If you’re familiar with endometriosis, you already know it’s no picnic. Pain and infertility are the most common signs of this condition, which affects at least 7-15% of women worldwide. Aside from potential fertility issues, endometriosis can also cause severe menstrual cramps that extend into the abdomen or lower back, pain during or after sex, and heavy or irregular periods. Other symptoms include pain during urination or bowel movement, and stomach problems like diarrhea, constipation, or bloating, aka “endo belly.”

Here’s the tricky part: staging doesn’t always reflect symptoms. Someone with stage 1 may have debilitating pain, while someone with stage 4 may have little to no discomfort. Still, understanding the stages can give you context for fertility risks, treatment options, and what’s happening in your body. Let’s break it down.

Different stages of endometriosis

Doctors typically use the American Society for Reproductive Medicine (ASRM) classification system to categorize endometriosis into four official stages — minimal, mild, moderate, and severe — based on the number, depth, and location of lesions, as well as scarring and adhesions.

But endometriosis isn’t a monolith, with doctors organizing this condition into four different stages. “Stages are classified based on the extent of disease and involvement of the tissue in the pelvis,” explains Cordelia Nwankwo, M.D., a board-certified OB/GYN in Washington, D.C. One of the most critical aspects of this classification system, however, is that a more advanced stage of endometriosis doesn’t automatically mean more severe symptoms or pain — or vice versa. “The extent of disease does not always correlate with the severity of symptoms,” says Dr. Nwankwo. “Someone with stage 1 minimal disease can have significant pain.”

You can find out your endo stage during laparoscopic surgery, when a surgeon can actually see the implants and adhesions. Each finding is scored — superficial implants, deep implants, cysts on the ovaries (endometriomas), and adhesions — and the points are added up:

  • Stage 1 (Minimal): 1–5 points
  • Stage 2 (Mild): 6–15 points
  • Stage 3 (Moderate): 16–40 points
  • Stage 4 (Severe): Over 40 points

Some specialists also talk about a so-called stage 5, or “diffuse” endometriosis, where the disease spreads beyond the pelvis.

Now, let’s look at what each stage actually means for symptoms, fertility, treatment, and quality of life.

Stage 1 endometriosis: Minimal

As previously stated, stage 1 of endometriosis is considered a “minimal” form of the disease. This is because it “involves a small amount of superficial lesions,” says Dr. Nwankwo. But that doesn’t mean patients with stage 1 endometriosis don’t experience substantial pain and discomfort.

Symptoms of stage 1 endometriosis

Even though it’s called minimal, with smaller, more scattered lesions, symptoms can still feel anything but. You might notice:

  • Period cramps that feel stronger than “typical” period pain, sometimes radiating to the lower back or thighs.
  • Spotting or light bleeding between cycles.
  • Pain during or after sex, often described as a sharp or burning sensation.
  • Mild digestive upset (constipation, loose stools, or bloating) that flares during menstruation.

Stage 1 endometriosis belly changes

Endo belly — the infamous bloating that makes your stomach swell — can still happen with stage 1, although it’s usually more typical of later-stage endometriosis. This is usually from inflammation and irritation in the pelvic cavity, not necessarily the amount of endo tissue.

Can stage 1 endometriosis cause infertility?

It’s possible, though less common. Early-stage endometriosis may interfere with fertility by creating inflammation around the reproductive organs or impacting egg quality. Some people conceive without difficulty, while others may struggle.

Stage 1 endometriosis treatment plan

Treatment often starts with pain relief (NSAIDs), or hormone therapy (like birth control pills, progestins, or GnRH analogues). Surgery to remove scarring or lesions isn’t typically offered until later stage endo.

Stage 1 endometriosis cancer risk

There’s no evidence that stage 1 endometriosis increases cancer risk in itself. While endometriosis has been linked to a slightly higher risk of ovarian cancer overall, the absolute risk remains very low.

Stage 1 endometriosis life expectancy

Endometriosis at any stage does not shorten life expectancy. What it can impact is quality of life — which is why symptom management is so important.

Stage 2 endometriosis: Mild

According to Dr. Nwankwo, stage 2 “has more lesions and may be more widespread but [the disease still remains superficial].” Scarring may also occur during this stage, which can potentially cause fertility issues. Make sure you have an honest discussion with your healthcare provider about your treatment plan if you’re planning on trying to conceive.

Endometriosis stage 2 symptoms

Symptoms are often similar to stage 1 but may be more frequent or intense. Possible symptoms include:

  • Menstrual pain that requires regular painkillers or disrupts daily life.
  • Increased pelvic tenderness throughout the month, not just during periods.
  • Occasional painful urination or bowel movements during menstruation.
  • Gastrointestinal issues like bloating, nausea, or indigestion that coincide with hormonal shifts.
  • More noticeable fatigue, especially around your period.

Stage 2 endometriosis fertility concerns

Scarring can begin to form at this stage, which may make it harder for eggs to travel through the fallopian tubes. Fertility struggles are possible, but not guaranteed.

Stage 2 endometriosis treatment options

Similar to stage 1 endo, treatment may involve hormone therapy, pain management, or surgery to remove lesions and scar tissue. For those trying to conceive, assisted reproductive technologies (ART) may be considered if surgery alone doesn’t help.

Stage 2 endometriosis life expectancy

Life expectancy isn’t affected by stage 2 endometriosis, but that doesn’t mean it should be brushed off. Without treatment, inflammation and scar tissue can build up over time, sometimes pushing the disease into later stages and making symptoms harder to manage. Catching it early and keeping symptoms under control can make a huge difference in protecting both your day-to-day comfort and your long-term health.

Stage 3 endometriosis: Moderate

“Stage 3 tends to have deeper implants and can involve cysts, or endometriomas, on the ovaries,” says Dr. Nwankwo. These ovarian endometriomas are also known as “chocolate cysts,” because they’re filled with collected menstrual blood.

Stage 3 endometriosis symptoms

By stage 3, adhesions and ovarian endometriomas may start to appear, often amplifying symptoms. Signs may include:

  • Heavy menstrual bleeding or periods that last longer than usual.
  • Pelvic pain that persists outside of menstruation.
  • Painful ovulation (sometimes called mittelschmerz) due to cyst formation.
  • Chronic digestive complaints such as alternating diarrhea and constipation.
  • Deep pain with intercourse, especially with penetration in certain positions.
  • Abdominal or pelvic bloating that can cause visible changes in belly size (“endo belly”).

Can you get pregnant with stage 3 endometriosis?

Yes, but it can be harder. Adhesions may restrict the fallopian tubes, and ovarian cysts can affect ovulation. Many people with stage 3 conceive with fertility treatments, including IVF.

Stage 3 endometriosis treatment options

Surgery to remove cysts and adhesions is often recommended, especially if fertility is a goal. Hormonal suppression can help reduce recurrence after surgery.

Stage 3 endometriosis life expectancy

Stage 3 endometriosis doesn’t change your life expectancy, but endometriomas do need careful attention since they can rupture or harm ovarian tissue. If ignored, the disease can progress to stage 4, where adhesions become more widespread and symptoms tougher to manage. With the right monitoring and symptom care, though, many people are able to maintain a good quality of life at this stage.

Stage 4 endometriosis: Severe

“Stage 4 is the most severe and usually involves deep implants and significant adhesions, where tissue becomes stuck together,” explains Dr. Nwankwo. “It can involve surrounding organs in the pelvis.” The additional adhesions can also result in an increased risk of infertility.

Stage 4 endometriosis symptoms

Stage 4 usually involves deep implants, large cysts, and dense adhesions, which can cause a wide range of symptoms. These might include:

  • Severe pelvic pain that is constant or cyclical.
  • Sharp, stabbing pain during bowel movements or urination.
  • Infertility as a presenting symptom, sometimes without significant pain.
  • Pain that spreads beyond the pelvis, such as into the lower back, hips, or legs.
  • Gastrointestinal issues resembling irritable bowel syndrome (IBS), including cramping, bloating, diarrhea, or constipation.
  • Pain with simple movements like bending or stretching, if organs are tethered by adhesions.

But some people can get to stage 4 of endo without any noticable symptoms.

Stage 4 endometriosis and infertility

This stage carries the highest risk of infertility, since adhesions can block the fallopian tubes and ovarian cysts may reduce egg reserve. IVF is often the most effective treatment option.

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Stage 4 endometriosis treatment options

Stage 4 treatment often means surgery to clear away adhesions and cysts, paired with hormone therapy to help keep new growth from coming back. For day-to-day relief, doctors may recommend anti-inflammatories, pelvic floor physical therapy, or lifestyle shifts like gentle movement and dietary tweaks. Since stage 4 can pull multiple organs into the mix, having a team of specialists on your side can make symptom management more effective.

Stage 4 endometriosis life expectancy

Endometriosis doesn’t shorten lifespan, even in stage 4. But the disease can deeply impact quality of life without appropriate management.

Stage 5 endometriosis: Diffuse endo

Some doctors and patients use the term “stage 5” to describe diffuse endometriosis that spreads beyond the pelvis — to the diaphragm, lungs, or even distant organs. While not part of the official ASRM classification, it reflects the reality that endometriosis isn’t always confined to the reproductive system.

Diffuse endometriosis explained

When endo travels outside the pelvis, it can cause chest pain, shoulder pain, lung nodules, or rare complications like collapsed lung during menstruation (catamenial pneumothorax). Thoracic endometriosis is the most common form of extra-pelvic disease and often affects the diaphragm or lungs, leading to symptoms that mirror respiratory conditions. Although rare, diffuse endometriosis highlights how the condition can extend beyond reproductive health, impacting multiple systems in the body.

Stage 5 endometriosis symptoms

Diffuse or “stage 5” endometriosis extends outside the pelvis, so symptoms depend on where lesions are located. They may include:

  • Chest or shoulder pain that worsens around your period (a sign of diaphragmatic or thoracic endometriosis).
  • Shortness of breath, coughing up blood, or even lung collapse during menstruation in rare cases.
  • Severe abdominal swelling or pain from widespread inflammation.
  • Unpredictable digestive symptoms if the bowel is involved, from rectal bleeding to bowel obstruction.
  • Pelvic pain combined with systemic issues like extreme fatigue and hormonal imbalance.

Can you get pregnant with stage 5 endometriosis?

Fertility depends on whether the reproductive organs are involved. Some with diffuse disease still conceive naturally, but many require fertility treatments like IVF.

Stage 5 endometriosis treatment options

Stage 5 treatment looks different for everyone and often calls for a team approach. Surgery can be more involved at this stage, and hormone therapy is usually part of the plan to keep symptoms in check. When endo reaches the diaphragm or lungs, gynecologic and thoracic surgeons may work together to safely remove lesions. Most people find the best long-term relief comes from combining surgery with ongoing medical management to lower the risk of recurrence and protect quality of life.

Stage 5 endometriosis life expectancy

Even diffuse endometriosis doesn’t reduce lifespan, but it may severely affect quality of life and require ongoing management.

How to know what stage of endometriosis you have

Knowing your stage can feel helpful, but it’s mainly a tool for doctors to guide treatment decisions. “Knowing the stage of endometriosis can help providers determine the best treatment options or combination thereof,” says Dr. Nwankwo. “If surgery is being considered, knowing the stage helps in planning how extensive or aggressive surgical management should be.”

From the patient’s point of view, knowing the stages “can be helpful in understanding the extent of the disease and what is affected,” says Dr. Nwankwo. But it’s important to remember that individualized treatment is based on symptoms, not stages. That’s because “the symptoms don’t always correlate [to the endometriosis stage].” Also, “the impact on quality of life varies regardless of stage.”

If you’re living with endometriosis, what matters most is how it actually feels in your body — not the stage number written in your chart. Be open with your doctor about your pain and symptoms, because even stage 1 can cause intense discomfort that deserves to be taken seriously. The right treatment is always guided by your experience, not just the label of “minimal” or “severe.”

Still, getting to that treatment plan often starts with detection — and unfortunately, diagnosis can be a long road, with the average time to an official endometriosis diagnosis around 7 to 10 years. But new tools are changing that. The MyReceptiva test offers a powerful and proven way to identify endometriosis sooner, helping you and your provider create a plan that actually matches your symptoms and goals.

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Sarene Leeds holds an M.S. in Professional Writing from NYU, and is a seasoned journalist, having written and reported on subjects ranging from TV and pop culture to health, wellness, and parenting over the course of her career. Her work has appeared in Rolling Stone, The Wall Street Journal, Vulture, SheKnows, and numerous other outlets. A staunch mental health advocate, Sarene also hosts the podcast “Emotional Abuse Is Real.” Visit her website here, or follow her on Instagram, BlueSky, or Threads.