It is a common misconception that reproductive health issues come one at a time. Like some sort of twisted "buy one, get one free" deal nobody asked for, many people find themselves asking: can you have endometriosis and PCOS? The short answer is yes. Absolutely.
You can have both. It isn't even that rare, honestly. While Polycystic Ovary Syndrome (PCOS) is often framed as a hormonal, metabolic disaster and Endometriosis is seen as a structural, inflammatory nightmare, they aren't mutually exclusive. They don't cancel each other out. In fact, they can coexist in a way that makes diagnosis a literal game of medical whack-a-mole.
Imagine your body is a house. PCOS is a problem with the thermostat and the electrical wiring; everything is out of sync, the signals are wrong, and the timing is off. Endometriosis, on the other hand, is like having insulation growing outside the walls where it doesn't belong, catching fire every month and causing structural damage. You can definitely have bad wiring and a fire at the same time.
Why doctors often miss the "Double Diagnosis"
Medical gaslighting is real, but sometimes the oversight is just basic logic failing in a complex system. Doctors love a "unified theory." They want one single diagnosis to explain all your symptoms. If you have irregular periods and weight gain, they scream "PCOS!" from the rooftops. If you have debilitating pelvic pain that makes you want to curl into a ball on the bathroom floor, they might eventually land on "Endometriosis."
But what if you have both?
Often, the symptoms of one mask the other. If PCOS causes you to skip periods for three months, you might not notice the cyclical, agonizing pain of endometriosis as frequently. Conversely, the heavy bleeding associated with some cases of endo might be blamed on the hormonal imbalances of PCOS.
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Research published in Human Reproduction has shown that women with endometriosis may actually have a higher prevalence of PCOS than the general population, though the exact "why" is still being debated in labs worldwide. It’s a messy overlap.
The Hormonal Tug-of-War
PCOS is fundamentally about high androgens (like testosterone) and insulin resistance. It stops ovulation.
Endometriosis is estrogen-dependent. It thrives on it.
You’d think high testosterone would protect you from an estrogen-fueled disease, right? Nope. Biology isn't that clean. You can have high androgens and still have enough "unopposed estrogen" to fuel endometrial-like tissue growth outside the uterus.
Spotting the difference when you're caught in the middle
Distinguishing between the two requires being an advocate for your own pelvic floor.
The PCOS Signature:
- Irregular or totally absent periods.
- Excess hair growth on the chin, chest, or stomach (hirsutism).
- Thinning hair on the head.
- Stubborn acne along the jawline.
- "Cysts" on the ovaries, which are actually just follicles that never matured and released an egg.
The Endometriosis Signature:
- Pain. Not just "cramps," but "I can't breathe" pain.
- Pain during or after sex (dyspareunia).
- Painful bowel movements or urination, especially during your period.
- Chronic pelvic pain that happens even when you aren't bleeding.
- Heavy bleeding that involves large clots.
When you have both, your cycle (if you even have one) is a chaotic mess. You might go months without a period, only to be hit by a "period from hell" that combines the hormonal crash of PCOS with the inflammatory localized pain of endometriosis.
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Does one cause the other?
There is no definitive proof that PCOS causes endometriosis or vice versa. They are different beasts. However, they share a common thread: inflammation.
Dr. Heather Hirsch and other specialists in the field often point out that systemic inflammation is the "gasoline" for both conditions. If your body is in a state of high inflammatory stress due to insulin resistance (PCOS), it creates an environment where the inflammatory response of endometriosis can potentially worsen.
The diagnostic hurdle: Laparoscopy vs. Ultrasound
Here is the kicker. You can diagnose PCOS with a blood test and a standard transvaginal ultrasound. You look for the "string of pearls" on the ovaries and high testosterone levels.
You cannot reliably diagnose endometriosis with an ultrasound.
This is where the "double diagnosis" falls apart for most people. A patient gets an ultrasound, the tech sees polycystic ovaries, the doctor says "You have PCOS," and they stop looking. Meanwhile, the endometriosis is sitting there on the bowel or the bladder, invisible to the scanner, causing 90% of the patient's actual pain.
Gold standard for endo? Laparoscopic surgery.
Unless a surgeon goes in with a camera, they are often just guessing. If you have a PCOS diagnosis but your pain levels are off the charts, you have to push for that second look. Don't let a PCOS diagnosis be the end of the conversation if you're still suffering.
Managing the Chaos
Treating both at once is like trying to put out two different types of fires. What works for one might not help the other.
- Metformin and Inositol: Great for the insulin resistance of PCOS. Does absolutely nothing for the physical lesions of endometriosis.
- Birth Control: The standard "band-aid." It can regulate the cycle for PCOS and suppress the growth of endo, but it doesn't cure either. For some, it just masks the symptoms until they decide to try for a baby.
- Excision Surgery: This is the only way to actually remove endometriosis tissue. It won't fix your PCOS hormones, but it will likely stop the "stabbing" pain.
- Anti-Inflammatory Nutrition: This isn't about "cleanses." It's about reducing the load on your immune system. Many people find that reducing gluten or dairy helps with endo-bloat (the "endo belly"), while managing carb intake helps with the PCOS insulin spikes.
The Fertility Factor
This is usually when people get the most worried. "Can I get pregnant with both?"
It’s harder. I’m not going to lie to you. PCOS makes it hard to release an egg. Endometriosis can damage the fallopian tubes or create an inflammatory environment where an embryo struggles to implant.
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But "harder" isn't "impossible."
Fertility specialists deal with this combo frequently. They might use Letrozole to trigger ovulation (for the PCOS side) and then monitor the endometriosis (potentially using surgery or suppression before a transfer) to ensure the "soil" is ready for the "seed."
Knowledge is power here. Knowing you have both means you don't waste three years trying to fix your hormones when the issue is actually structural blockage from endo.
Actionable steps for the "Double Diagnosed"
If you suspect you're dealing with this dual-threat, don't just sit in the pain.
- Track your symptoms with specificity. Don't just write "it hurts." Write "sharp, stabbing pain in left hip during bowel movements." This points toward endo, not just PCOS.
- Demand a full hormonal panel. This includes Total and Free Testosterone, DHEA-S, fasting insulin, and a 4-hour glucose tolerance test if possible. This confirms the PCOS side.
- Find an Excision Specialist. Not just a regular OB-GYN. You want someone who specializes in minimally invasive gynecologic surgery (MIGS). They are trained to see the endo that others miss.
- Address the insulin. Even if you don't "look" like the stereotypical PCOS patient, insulin resistance is often the driver. Managing this can lower systemic inflammation, which sometimes takes the "edge" off the endo pain.
- Check your pelvic floor. Chronic pain from endometriosis often causes the pelvic floor muscles to "guard" or seize up. This creates a secondary source of pain that even surgery won't fix. Pelvic floor physical therapy is a game-changer for the "both" crowd.
Living with endometriosis and PCOS is exhausting. It's a full-time job managing the appointments, the supplements, and the flares. But identifying that you are fighting a two-front war is the first step toward actually winning some ground. You aren't crazy, and it isn't "just a bad period." It's a complex endocrine and inflammatory situation that requires a nuanced, multi-layered approach to heal.
Focus on the inflammation first. Get the surgical consult second. Regulate the insulin third. Take it one layer at a time.