Endometriosis: Diagnosis, Pain Management, and Fertility

Endometriosis is a condition where endometrial tissue, normally found inside the uterus, is located outside the uterus (ovaries, fallopian tubes, peritoneum, rarely intestines and bladder). It occurs in 6-10% of women of reproductive age. There is an average diagnostic delay of 7-10 years — being aware of this issue is critically important.

Main symptom: Period pain (dysmenorrhea) — severe, progressive, unresponsive to painkillers, disrupting daily life. Other symptoms:

• Deep pain during intercourse (dyspareunia)
• Pelvic pain (also outside menstrual period)
• Toilet pain during period (dyschezia, dysuria)
• Bowel complaints (constipation-diarrhea cycle, IBS-mimicking)
• Excessive fatigue
• Infertility (in 30-50% of cases)

Reasons for diagnostic delay: Period pain considered "normal," doctors dismissing it as "pain variation," not always visible on imaging, and for many years waiting for surgery (laparoscopy) to confirm it. Current guidance (ESHRE 2022) no longer considers laparoscopy mandatory for diagnosis. If you have severe and progressive dysmenorrhea, don't "accept" it, specifically ask about endometriosis.

Imaging:

• Transvaginal ultrasound and pelvic MRI — first-line imaging; they can show endometriomas and deep endometriosis, but neither is a "gold standard" on its own
• Laparoscopy + biopsy — used when imaging is inconclusive or when treatment is planned at the same time

Note: Diagnosis can be made based on clinical presentation even with negative imaging (ESHRE 2022 guideline)

Pain management (1st line):

• Anti-inflammatory pain relievers your doctor recommends — should start before menstruation
• Heat (hot water bottle, bath) — evidence-based effective
• Regular exercise — endorphin release
• Pelvic physiotherapy — for muscle tension
• Diet (low inflammation: omega-3, antioxidants, low red meat)

Hormonal treatment (1st line suppression):

• Combined oral contraceptive — continuous use (period suppression)
• Progestin tablets (dienogest, norethisterone) — suppresses endometrial activity
• LARC: hormonal IUD (Mirena) — strong local effect
• GnRH agonist/antagonist — in severe cases (side effect menopause-like, add-back therapy needed)

Surgery: Excision (cutting out) is superior to ablation, 1st line if hormonal fails or accompanies infertility. Hysterectomy is last resort — endometriosis is not "definitive cure"; recurrence possible even with ovaries preserved.

Infertility and pregnancy: Mild endometriosis may give a chance with IUI or timed intercourse. IVF is most effective in moderate-severe cases. Realistic discussion of "pregnancy chances" with endometriosis treatment is essential — laparoscopy doesn't always increase fertility. Reproductive specialist referral is valuable.

Dear woman, "your pain is not ordinary" — endometriosis is an invisible disease but real. Making your voice heard is your right. Getting multiple doctor opinions, being your own advocate is valuable. The disease is manageable, not hopeless — with the right team, quality of life can be largely regained.