When I had endometriosis, I didn’t know there was a name for what I now know were endometriosis flares. I used to call them “attacks” – because that’s exactly what they felt like.
I know what it feels like when you’re on the bathroom floor, dripping in a cold sweat and feeling like you’re going to vomit because the pain is so intense. In that moment, you’re not wondering about prostaglandins, inflammation or what might have triggered it. You just want the pain to stop – and you’ll try just about anything that might help.
Maybe your flares look different. Your pelvic pain suddenly ramps up. Your stomach becomes painfully bloated. Your bowels start playing up, you’re exhausted and you’re mentally retracing the last few days trying to work out what you did wrong.
Was it something I ate? Is my period coming? Did I do too much? Was it that glass of wine? Why has this happened again?
If that sounds familiar, understanding why your endometriosis flares happen can be incredibly useful.
Because managing endometriosis flares isn’t only about finding ways to get through them once you’re already in pain. When you start recognising your own flare patterns and understanding what may be contributing to them, you can also start looking at what you might be able to do before a flare happens to reduce its frequency or severity.
In this article, we’ll look at what an endometriosis flare actually is, some of the most common endometriosis flare triggers, what you can do when you’re in the middle of one and strategies that may help prevent the next one.
What Are Endometriosis Flares?
Endometriosis flares, often shortened to an “endo flare”, is a period when your usual endometriosis symptoms suddenly become more intense.
It’s not a formal medical diagnosis and there isn’t a set definition of what an endometriosis flare should look like. Your flares may therefore look completely different from someone else’s – and they may even change from month to month.
For some women, a flare means a sudden escalation in pelvic pain and cramping. For others, bloating, bowel symptoms, fatigue or nausea may worsen alongside the pain. Some flares are very predictable and occur around menstruation or ovulation, while others appear to come out of nowhere.
Importantly, an increase in symptoms doesn’t necessarily mean your endometriosis has suddenly progressed.
The symptoms you experience are influenced by much more than the lesions themselves. Hormones, inflammatory signalling, the nervous system, pelvic floor muscles, bowel and bladder function and other factors can all contribute to how you feel.
Understanding this allows us to ask a much more useful question: what might be contributing to your flares?
What Are the Symptoms of an Endometriosis Flares?
Severe pelvic pain is probably the symptom most commonly associated with an endometriosis flare, but a flare can involve much more than pain.
Common endometriosis flare symptoms can include:
- increased pelvic or abdominal pain
- intense cramping
- lower back or leg pain
- bloating or abdominal distension, often called “endo belly”
- nausea or vomiting
- painful bowel movements
- constipation or diarrhoea
- bladder pain or pressure
- pain around menstruation or ovulation
- pain during or after sex
- headaches
- increased fatigue
You may experience only one or two of these symptoms, or several may worsen at the same time.
This is why recognising your own flare pattern is often more useful than comparing your symptoms with someone else’s.
How Long Does an Endometriosis Flares Last?
There is no set amount of time an endometriosis flare lasts.
For some women, symptoms may intensify for a few hours. For others, a flare can continue for several days, particularly when it occurs around menstruation.
The duration can also vary depending on what’s contributing to the flare. A short mid-cycle flare may look very different from several days of worsening symptoms around your period.
If symptoms are new, unusually severe, persistent or different from your normal endometriosis symptoms, don’t automatically assume you’re experiencing a flare. It’s important to have new or concerning symptoms medically assessed.
What Causes an Endometriosis Flares?
When your symptoms suddenly become worse, it’s easy to wonder whether your endometriosis itself has become worse.
That’s not necessarily the case.
Endometriosis is an inflammatory, oestrogen-dependent condition, but symptoms are influenced by much more than the lesions themselves. Hormonal changes, inflammatory signalling, prostaglandins, pelvic floor function, bowel and bladder function, sleep and your nervous system can all contribute to how symptomatic you feel at a particular time.
Central sensitisation can also become part of the picture, particularly after persistent or recurrent pain. Repeated pain signalling can make the brain and spinal cord more responsive to pain signals – essentially turning up the volume on pain.
This doesn’t mean the pain is psychological or “in your head”. It reflects changes in the way the nervous system processes pain and helps explain why pain severity doesn’t always correspond with the amount of endometriosis seen on imaging or during surgery.
There also isn’t one universal list of endometriosis flare triggers. Sometimes one factor is fairly obvious. Other times, several things may have been building in the background.
1. Your Period
Endometriosis flares commonly occur around menstruation.
Prostaglandins help stimulate the uterine contractions required during your period, but they’re also involved in inflammation and pain. Changes in reproductive hormones and inflammatory signalling at this time can further influence symptoms.
If your flares consistently occur around your period, that predictability can actually be useful. It gives you an opportunity to have your flare-management strategies in place before symptoms reach their peak.
2. Ovulation
Some women notice their endometriosis symptoms worsen around the middle of their cycle rather than during their period.
Ovulation involves rupture of the ovarian follicle and local inflammatory signalling. In an already sensitive pelvis, this may be more noticeable. Endometriomas, adhesions and other pelvic conditions may also contribute to mid-cycle symptoms.
Ovulation itself may not always be the whole explanation either. Histamine activity around this point in the menstrual cycle may also be relevant for some women, which we’ll come to shortly.
3. Gut and Bowel Changes
The bowel and reproductive organs share a very crowded neighbourhood, so changes in one can easily affect how the other feels.
Constipation, bloating and bowel distension can add pressure and discomfort to an already sensitive pelvis. Gastrointestinal symptoms and conditions such as IBS also commonly overlap with endometriosis.
This is why worsening symptoms after eating something doesn’t automatically mean that particular food has “inflamed your endometriosis”. Sometimes what has changed is your gut or bowel function, which has then aggravated your pelvic symptoms.
4. Poor Sleep
Pain and sleep can feed into one another.
Endometriosis symptoms may disrupt your sleep, while inadequate or poor-quality sleep can increase pain sensitivity. Over time, this can become a cycle of pain disrupting sleep and poor sleep amplifying pain.
If you repeatedly notice flares following several nights of poor sleep, sleep may be one of the factors worth addressing.
5. Stress, Emotional Triggers and Your Nervous System
Stress doesn’t cause endometriosis. However, significant physical or emotional stress can influence the nervous system, muscle tension, sleep, gut function and the way pain is processed.
Emotional triggers can matter too. Grief, anxiety, relationship difficulties, feeling overwhelmed or other significant emotional experiences may coincide with worsening symptoms, particularly when the nervous system is already sensitised by persistent pain.
Where possible, reducing ongoing sources of stress and addressing recurring emotional triggers can be helpful. For the stressors we can’t remove, supporting nervous system regulation and improving our capacity to respond to stress becomes important.
6. Pelvic Floor Tension
Living with recurrent pelvic pain can cause the body to start guarding against it.
Some women with endometriosis develop an overactive pelvic floor, where the muscles have difficulty relaxing properly. This can contribute to pelvic pain, pain during sex and bowel or bladder symptoms.
Pain can then cause further muscle guarding, which perpetuates the cycle. If pelvic floor tension is contributing to your symptoms, pelvic floor physiotherapy can be an important part of management.
7. Histamine, Mast Cells, Mould and Environmental Exposures
If your endometriosis flares seem to occur at particular points in your cycle, histamine may be another piece of the puzzle.
You probably associate histamine with allergies, but histamine is also involved in inflammation and interacts with reproductive hormones. Histamine activity and reactivity can increase around ovulation when oestrogen is high.
So if you consistently flare around ovulation, it may not necessarily be the physical process of ovulation alone that’s contributing. Histamine may also be part of the picture, particularly if your flares coincide with symptoms such as headaches, digestive changes, congestion, flushing or itching.
This is also interesting in endometriosis because histamine is released by mast cells, and mast cells have been identified within endometriosis lesions and implicated in inflammatory processes associated with the condition.
But your cycle isn’t the only potential influence.
Perhaps you’ve spent the night in a hotel room with that unmistakable musty smell and woken up feeling awful. Or you’ve realised the air-conditioning unit beside your bed hasn’t been cleaned in months and you’re waking congested, headachy or generally feeling more reactive – at the same time as your endometriosis symptoms flare.
Mould can affect the body through allergic and inflammatory responses. Certain moulds also produce mycotoxins, some of which have endocrine-disrupting properties. Zearalenone, for example, has oestrogenic activity, which is particularly interesting in an oestrogen-dependent condition such as endometriosis.
This doesn’t mean histamine or mould is behind every flare. But if you repeatedly notice the same pattern around particular points in your cycle or after spending time in damp or musty environments, it’s worth paying attention to.
8. Alcohol
Alcohol can potentially contribute to a flare through several pathways, including its effects on sleep, gut function, inflammatory signalling, histamine and oestrogen.
This doesn’t automatically mean alcohol needs to be removed completely (although it is what I recommend). What matters is your overall pattern. If your endometriosis repeatedly flares after drinking, or you notice that particular types or amounts of alcohol are more problematic, that’s useful information.
9. Overexertion and Physical Stress
Periods of increased physical exertion can sometimes coincide with an endometriosis flare, particularly if you’re already fatigued, under-slept or recovering from a previous flare or major life stress.
This doesn’t mean things like exercise should be avoided. Regular, gentle movement is beneficial for all women with endometriosis.
However, if flares repeatedly follow periods when you’ve pushed significantly beyond your current capacity, pacing your activity and allowing adequate recovery may help.
Not every endometriosis flare will have an obvious trigger, and sometimes several factors may be contributing at once.
The aim isn’t to analyse everything you did in the days before a flare or feel as though you’ve somehow caused it. Instead, look for patterns that occur repeatedly. These can give you useful clues about what may be contributing and where you may be able to intervene.
How Do You Know If You’re Having an Endometriosis Flare?
If you experience endometriosis symptoms most days, it isn’t always obvious where your “normal” symptoms end and a flare begins.
The key difference is usually a noticeable change from what’s normal for you.
Your usual pelvic pain may suddenly become much more intense. Alternatively, your bloating, bowel symptoms, fatigue or nausea may worsen, or several symptoms may escalate together.
A flare may also have a recognisable beginning and end. You might be relatively stable, experience a significant worsening of symptoms for several hours or days, and then gradually return to your usual baseline.
There isn’t a clinical test that tells you whether you’re experiencing an “endo flare”, and the term itself doesn’t have a formal medical definition. Knowing your own baseline is therefore important.
It’s equally important not to attribute every new symptom to endometriosis. New, unusually severe or significantly different symptoms should be medically assessed.
What to Do During an Endometriosis Flare
When a flare is already underway, this isn’t the time to start analysing what triggered it. The priority is getting the pain and other symptoms under control.
This is also why having a plan before you need it can make such a difference. When you’re nauseous, exhausted and in significant pain, you don’t want to be searching through cupboards or trying to get a last-minute doctor’s appointment.
Get on Top of the Pain Early
If you know your pain can escalate quickly, have a pain-management plan ready.
Over-the-counter options such as paracetamol (Panadol) and anti-inflammatory medications such as naproxen (Naprogesic) are commonly used for menstrual and endometriosis-related pain. Paracetamol and an NSAID can sometimes be taken together, but speak with your GP or pharmacist beforehand about whether this is appropriate for you, how to take them safely and when to take them.
If over-the-counter medication doesn’t adequately manage your pain, speak with your GP about having appropriate prescription medication organised before the next flare happens.
Opioids are sometimes used when pain is severe. They can provide genuine pain relief when needed, but they primarily work within the nervous system to reduce pain signalling and change how pain is experienced. They don’t address the underlying endometriosis or the factors contributing to the flare, and repeated or longer-term use carries additional risks. But on occasion, when you need them you need them – so take them when necessary.
Adequately managing recurrent pain is important. Persistent pain signalling can contribute to sensitisation of the nervous system over time, which can make pain increasingly difficult to manage.
When in Doubt, Seek Medical Help
You know what your usual endometriosis symptoms feel like. If something feels different, unusually severe or simply doesn’t feel right, don’t assume it’s just another flare.
Severe pelvic or abdominal pain can have causes other than endometriosis.
If you’re concerned about the severity of your pain, go to hospital or seek urgent medical care. Don’t be afraid to call an ambulance if the pain is extreme or you’re seriously unwell, particularly if you’re fainting or collapsing, experiencing very heavy bleeding, persistent vomiting, fever or sudden severe one-sided pain.
When in doubt, get assessed.
Use Heat
Heat can be one of the simplest strategies to reach for during a flare.
A warm bath can help relax the body, while a heat pack or hot water bottle can be placed over the lower abdomen or back. Some women prefer an infrared heat mat, particularly when symptoms extend across a larger area.
Heat increases local circulation, helps relax muscles and can influence pain signalling.
Be careful with very high temperatures and prolonged direct contact with your skin, particularly if you’re using heat for several hours or you’re likely to fall asleep.
Natural Pain Support
Natural medicines can also form part of a flare-management plan.
Depending on the individual, options I may consider include curcumin, Boswellia and palmitoylethanolamide (PEA) for their anti-inflammatory and pain-modulating properties.
CBD is another option worth discussing with your doctor, particularly if your current pain-management approach isn’t providing adequate relief.
These are best considered ahead of time rather than experimenting with something new when you’re already in significant pain.
Castor Oil Packs
A warm castor oil pack over the lower abdomen is another supportive strategy some women find soothing for pelvic discomfort, cramping and tension.
I generally recommend using castor oil packs between periods rather than during menstruation, as they can worsen bleeding during a period.
If they’re something you find helpful, keep everything together and ready to use rather than trying to assemble a castor oil pack in the middle of a flare.
Try Acupressure
Acupressure is another simple strategy that can be used at home.
Points traditionally used for menstrual and pelvic discomfort include SP6 (Sanyinjiao) on the inner lower leg and LI4 (Hegu) on the hand. P6 (Neiguan) on the inner wrist is particularly useful to know if nausea accompanies your flares.
This is something worth learning before you need it. A good place to learn about these points and how to massage them is youtube. Or save a diagram showing where the points are so you aren’t trying to find them when you’re already feeling unwell.
Manage Nausea and Vomiting
I know how quickly severe endometriosis pain can progress from feeling nauseous to sweating on the bathroom floor feeling as though you’re going to vomit.
At that point, managing the nausea as well as the pain can make the flare considerably more manageable.
Try small, frequent sips of water or an electrolyte drink rather than drinking a large amount at once. Ginger tea, ginger chews or crystallised ginger may help with nausea. Peppermint tea can also be soothing, particularly when nausea occurs alongside digestive discomfort.
You can also try massaginf the P6 acupressure point for nausea, slow breathing, cool or fresh air and a cool compress over your forehead or the back of your neck. Strong smells can make nausea considerably worse, so keeping the room well ventilated may help too.
If nausea or vomiting regularly accompanies your severe flares, speak with your GP beforehand about whether prescription anti-nausea medication such as ondansetron is appropriate for you. If it is, having it already organised is much easier than trying to arrange medication once you’re vomiting.
If you can’t keep fluids down or vomiting is persistent, seek medical care immediately.
See a Pelvic Floor Physiotherapist
Pelvic floor physiotherapy isn’t only something to think about when you’re in pain.
If you regularly tense or brace your pelvic floor in response to endometriosis pain, working with a pelvic floor physiotherapist between flares may help reduce pelvic floor tension and improve the way those muscles respond when pain occurs.
A pelvic floor physiotherapist can assess whether your muscles are overactive, tender or having difficulty relaxing and teach you strategies to work on this regularly.
If pelvic floor guarding is one of the factors amplifying your flares, addressing it between flares may mean there is less muscular tension adding to the pain when the next flare occurs.
It’s particularly worth considering if you also experience pain with sex, pelvic tightness or heaviness, bowel or bladder difficulties, or notice yourself instinctively clenching your abdomen and pelvic floor when pain starts.
Find a Position That Lets Your Body Relax
There isn’t one “correct” position for an endometriosis flare. The best position is the one that reduces tension through your abdomen, pelvis and lower back.
Try lying on your side with your knees comfortably bent and a pillow between them. Alternatively, lie on your back with a pillow or bolster underneath your knees.
Many women instinctively curl tightly into a ball when the pain becomes severe. If that feels comfortable, that’s fine. But notice whether you’re also clenching your jaw, abdomen or pelvic floor. Supporting yourself with pillows may make it easier for those muscles to relax rather than continually brace against the pain.
Try Gentle Yoga Positions
If movement feels soothing rather than aggravating, a couple of gentle, supported yoga positions may help release some of the muscular tension around the pelvis and lower back.
Child’s Pose can be comfortable with the knees apart and your upper body supported on pillows or a bolster.
Another option is Reclined Butterfly Pose. Lie on your back with the soles of your feet together, allowing your knees to fall gently outwards. Place pillows underneath both knees so your inner thighs and pelvic floor can relax rather than being forced into a stretch.
This isn’t the time for a yoga workout. If a position increases your symptoms, stop.
Give Your Brain Something Else to Focus On
When pain becomes intense, your attention naturally narrows onto it. You start anticipating the next wave, monitoring whether it’s getting worse and wondering how long it’s going to last.
Distraction isn’t pretending the pain isn’t real. It’s simply giving your brain something else to process while the other strategies you’ve put in place start working.
Put on a familiar television series that doesn’t require much concentration. Listen to music, an audiobook or podcast. Try slow breathing, a guided meditation or progressive muscle relaxation. Call someone who makes you feel safe, or play something simple on your phone if it helps occupy your attention.
You don’t need to do all of these things.
The aim is to have several tools available so that when a flare happens, you’re not relying on one strategy and hoping it works.
And, ideally, you’re not trying to work out what to do while you’re already on the bathroom floor.
Why I Do What I Do
One of the hardest things about living with endometriosis is that symptoms don’t always seem to make sense.
You can do everything you think you’re supposed to be doing and still suddenly find yourself in a flare. Or you may notice patterns – around your cycle, your gut, sleep, stress or environment – without understanding why they might be connected.
Having experienced endo symptoms myself, I know how consuming that can become.
It’s also why my approach isn’t simply about looking at endometriosis in isolation. I want to understand what else is happening in the body and connect the dots when symptoms don’t seem to fit together.
Sometimes that means looking at hormones and inflammation. Sometimes it’s the gut, histamine, pelvic floor or nervous system. Often, particularly in complex health presentations, several of these things are interacting.
Understanding those patterns doesn’t mean you’ll be able to prevent every flare. But it can help you understand your body better, recognise where you may be able to intervene and feel more prepared when a flare does happen.
If you are looking for more guidance about how to get diagnosed with endometriosis, please book a consultation with me or download my free guide here.
Warmly,
