Frequently Asked Questions About Endometriosis
- Nafiye Yılmaz
- 6 hours ago
- 5 min read
Murat Aksoy: First of all, could you provide a definition for those who are unfamiliar with endometriosis?
Prof. Dr. Nafiye Yılmaz: Certainly. Endometriosis is a chronic disease characterized by the presence of endometrial-like tissue—the lining that normally sheds with blood during each menstrual cycle—outside of its normal location. This tissue can be found on the exterior of the uterus, the fallopian tubes, the ovaries, the pelvic peritoneum, or other intra-abdominal organs such as the intestines and the bladder. It is a chronic condition presenting with pain and inflammation, significantly impacting the quality of life.
Murat Aksoy: What exactly causes the pain? For instance, if there is endometriotic tissue on the intestine, what mechanism triggers the pain?
Prof. Dr. Nafiye Yılmaz: Normally, menstrual blood flows from the uterus through the vagina. However, these ectopic foci are hormone-sensitive, just like the internal uterine lining, and cause bleeding within the abdominal cavity during each cycle. Consequently, the changes initiated by these foci lead to adhesions between tissues and increased inflammation. The cell's self-defense mechanisms, the immune system, and the oxidant-antioxidant balance are disrupted. Specifically, the formations we call adhesions (tissues sticking together) constitute the primary cause of pain. Due to prior bleeding, intestines may adhere to one another, impairing motility. It can be conceptualized as internal bleeding; while not life-threatening, it is a condition that severely compromises the quality of life.
Murat Aksoy: Why does such a problem arise? Is it a condition that develops during fetal development in the womb?
Prof. Dr. Nafiye Yılmaz: Although the exact mechanism remains unknown, the most prominent theory is retrograde menstruation—the backward flow of menstrual blood through the fallopian tubes into the pelvic cavity, where it forms foci. Additionally, research continues into various factors such as genetic predisposition, environmental factors, immunological triggers, stress, nutrition, and elements that increase systemic inflammation. It is a multifactorial disease, which explains the extensive volume of ongoing studies. Due to the high number of unknowns and its negative impact on life quality, treatment options vary. The spectrum of symptoms from patient to patient, and the duration until diagnosis, also differ. We can generally categorize it as multifactorial.
Murat Aksoy: It wouldn't be incorrect to predict a correlation with menstruation, then.
Prof. Dr. Nafiye Yılmaz: Correct.
Murat Aksoy: For example, can symptoms emerge from the onset of the first period (menarche), or can they manifest years later?
Prof. Dr. Nafiye Yılmaz: The disease is progressive. Due to the damage caused to the tissue, the harm to surrounding structures increases over time if not diagnosed early. However, during adolescence, many consider menstrual pain as "normal" or "expected." Yet, not all menstrual pain is normal. If it is particularly severe, compromises quality of life, is bedridden, non-responsive to analgesics, persistent, and leads to loss of productivity (work/school), the possibility of endometriosis should be considered even at a young age. The process is hormone-dependent over the years. Changes in the balance between estrogen and progesterone, and alterations in tissue sensitivity to these hormones, are critical. Therefore, symptomatic flare-ups occur rhythmically with each cycle. As the duration increases—meaning earlier menarche, later menopause, heavy bleeding (menorrhagia), high frequency of periods, or absence of pregnancy (lack of a hormone-suppressive environment)—the disease presents with a chronic, progressive, and debilitating clinical profile.
Murat Aksoy: It seems like a paradox. Endometriosis is a condition that progresses and manifests symptoms as age advances, yet small foci might have existed within the "closed box" of the abdomen since youth. Thus, I assume early diagnosis is difficult until pain manifests.
Prof. Dr. Nafiye Yılmaz: Endometriosis has several forms. One, as you mentioned, consists of the most common punctate foci on the peritoneum, tubes, ovaries, intestines, upper abdomen, or rarely, extra-pelvic sites (thorax, nose, eyes). Another form, which is relatively easier to diagnose, is the cystic form in the ovaries. This is colloquially known as a "chocolate cyst" (Endometrioma). Its name sounds sweet, but the damage it causes is unfortunately not. When the cystic form is present, both physician awareness and patient follow-up rates increase, making them seemingly easier to identify. There is also a third form: Deep Infiltrative Endometriosis (DIE), where nodules form in the lower intestines, rectum, or the junction of these tissues. These nodules may vary in size—like a chickpea or a hazelnut—but they cause hardening, fibrosis, and adhesions following inflammation and bleeding at depth. Diagnosis in these patients can be delayed. Even for a gynecologist, if there is a lack of awareness regarding this specific type, deep nodules can be overlooked. Therefore, the specific form of the disease dictates the diagnostic delay, which statistically ranges between 3 to 10 years.
Murat Aksoy: The next question that comes to mind is: Since we are discussing reproductive organs and ovaries, can endometriosis cause infertility?
Prof. Dr. Nafiye Yılmaz: Endometriosis has two major impacts on a woman's life. One is the pain we have discussed. The second is its "silent" progression. Punctate foci on the fallopian tubes can lead to tubal occlusion (blockage) through adhesions during the healing process. As for the "chocolate cysts" in the ovaries, the accumulation of menstrual blood and the rise of inflammatory markers within the cyst can negatively affect both the ovarian reserve and egg quality. Furthermore, it can disrupt the communication between the tube and the ovary, creating obstacles for the sperm to reach the egg even if the tubes are open. Another form is adenomyosis, where the tissue is within the uterine muscle (myometrium), commonly seen in women of reproductive age (20–40). In women with heavy bleeding, dysmenorrhea, or dyspareunia (painful intercourse), it creates microscopic lesions within the muscle. This can lead to pain or recurrent pregnancy loss. In summary, it can cause infertility by affecting ovarian reserve, distorting tubal anatomy, and impacting the endometrium where the embryo implants. However, this does not mean every patient with endometriosis is infertile. The severity, tissue damage, and location vary. If anatomy is preserved and ovarian reserve is normal, we cannot directly label it as infertility. Regarding pain: Deep pain during intercourse suggests Deep Infiltrative Endometriosis. Vaginal examination is vital for diagnosis in sexually active women.
Murat Aksoy: As you described these diverse locations—from the thorax to the ovaries—I thought a systemic approach might be necessary. What is the first step in treatment?
Prof. Dr. Nafiye Yılmaz: First, an accurate diagnosis is paramount. For sexually active patients, the most critical tool is a vaginal examination, followed by 3D ultrasound, which is our "eyes and ears." We can visualize the location of the disease, deep nodules, and tubal obstructions. For virginal patients, radiological methods like MRI assist in diagnosis.
Murat Aksoy: Does the timing of the menstrual cycle matter for diagnosis?
Prof. Dr. Nafiye Yılmaz: Ultrasound or MRI performed during the second half of the cycle (luteal phase) can sometimes lead to confusion with ovulation cysts (hemorrhagic cysts). However, the most critical element is the patient's anamnesis (medical history). While we have imaging and certain blood tests, these tests are not 100% diagnostic; a negative result does not exclude the disease.
Murat Aksoy: Once diagnosed, what are the treatment options?
Prof. Dr. Nafiye Yılmaz: Treatment is tailored to the patient’s primary complaint: pain or infertility. If the patient has not completed their family planning, we inform them about fertility preservation. Options like oocyte (egg) freezing or embryo cryopreservation are discussed before any ovarian surgery. Treatments are classified into two:
Medical Treatment: Ranging from simple analgesics to combined oral contraceptives (estrogen/progesterone), progestin-only intra-uterine systems (IUS/Spiral), or GnRH analogues (monthly/3-month injections). The logic is to suppress the rhythmic cycle and prevent flare-ups.
Surgical Treatment: If medical therapy fails, minimal invasive surgery (laparoscopy or robotic surgery) is preferred. A multidisciplinary approach is mandatory. We work with specialists in gastroenterology, general surgery, urology, radiology, and even physical therapy, as endometriotic nodules can sometimes affect nerve pathways, causing referred pain in the back or legs.
Murat Aksoy: Thank you very much. This was also Endometriosis Awareness Month. Increasing awareness among both patients and physicians will accelerate early diagnosis and improve the quality of life.
Prof. Dr. Nafiye Yılmaz: Thank you. 🍀
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pebek
Thank you... There is always hope.
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