The Hidden Story of Endometriosis Pain, Lesions and the Microbiome Endometriosis affects nearly one in ten women of reproductive age worldwide and remains one of the most underdiagnosed causes of chronic pelvic pain and infertility. A key clinical question is often overlooked. What type of endometriosis lesions are actually present? Types of endometriosis lesions Broadly, endometriosis lesions are classified into three types. 1. Endometriomas or ovarian cysts 2. Deep infiltrating endometriosis involving tissue deeper than the peritoneum 3. Superficial peritoneal lesions Limitations of imaging Advanced transvaginal ultrasound and MRI can reliably detect endometriomas and deep infiltrating disease. However, superficial lesions are often not visible on imaging and are usually detected only during surgery. This explains why pain severity often does not correlate with scan findings. The microbiome connection Emerging research has added a new dimension to our understanding of endometriosis. A study from Nagoya University identified Fusobacterium species within endometriosis lesions. Targeted antibiotic treatment resulted in reduced lesion size and significant pain improvement, suggesting a possible infectious and inflammatory component in selected patients. Important differentials Chronic pelvic pain should not automatically be labeled as endometriosis. It must be differentiated from pelvic congestion syndrome, fibromyalgia, pelvic floor muscle tension, and functional gut disorders. A whole person approach to pain Chronic pelvic pain behaves like other persistent pain states. Best practice requires a multidimensional approach that includes evaluation of the gut immune and nervous system interactions, individualized care plans, and a focus on symptom relief and functional recovery even when visible lesions are absent. Key message Women’s pain is real, whether or not it appears on imaging. Treatment should aim to relieve pain and improve quality of life, not only to identify or remove lesions. Modern gynecology must move from lesion focused care to truly woman centered care.