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The lining of the uterus is known as the endometrium. Endometriosis is a condition in which endometrial tissue spreads outside the uterus. Symptoms can include heavy menses, irregular bleeding, pain with menses and/or during intercourse, gastrointestinal symptoms, and difficulty conceiving. It can also be emotionally challenging to live with these symptoms.
Endometriosis is underdiagnosed, since many symptoms overlap with those of other conditions. Early diagnosis is beneficial to treatment, so girls and women should discuss any symptoms with their physician. For example, women who regularly experience severe menstrual pain should be screened for endometriosis.
A range of treatments are available for endometriosis, including hormonal therapy, complementary medicine, and surgical intervention.
Both the symptoms and treatment of endometriosis can have halachic implications:
Long periods and irregular bleeding can make a woman niddah more often, or make it difficult to get to the mikveh. A woman can sometimes avoid becoming niddah from staining associated with endometriosis by taking precautions based on the laws of stains. We discuss these here.
If a woman can determine that her bleeding is from a source outside the uterus, such a lesion on the outer cervix or in the vaginal canal, it is dam makkah (blood from a wound) and not dam niddah. The status of endocervical bleeding (inside the cervix) is subject to debate.
Dam makkah does not make a woman niddah. However, since bleeding from outside the uterus often coincides with menstrual bleeding from inside the uterus, it can be complicated to apply leniencies based on dam makkah.
Bleeding after Relations
Endometriosis in the vagina or vaginal cervix can also lead to bleeding after relations. Women with endometriosis should be especially careful about the following precautions, which are advisable for all couples:
- Use only colored sheets or towels.
- After relations, both husband and wife should wipe themselves only with disposable tissues or colored towels. The husband should wipe himself before looking, to avoid seeing blood on his body.
- Husband and wife should wait a minute or two from the end of relations before looking at anything or wiping themselves.
A woman experiencing pain associated with endometriosis may not wish to have relations. It is fully permissible for a couple to forgo relations when they would lead to discomfort.
Some forms of hormonal therapy can lead to breakthrough bleeding. A woman should discuss this in advance with her physician. She should also consult with a halachic authority to avoid unnecessarily becoming niddah or interrupting the clean days.
A woman with endometriosis may undergo various diagnostic or therapeutic medical procedures. We discuss considerations of niddah and scheduling for these procedures here.
Endometriosis can affect fertility. Yoatzot Halacha Fertility Counselors provide free personal consultations to help couples address this or other fertility challenges.