PCOS, you typically need to meet two out of the following three criteria:

1. High Androgen Symptoms: Acne, facial/body hair, or hair thinning (male pattern baldness).
2. Ovulatory Dysfunction: Irregular periods (cycles longer than 35 days) or fewer than 8 periods a year.
3. PCOS Morphology: “Polycystic” looking ovaries on an ultrasound OR a high AMH (Anti-Müllerian Hormone) level.

Crucially: You do not need to be overweight to have PCOS. You do not need to have cysts. You do not need high testosterone on a blood test.

The 4 Phenotypes of PCOS

One of the reasons PCOS and Endometriosis are missed is that they don’t look the same in everyone. PCOS has four distinct “looks” or phenotypes:

• Phenotype A (Classic): Meets all three criteria (High androgens, irregular periods, polycystic ovaries).
• Phenotype B: High androgens and irregular periods, but normal-looking ovaries.
• Phenotype C (Ovulatory PCOS): High androgens and polycystic ovaries, but regular periods. These women often don’t realize they aren’t ovulating properly.
• Phenotype D: Irregular periods and polycystic ovaries, but normal androgen levels (no acne or excess hair).

The 4 Pillars Driving PCOS

PCOS is not just a gynecological issue; it is a metabolic and inflammatory disaster. To treat it, you must understand the four pillars driving the symptoms:

1. The Brain-Ovary Axis

In a healthy cycle, the brain sends pulses of FSH and LH to the ovaries to mature an egg. In PCOS, the pulse of GnRH (a hormone regulator) is too fast. This causes LH to skyrocket. High LH stimulates the ovaries to pump out testosterone (androgens) instead of maturing an egg. The egg freezes, ovulation fails, and the follicle remains.

2. Insulin Resistance

This is the core of the problem for 80% of PCOS patients. Even lean women with PCOS can be insulin resistant.

• The Vicious Cycle: High insulin stimulates the ovaries to make more testosterone. High testosterone makes you more insulin resistant.
• The Result: Weight gain (specifically visceral belly fat), sugar cravings, and “hangry” episodes.

3. Inflammation

Chronic inflammation is the fire that fuels PCOS and Endometriosis. Visceral fat (belly fat) releases inflammatory cytokines, which worsen insulin resistance and disrupt ovulation. This is why many women feel bloated, achy, and tired.

4. Genetics and Epigenetics

If your father has diabetes or your mother had irregular periods, you are genetically “loaded” for PCOS. However, your environment—stress, sleep, and diet—pulls the trigger.

How to Treat PCOS (Beyond Birth Control)

The standard of care—”Here’s a birth control pill, lose weight, see you later”—is insufficient.

• Lifestyle: Sleep, stress reduction, and low-inflammatory diet.
• Supplements: Inositol (improves insulin sensitivity), Vitamin D, and CoQ10.
• Medications: Metformin (to lower insulin), Spironolactone (for acne/hair), and increasingly, GLP-1 agonists (like Semaglutide) for weight management and metabolic reset.

Part 2: Endometriosis – The Hidden Pain

If PCOS is the metabolic monster, Endometriosis is the silent torturer. It is a condition where tissue similar to the uterine lining grows outside the uterus—on the bladder, bowels, ovaries, and pelvic walls.

The “Crazy” Label

It takes an average of 9 to 11 years for a woman to be diagnosed with Endometriosis. Why? Because society normalizes women’s pain.

• The Red Flags: If you miss school or work due to cramps, that is not normal. If you have pain during sex, pain with bowel movements, or chronic bloating (“Endo belly”), these are classic signs.
• The “Silent” UTI: Many women go to the doctor for urinary tract infection symptoms (burning, urgency) but test negative for bacteria. This is often Endometriosis on the bladder.

The Link Between PCOS and Endometriosis

Dr. Aliabadi estimates that over 50% of her PCOS patients also have Endometriosis. This is a staggering overlap. Because both conditions are inflammatory and involve immune dysfunction, they often travel together. If a doctor treats only the PCOS and ignores the pain of Endometriosis, fertility will remain elusive.

Diagnosing Endometriosis

You do not need a fancy blood test. Diagnosis starts with listening.

• Clinical Diagnosis: Based on symptoms (Painful periods, GI issues, painful sex).
• Ultrasound: Can catch “Endometriomas” (chocolate cysts) in the ovaries, but often misses superficial implants.
• Laparoscopy: The gold standard. A minimally invasive surgery to visualize and cut out the lesions. Note: Burning (ablation) is ineffective; the tissue must be cut out (excision).

Treatment Strategies

Endometriosis acts like a benign cancer—it invades tissue and creates its own blood supply.

• Surgery: Excision surgery by a specialist is the gold standard for removing the disease.
• Suppression: Because Endometriosis is fueled by estrogen, treatments focus on progesterone (IUDs, pills) or temporarily shutting down the ovaries (GnRH antagonists) to starve the lesions.

Part 3: The Fertility Checklist (The “Buckets”)

Whether you are trying to conceive now or in ten years, you need to assess your fertility “buckets.” Do not accept “unexplained infertility” as a diagnosis until you have checked these four areas:

Bucket 1: Female Factor (Hormones)

• Check FSH, Estradiol, Thyroid, Prolactin.
• Crucial: Check your AMH (Anti-Müllerian Hormone). This tells you your egg count. If you have PCOS, this number might be falsely high. If you have Endometriosis, it might be frighteningly low.

Bucket 2: Male Factor

• Sperm counts are dropping globally. A semen analysis takes one minute and is non-invasive. Rule this out immediately.

Bucket 3: Anatomy

• Is there a septum in the uterus? Are the tubes open?
• Do you have fibroids? (Fibroids are benign tumors; location matters more than size).
• Action: Demand a pelvic ultrasound, not just a pap smear.

Bucket 4: Disease (PCOS and Endometriosis)

• Do you have the symptoms of high androgens or insulin resistance? (PCOS)
• Do you have chronic pain or inflammation? (Endometriosis)
• Autoimmune Connection: Both conditions have autoimmune components. If you have recurrent miscarriages, check for clotting disorders and autoimmune markers.

Part 4: Breast Cancer Risk – Know Your Number

While PCOS and Endometriosis dominate the fertility conversation, general women’s health must include breast cancer awareness. The guideline to start mammograms at 40 is for average risk women. But do you know if you are average?

The Tyrer-Cuzick Score

Every woman should calculate her lifetime risk of breast cancer using the Tyrer-Cuzick calculator (available online for free).

• Low Risk: <15%
• Intermediate Risk: 15-20%
• High Risk: >20%

If your lifetime risk is over 20%, you should not wait until 40. You may need MRIs and mammograms starting as early as age 30. Dense breast tissue, family history, and late childbirth all increase this risk.

The Well-Woman Exam: A Call to Action

The current “well-woman” exam is broken. A pap smear and a listen to the heart are not enough.

What You Should Demand:

1. Pelvic Ultrasound: To screen for cysts, fibroids, and ovarian health.
2. AMH Test: To know your ovarian reserve.
3. Metabolic Panel: Insulin, Glucose, HbA1c (especially for PCOS).
4. Vitamin D Levels: Critical for hormone health and insulin sensitivity.
5. Thyroid Panel: TSH, Free T3, Free T4, Antibodies.

Advocacy is Your Best Medicine

The medical system is overwhelmed. Doctors are often burnt out, delivering babies all night and seeing clinic patients all day. It is up to you to be the CEO of your own body.

If you suspect you have PCOS and Endometriosis, do not let a provider dismiss you. Track your symptoms. Write them down. If a doctor says you are fine but you are in pain, find another doctor.

Frequently Asked Questions

Conclusion

PCOS and Endometriosis are not just “bad periods.” They are systemic conditions that affect your metabolism, your mental health, your fertility, and your quality of life. The high prevalence of these conditions—affecting millions of women—contrasted with the lack of diagnosis is a public health crisis.

By understanding the symptoms—the irregular cycles, the visceral fat, the debilitating cramps, the gut issues—you can step out of the shadow of “unexplained infertility” and into the light of diagnosis and treatment.

You are not crazy. Your pain is real. And there are solutions.

Disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult with a qualified healthcare provider for diagnosis and treatment.