When a patient complains of painful periods, fatigue or cycle disturbances, how do you know whether you are dealing with endometriosis, PCOS, or a bit of both?
Diagnosis is often long and complex, especially in perimenopause where symptoms overlap. Yet asking the right questions and referring quickly can change the whole trajectory of care.
1. Main differences between endometriosis and PCOS
To help you get a quick handle on this in practice, here is an overview of the main differences between endometriosis and PCOS. This table summarises the key points from the webinar organised by Simplycure in partnership with the brand MiYé.
CriteriaPCOSEndometriosisNature of the disorderEndocrine imbalanceChronic inflammatory diseasePelvic painUncommon outside of complicationsVery common, often cyclical and disablingCycle disturbancesIrregular cycles, amenorrhoea, long cyclesVery painful periods, heavy flowFertilityOvulation difficulties (anovulation)Mechanical infertility linked to adhesionsSkinAcne, excess hair growth (hirsutism)Few typical skin signsDigestive disturbancesRarely presentCommon: bloating, intestinal painChronic fatigueCommon, often linked to metabolic imbalancesPresent, worsened by chronic pain and inflammationOther associated signsFrequent excess weight, possible insulin resistanceLower back pain, pain during intercourse (dyspareunia)
2. Endometriosis or PCOS: spotting the symptoms in practice
In practice, some patients describe their cycle, others their pain, others again their fatigue or their skin. When symptoms overlap, it is often a detailed, targeted history that makes all the difference.
Endometriosis: what the pain tells you
The cardinal symptom is pain: intense, cyclical, often disabling. And not only during periods.
Points to watch for when taking the history:
- Cyclical pelvic pain, radiating to the lower back or legs, often described as "deep" or "burning".
- Dyspareunia (pain during intercourse), sometimes kept quiet for years.
- Cyclical digestive disturbances: bloating, pain on defecation, peri-menstrual diarrhoea.
- Menorrhagia: very heavy periods, sometimes with clots or vasovagal episodes.
- Chronic fatigue, often multifactorial: pain, low-grade inflammation, sleep disturbance.
Keep in mind: endometriosis lesions can be invisible on ultrasound and poorly correlated with pain intensity. Listening to the patient remains a major diagnostic tool.
PCOS: discreet but cumulative symptoms
PCOS shows itself less through pain than through progressive endocrine signs, often dismissed as trivial.
Points to watch for when taking the history:
- Cycle disturbances: intermittent amenorrhoea, long cycles (>35 days), spotting.
- Signs of hyperandrogenism: persistent acne (especially along the jawline), excess hair growth, early androgenetic alopecia.
- Unexplained weight gain or resistance to weight loss despite a balanced lifestyle.
- Chronic fatigue, sometimes linked to silent insulin resistance: sugar cravings, a post-meal energy slump.
- Mood disturbances or anxiety, common in hyperandrogenic forms.
Keep in mind: a patient can have PCOS without being overweight, and without acne or hirsutism. It is the subtle accumulation of signs that should raise a flag.
3. Diagnostic approach: which tests to request, and when?
A well-defined clinical steer from the very first consultation helps target the right tests, and avoid costly investigations with little added value.
TestEndometriosisPCOSClinical examinationCyclical pain, dyspareunia, peri-menstrual digestive disturbancesLong or irregular cycles, acne, hirsutism, chronic fatiguePelvic ultrasoundOften normal in deep or retrocervical formsPossible multifollicular appearance ("string of pearls")Pelvic MRIUseful as a second-line option (digestive or ligamentous involvement)Not routineLaparoscopyGold standard when confirmation is needed or in complex formsNot indicatedHormone work-upNot routine (useful in cases of doubt or comorbidities)Diagnosis based on at least 2 of the 3 criteria: cycle disturbances, hyperandrogenism, polycystic ovaries on ultrasound. Plus an insulin resistance work-up, often relevantFurther testsDepending on involvement: colonoscopy, CT urography, targeted digestive investigationsMetabolic work-up: blood glucose, lipids, waist circumference, blood pressure
When both conditions coexist
Endometriosis and PCOS are not mutually exclusive. Some patients present with overlapping diagnostic criteria, with cyclical pain alongside a disrupted hormonal profile.
- Care should be personalised, symptom-led and progressive.
- Attention should be paid to lifestyle, emotional support, and a multidisciplinary approach.
- Clinical listening takes priority over normal test results.
4. Adapting care: practical advice by clinical profile
The care approach differs markedly between endometriosis and PCOS. Adjusting lifestyle and micronutrient intake can make a real difference day to day.
Priority areasEndometriosisPCOSReducing inflammationAnti-inflammatory diet (omega-3, vegetables, few fast-releasing sugars), avoiding endocrine disruptorsBalanced low-GI diet to limit low-grade inflammationLiver supportGentle liver-supporting herbs (rosemary, desmodium), without a harsh "detox" effectLess central, but watch hepatic metabolism if supplementingStress managementFundamental pillar: stress = pain ↗; gentle adaptogens (ashwagandha, lemon balm), restorative sleepStress = adrenal exhaustion; work on daily rhythm, cortisol, magnesium, sleepHormonal supportAim for natural balance without phytohormones: modulating inflammation and circulating oestrogensWork on the insulin-ovulation axis, limit LH spikes, support the metabolic terrainKey supplementsAntioxidants (burdock, rosemary), omega-3, magnesium according to profileMyo-inositol, chromium, alpha-lipoic acid, magnesium, griffonia, saffronTo avoidSuspected phytohormones (soya, red clover, etc.), poorly dosed essential oils, harsh detoxesSame: unregulated phytohormones, endocrine disruptors, overly "hormone-like" approaches
Clinical note: All of these approaches are drawn from the Simplycure webinar with the brand MiYé and can be offered without risk as a first-line option. All the supplements mentioned are free from suspected phytohormones, well tolerated, and compatible with conventional or hormonal care.
5. Three typical profiles to refine your clinical approach
Profile 1: Deep endometriosis with digestive involvement
Profile: a 36-year-old patient, regular cycles but major pelvic pain, peri-menstrual digestive disturbances, significant dyspareunia. Diagnosis delayed despite symptoms present for several years.
Care priorities: anti-inflammatory diet (omega-3, plant fibre), gentle liver drainage, gentle adaptogens (ashwagandha, lemon balm), targeted antioxidants (rosemary, burdock).
Profile 2: Classic metabolic PCOS
Profile: a 24-year-old patient, BMI 27, cycles spaced 45 to 60 days apart, persistent acne, family history of type 2 diabetes.
Care priorities: low-GI diet, improved sleep, bioavailable magnesium, saffron and griffonia for cravings and neuroendocrine support.
Profile 3: Mixed PCOS and endometriosis
Profile: a 41-year-old patient, irregular cycles (35 to 45 days), cyclical pelvic pain, chronic fatigue, peri-menstrual bloating. Perimenopausal, with a family history of hormonal disorders.
Care priorities: low-GI & anti-inflammatory diet, moderate liver support, magnesium, gentle adaptogens, plant-based omega-3, specific antioxidants.
Conclusion: spotting it better to support it better
Knowing how to tell endometriosis and PCOS apart from the very first clinical conversations means, above all, shortening the diagnostic wandering, targeting tests more precisely, and quickly adapting the advice given to patients.
But beyond the diagnosis, every woman carries a unique hormonal story, one that deserves careful listening, clear reference points, and tailored answers.
This guide was designed to help you sharpen your clinical observation and better support those who need it.
