Endometriosis: Symptoms, Diagnosis and Treatment Options

Endometriosis is an oestrogen-dependent, chronic condition that affects roughly 1 in 10 women of reproductive age. Tissue similar to the uterine lining (endometrium) implants outside the uterus — on the ovaries, fallopian tubes, peritoneum, bowel, or, rarely, in more distant sites. Like the endometrium, this ectopic tissue bleeds with every menstrual cycle; because the blood cannot leave the body, chronic inflammation, adhesions, and pain develop.

What is endometriosis?

Endometriosis is the presence — outside the uterus — of glandular and stromal tissue that is histologically similar to the uterine lining. The ovaries are the most commonly involved site; dark-brown cysts that develop within the ovary are called endometrioma or, colloquially, "chocolate cysts". Superficial peritoneal lesions, deep infiltrating disease between the uterus and bowel, and adhesions are other manifestations.

Causes and risk factors

The exact cause is unknown, but several mechanisms are thought to contribute: retrograde menstruation delivering endometrial cells into the peritoneal cavity, failure of the immune system to clear these cells, hormonal factors, and genetic predisposition. The main risk factors are:

• Family history of endometriosis (mother or sister)
• Early menarche (before age 12), late menopause
• Short (fewer than 27 days) or long menstrual cycles
• Nulliparity or first pregnancy at an older age
• Low body mass index

Symptoms of endometriosis

Symptom severity does not always correlate with disease extent: small lesions can cause severe pain, while large cysts may be silent. The most common presentations are:

1. Severe menstrual pain (dysmenorrhoea)

Cramping pain that starts 1–2 days before menstruation, is severe enough in the first days to interfere with work or school, responds only partially to analgesics, and worsens over the years. What sets it apart from ordinary dysmenorrhoea is its progression over time and its impact on daily life.

2. Chronic pelvic pain

Pelvic pain unrelated to menstruation, lasting at least six months. It may radiate to the lower back and hip and can worsen with prolonged standing and physical activity.

3. Painful intercourse (dyspareunia)

Pain during deep penetration, persisting for several hours after intercourse, is a classic sign of endometriosis lesions in the posterior fornix and in the pouch of Douglas (cul-de-sac).

4. Infertility

About 30–50% of women with endometriosis experience difficulty conceiving. Reduced ovarian reserve, tubal adhesions, chronic pelvic inflammation, and impaired embryo implantation are the principal underlying mechanisms.

5. Bowel and urinary symptoms

Painful bowel movements during menstruation, diarrhoea or constipation, rectal pressure, painful urination, or blood in the urine (particularly during menstruation) may indicate bowel or bladder involvement.

6. Other symptoms

• Chronic fatigue and low energy
• Nausea and headache during menstruation
• Intermenstrual spotting
• Abdominal bloating ("endo belly")

Stages

The American Society for Reproductive Medicine (ASRM) classification defines four stages. The stage reflects the extent of disease but does not always correlate with pain severity:

• Stage 1 (minimal): isolated superficial lesions.
• Stage 2 (mild): more superficial lesions and mild adhesions.
• Stage 3 (moderate): endometrioma (chocolate cyst) and more prominent adhesions.
• Stage 4 (severe): large endometrioma, extensive deep infiltrating disease, and adhesions between the uterus and bowel.

How is the diagnosis made?

The diagnosis is based on clinical assessment, imaging, and — when required — surgical confirmation. The interval from initial suspicion to definitive diagnosis varies between women; early evaluation is important.

• Detailed history and examination: pattern of pain, menstrual history, family history, and pelvic examination for tenderness and nodularity.
• Transvaginal ultrasound: endometrioma (chocolate cyst), deep infiltrating lesions, and uterine–bowel adhesions can be assessed with a high degree of accuracy.
• MRI: provides detailed mapping of bowel, bladder, and deep infiltrating disease and guides surgical planning.
• CA-125: may be elevated in some cases; not diagnostic on its own but useful for follow-up.
• Laparoscopy: the gold standard for definitive diagnosis. Small abdominal ports allow both visualisation and treatment in the same session, with biopsy confirmation.

Treatment options

Treatment is individualised on the basis of age, symptom severity, stage of disease, reproductive plans, and ovarian reserve. There is no single "best treatment"; the aims are to control pain, halt disease progression, and preserve fertility.

1. Medical therapy (pain management)

Non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line option for mild to moderate pain. Regular use, started 1–2 days before menstruation and continued through the period, is more effective than intermittent dosing.

2. Hormonal therapy

By suppressing ovulation and menstruation, hormonal therapy prevents bleeding and growth of endometriosis lesions. Options include:

• Combined oral contraceptives (especially continuous use)
• Progestin-dominant tablets (dienogest, norethisterone acetate)
• The levonorgestrel-releasing intrauterine device
• GnRH agonists or antagonists — these induce a temporary menopause-like state; usually used for 3–6 months with add-back therapy

Hormonal therapy does not cure the disease; symptoms may return after treatment is stopped. It is not suitable for patients who wish to conceive.

3. Laparoscopic surgery

Surgery is considered when pain is refractory to medical therapy, for endometriomas 4 cm or larger, when imaging findings are suspicious, when the fallopian tubes are blocked, or as part of infertility evaluation. Laparoscopy (keyhole surgery) is the current gold standard:

• 3–4 small incisions (0.5–1 cm) in the abdominal wall; scarring is minimal.
• Endometrioma is removed together with the cyst wall; ovarian tissue is preserved.
• Superficial lesions are treated with cautery or laser, or excised.
• Adhesions are released and tubal patency is assessed.
• Recovery is short (usually about one week); hospital stay is typically one night.

4. Fertility treatment

In women trying to conceive with endometriosis-related infertility, management depends on stage and age. In mild disease, spontaneous conception is more likely after laparoscopy; in advanced disease or when ovarian reserve is low, IVF may be planned directly. Careful preoperative planning is important to preserve ovarian reserve.

Lifestyle and supportive measures

• Regular physical activity and pelvic floor exercises can reduce chronic pain.
• An anti-inflammatory diet (rich in omega-3, low in processed foods and trans fats) may ease symptoms.
• Warm compresses and pelvic relaxation techniques help with menstrual pain.
• Chronic pain can have a psychosocial impact; do not hesitate to seek specialist support.

When to seek immediate care

• Sudden severe one-sided pelvic pain (possible endometrioma rupture or torsion)
• High fever with pelvic pain
• Heavy intermenstrual bleeding, fainting
• Pain unresponsive to analgesics and interfering with daily life

Endometriosis treatment in Adana

With timely diagnosis and experienced laparoscopic surgery, endometriosis is a condition in which quality of life can be substantially improved. Op. Dr. Sadık Kükrer offers individualised care in Adana for endometriosis — from diagnosis to laparoscopic surgery — with the aims of controlling pain and preserving fertility. If you experience severe menstrual pain, painful intercourse, or difficulty conceiving, you can contact the clinic for an assessment.