Most people have felt tired at one point or another. However, for those living with endometriosis, fatigue — the feeling of being overly exhausted and unable to overcome that tiredness even after rest — can be much more common. People with endometriosis (also called endo) are twice as likely to feel fatigued or constantly exhausted than the general population.

“I am struggling with fatigue,” said a member of MyEndometriosisTeam. “Literally nothing helps … not sleep, not staying hydrated, not caffeine, not exercising. It’s like my body is just falling apart.”

As this member noted, fatigue can interfere with regular life activities. It’s not easily treated by appropriate rest, and it can last for a long time. Here’s what you need to know to better understand and manage fatigue with endometriosis.

How Is Endometriosis Associated With Fatigue?

Endometriosis is a medical condition in which the tissue that normally lines the uterus, called the endometrium, grows outside of the uterus. The endometrial cells can create cysts or lesions that grow on the ovaries, fallopian tubes, and even the intestines. These cysts still respond to the hormone signals during the menstrual cycle. The most common symptoms of endometriosis include excessive bleeding as well as pelvic pain during menstruation, intercourse, and bowel movements.

Fatigue is reported as a common symptom of endometriosis. As one member wrote, “All month long: pain, fatigue, bloating.” Another member shared, “I’m always fatigued, too and get severe brain fog.”

The exact prevalence of fatigue in people who have endometriosis is not clear. One study found that more than one-third of women with chronic fatigue syndrome (a medical condition in which the person feels constantly exhausted) also had endometriosis. In addition, the study showed that women with endometriosis were eight times more likely to have chronic fatigue syndrome.

Another study found that 50 percent of women who self-reported endometriosis also reported that they had “stayed in bed all day because of their condition at some time during the past year.”

What Causes Endometriosis-Related Fatigue?

More research is needed to understand the exact relationship between endometriosis and frequent fatigue, but several endo-related factors are thought to contribute.

Anemia

Endometriosis can cause excessive bleeding, which can sometimes lead to anemia. Anemia is a condition that can cause weakness and fatigue because the blood cannot circulate enough oxygen throughout the body.

Inflammation

Inflammation is a key factor in endometriosis. Not only are inflammatory chemicals likely involved in the development of the condition, but endometriosis triggers the production of cytokines (inflammatory substances). Inflammation is one of the biggest contributors of pain for those with endo.

Studies have not identified the exact link between inflammation and fatigue, but it is well-established that fatigue is a common symptom for people with inflammatory diseases.

Pain

Any condition that causes pain can create sleep problems, which in turn can increase fatigue. One member wrote, “I haven’t had a decent night’s sleep in a couple of weeks due to pain-induced insomnia. I’ve almost fallen asleep standing up at work but can’t sleep at night.”

“Painsomnia” — insomnia caused by pain — is often a cyclical problem for people living with endometriosis. The person has a hard time sleeping because they are in pain, which can trigger the immune system to activate excessive inflammatory responses. The activation of the immune system can result in more pain, further promoting sleep disturbances and leaving the person fatigued or overly exhausted.

Migraines

Like endometriosis, migraines are a common occurrence among women of reproductive age. One study showed that women with endometriosis, in particular, are more likely to have migraines. Similar to general pain, fatigue is a common symptom for those who have migraines.

Anxiety and Depression

People with endometriosis may also be prone to mental health issues including anxiety and depression. One member wrote, “Feeling deflated, depressed, and fatigued.”

One study found that fatigue was associated with higher anxiety and depression, as well as poor quality of sleep. The study, which included 230 women with endo, found that those who experience moderate to severe fatigue had higher anxiety and depression compared to those with mild fatigue symptoms.

A study of 1,120 women (560 of whom had endometriosis) found that fatigue was associated with higher levels of pain, insomnia, depression, and occupational stress. The findings suggest that doctors provide psychological or pharmaceutical treatment for fatigue in addition to medication to treat endometrial pain.

How To Address Endometriosis Fatigue

Effective treatment of fatigue often requires a multifaceted approach. It is important to seek medical advice before beginning any treatment to ensure that the treatment is appropriate for your needs.

Endometriosis Treatment

Better controlling your endometriosis overall may help reduce fatigue. Gynecologists typically recommend over-the-counter pain medications to reduce cramping or painful periods. Hormonal contraceptives that have a combination of estrogen and progestin (birth control pills or patches) may also help ease the symptoms of endometriosis that may be contributing factors to fatigue. Your doctor may have you fill out a questionnaire to help determine what medical treatments best address the symptoms of your endometriosis.

Learn more about treatments for endometriosis.

Iron Supplements

If your fatigue is caused by anemia due to excessive bleeding, taking an iron supplement or adding more iron-rich foods (such as meat and leafy greens) to your diet may help combat feelings of tiredness and weakness. If your anemia is very severe, you may need a blood transfusion.

Learn more about foods to eat and avoid when living with endometriosis.

Ginseng

A systematic review of 10 studies that used either Asian Panax ginseng or American Panax ginseng to treat fatigue found modest evidence for efficacy and low risk of adverse effects, suggesting that ginseng may be used to treat fatigue.

Medication

A clinical study of women with endometriosis who received certain doses of oral elagolix (a gonadotropin-releasing hormone antagonist) had a significant decrease in their fatigue compared to women who took placebo. The women taking the treatment also reported reduced menstrual pain, non-menstrual pain, and pain during intercourse.

Cognitive Behavioral Therapy

A review article of effective treatments for fatigue suggests that cognitive behavioral therapy — the psychological treatment by a therapist or psychologist to help the person develop coping skills to modify their behavior — may help address fatigue.

Exercise Therapy

The same study goes on to state that a second effective therapy for fatigue is graded exercise therapy, a structured exercise program focused on the gradual increase in time spent doing physical activity. Graded exercise therapy is effective for the treatment of fatigue, although it typically should not be used until the person’s physical activity capability has been established by a physiotherapist or an occupational therapist.

Learn more about exercise with endometriosis.

Talk With Others Who Understand

MyEndometriosisTeam is the social network for people with endometriosis. On MyEndometriosisTeam, more than 121,000 members come together to ask questions, give advice, and share their stories with others who understand life with endometriosis.

Do you experience fatigue with your endometriosis? What helps? Share your experience in the comments below, or start a conversation by posting on MyEndometriosisTeam.