Endometriosis is a disease that occurs when the endometrial layer, which normally covers the internal part of uterus, is located in other parts of the body. It is not clear why it occurs. But genetic predisposition, that is, family members, weakness of the immune system or exposure to certain toxic substances is suggested to trigger the formation of this disease.

Endometriosis is usually seen in reproductive age women. It has been suggested that one in 10 women has this disease. In recent years, it is known that this disease may be present in young girls and in unmarried young women and the most obvious indicator of this is severe menstrual pain. Endometriosis is the most common problem in young girls whose menses are very painful and whose pain is not improved even with painkillers.

What kind of complaints does endometriosis cause? Endometriosis is suspected in women with severe menstrual pain, pain during intercourse and infertility. Therefore, severe menstrual pain or pain in the sexual intercourse should not be considered normal and should be consulted by a gynecologist. Other complaints caused by endometriosis vary according to the organ involved and may be; fatigue, pain during urination, bleeding in the urine, constipation, bloating, gas pains, intermenstrual bleeding, severe menstrual pain and brownish onset and prolonged duration of menses, pressure sensation in the groin, pain during sexual intercourse, infertility.

In the evaluation of couples who want to have a baby and examined for infertility, endometriosis is the underlying factor in almost one third of the couples with normal sperm analysis. For this reason, endometriosis is considered first when a woman has painful periods, has difficulty in sexual intercourse and wants to have a baby. Endometriosis can lead to infertility by obstructing the tubes, making a cyst in the ovaries (endometrioma, chocolate cyst) or by narrowing or compressing the uterus (by adenomyosis). On the other hand, every patient with endometriosis does not experience infertility. There are women with endometriosis who have spontaneous pregnancy. Therefore, infertility may not be present in all patients with endometriosis, but when endometriosis is detected, pregnancy should not be postponed and if necessary, assisted reproductive treatments should be started.

How do we diagnose endometriosis? Firstly, gynecological examination is performed. In the ultrasonography, the masses in the ovaries which are endometrioma or in the uterus which are called adenomyosis can be detected and also the small nodules which are called deep endometriosis can be detected. A careful ultrasound evaluation should be performed to see these structures. Especially in women who want baby, tube film must be performed, the use of antibiotics during the film is important. A good MRI examination in women with deep endometriosis after ultrasound examination may reveal detailed description of the masses and its relationship with the surrounding organs.

One of the most important problems of endometriosis is the late diagnosis. Internal medicine physicians, emergency doctors and physical therapists are being consulted for pain. To be aware of the disease and being suspicious about it is important for early diagnosis. Therefore, it is urgent to raise awareness about this disease. Especially adolescent girls and unmarried young women shoud be diagnosed without delay in order not to face infertility problems in the future.

How is endometriosis treated? Treatment depends on what the complaint is and the age of the woman. If a young girl has severe menstrual pain due to endometriosis, the drug is administered. In young girls who do not respond to the drugs, endometriotic lesions that cause pain can be removed by laparoscopy. In an endometriosis patient whose pain is unbearable, the ovaries can be removed surgically if she does not want to have a baby. If an endometriosis patient wants to have a baby, firstly the ovarian reserve and the tubes patency are evaluated. If there is a sperm problem, IVF treatment is applied. If the ovarian reserve is limited or the tubes are obstructed, IVF treatment is carried out. However, if there are large cysts or swellings in the tubes, initially these problems are solved with laparoscopy and IVF treatment is started afterwards if a spontaneous pregnancy does not ocur meanwhile. It is important to be followed by an experienced infertility speacialist during IVF treatment.

When drug treatment is decided to be administered in patients with endometriosis, there are different alternatives; painkillers, contraceptives, progesterone-containing pills, medicated spirals and monthly or quarterly needles. The medication that is good for a woman may not show any benefit to the other, the drug treatment is planned individually. In women with infertility problems, drug therapy does not work.

In endometriosis disease, surgical treatment methods are performed when drug treatment is not beneficial. Surgical treatment methods are performed laparoscopically with a thin camera inserted through the umbilicus. During laparoscopy, adhesions in the abdomen are treated, chocolate cysts are removed, deep endometriosis foci are removed, and if the woman is older, the uterus and ovaries can also be removed. When determining the method in endometriosis surgery, the age of the woman, whether there is a child request and the ovarian reserve are important factors and depending on those factors the surgical treatment will be tailored. After surgical treatment for endometriosis, the disease may recur. Therefore, following endometriosis surgery, suppressive treatment methods should be applied to prevent the recurrence of the disease and the relapse of endometriotic lesions with pills or medicated spirals. Indeed, close follow-up is important after endometriosis surgery. If there is no pregnancy within one year following endometriosis surgery, IVF treatment is considered.

As a conclusion, endometriosis is a disease that requires constant control such as diabetes and needs to be under suppression with treatments. One of the most important problems is the delay in diagnosis because the complaints it creates can be neglected. If endometriosis is diagnosed early and kept under control by treatments, it may not adversely affect female life. Endometriosis does not turn into cancer, but if it is not suppressed, it can cause serious consequences and decrease the quality of life in women and cause serious pain. For this reason, an experienced gynecologist should be the treating physician. Endometriosis is an important and debilitating disease nowadays all over the world and the diasese awareness should be raised in order to diagnose early and thus prevent its irreversible consequences.      

                                                                       Banu Kumbak Aygun, M.D., Professor  

                                                                                 Gynecology & Obtetrics

                                                                                         IVF Specialist