Abstract: The abnormal bleeding that can accompany endometriosis may affect the marital relationship of niddah observant couples. Pain that might be confused with premenstrual symptoms can also affect halachic observance. When scheduling diagnostic procedures, the woman's halachic status should be considered as much as possible . If prescribing hormonal therapy, the impact of breakthrough bleeding should be remembered.

Discussion: Clinical symptoms of endometriosis include many forms of abnormal uterine bleeding. Each of these can have significant impact on the niddah observant woman.

Research has demonstrated that women with endometriosis experience significantly greater blood loss, dysmenorrhea, and longer menstrual periods than women without endometriosis [1] [2].  Each additional day (even partial) of minimal bleeding is another day the couple must wait until they are physically reunited. 

Clinical literature minimizes menstrual dysfunction related to premenstrual spotting [3].  However, for the niddah observant woman, premenstrual spotting can add additional days of niddah prior to menses every month. 

Irregular bleeding such as inter-menstrual or midcycle bleeding or spotting related to endometriosis [4] generally poses the largest problem for the niddah observant woman. Halachically significant bleeding during the seven clean days will require her to begin a new week of examinations and counting before she can immerse. If this phenomenon repeats itself, she may not succeed in getting to the mikveh immersion stage until her next regular menses commence, and months may pass before physical contact between husband and wife is permitted.

Other symptoms of endometriosis can also negatively affect the halacha observant woman. The pain from GI or pelvic area lesions that can accompany this condition may lead to an assumption that her menses are about to begin and proscribe relations at that time as well.

A woman with endometriosis in the vagina or vaginal cervix is likely to experience post-coital bleeding [5] or find stains on her bedikah cloths.  In these circumstances, even minute stains are halachically significant and can lead to prolonged periods of niddah, if not even more severe halachic implications regarding the viability of the marriage.  Cervical bleeding is particularly challenging due to the controversy regarding the halachic status of the cervix and its ramifications for the establishment of niddah status. 

Women with endometriosis often undergo diagnostic and therapeutic procedures. The timing of procedures in this population is important.  If the procedure will render her niddah, a woman is likely to prefer that it be done close to her expected time of niddah.  If the procedure will cause bleeding but does not cause sufficient uterine opening to render her niddah, then she is likely to prefer not to have it performed during her seven clean days, when any bleeding could create halachic complications.  These considerations are discussed further in the article on gynecological procedures. Forms designed to assist the woman in transmitting medical information to a halachic authority before and after a procedure are available on this site.

It is important to remember than not every spot will render a woman niddah. Therefore, prior to undertaking medical therapy for a woman whose chief complaint is spotting only, a halachic authority should be consulted to determine if halachic interventions alone can help her avoid the niddah status. If this does not work and hormonal intervention is recommended, the impact of breakthrough bleeding from this medication should be remembered.

Implications for Patient Care: Endometriosis poses additional challenges for the niddah observant woman. 

By understanding the potential implications of this condition on the niddah observant woman's quality of life, and being willing to address her concerns, the health care provider can be of much assistance to this patient population.

Proper coordination of efforts between the woman's health care provider and her particular halachic authority can maximize the provision of appropriate care.

Medical References

[1] Vercellini P, De Giorgi O, Aimi G, Panazza S, Uglietti A, Crosognani PG. Menstrual characteristics in women with and without endometriosis. Obstetrics and Gynecology 1997;90(2):264-268.

[2] Darrow SL, Vena JE, Batt RE, Zielezny MA, Michalnek AM, Selman S. Menstrual cycle characteristics and the risk of endometriosis. Epidemiology 1993;4(2):135-142.

[3] Speroff L, Glass LH, Kase NG. Clinical Gynecologic Endocrinology and Infertility (6th ed.) Philadelphia: Lippincott, Williams and Wilkins 1999; chapters 22, 28.

[4] Scott JR, Gibbs RS, Karlan BY, Haney AF (ed.). Danforth's Obstetrics and Gynecology (9th ed.)  Philadelphia: Lippincott, Williams and Wilkins 2003; chapter 40.

[5] Doshi J, Doshi S, Sanusi FA, Padwick M. Persistent post-coital bleeding due to cervical endometriosis. Journal of Obstetrics and Gynaecology 2004;24(4):468-469.