Deep Endometriosis Explained: A Q&A With Dr. Tamer Seckin

When I began practicing gynecologic surgery in New York in the early 1990s, many women with chronic pelvic pain were routinely evaluated for infections, even when laboratory testing repeatedly came back negative. At the time, endometriosis received very little attention during medical training.
As I performed laparoscopic surgeries, I began recognizing lesions that were consistent with endometriosis. Removing those lesions dramatically improved many patients’ symptoms. Their recovery—and their gratitude—convinced me that this disease deserved far greater attention.
Those early experiences ultimately shaped my career and later led to the creation of the Endometriosis Foundation of America, whose mission is to improve awareness, education, and research.

One of the biggest challenges is that severe menstrual pain is often dismissed as “normal.”
Many girls begin experiencing debilitating pain during adolescence, yet they are reassured that painful periods are simply part of growing up. While mild discomfort can occur with menstruation, severe pain that limits daily activities or continues beyond the first couple of days should never be ignored.
Parents—especially mothers—play a vital role in recognizing persistent symptoms and advocating for proper evaluation. Early awareness can significantly shorten the delay to diagnosis.

Deep infiltrating endometriosis develops when endometriosis extends beneath the surface of the pelvic lining and invades deeper tissues.
Unlike superficial disease, deep lesions may involve the bowel, bladder, pelvic ligaments, ureters, nerves, and surrounding connective tissue. As inflammation progresses, scar tissue and fibrosis develop, making symptoms more severe and treatment more complex.
Early diagnosis offers the best opportunity to prevent this progression.

Pain evolves as the disease progresses.
I generally describe three types of pain:
Uterine pain associated with menstruation.
Peritoneal pain caused by irritation of the pelvic lining.
Deep retroperitoneal pain that occurs when disease affects deeper structures and pelvic nerves.
Patients with deep disease often describe persistent one-sided pelvic pain, lower back pain, groin pain, sciatica, painful bowel movements, and pain during intercourse. These symptoms suggest the disease has extended beyond superficial lesions.

Symptoms that deserve evaluation include:
Severe menstrual cramps lasting longer than two days
Chronic pelvic pain
Pain during intercourse
Pain with bowel movements
Constipation or diarrhea that worsens during menstruation
Painful urination during periods
Ovulation pain
Persistent fatigue associated with menstrual cycles
Perhaps the most important question is whether these symptoms consistently worsen during menstruation. If multiple symptoms flare with the menstrual cycle, endometriosis should always be considered.

Absolutely.
Although many people associate endometriosis only with the ovaries, deep disease can involve the bowel, bladder, ureters, diaphragm, pelvic nerves, and in rare situations even the chest cavity.
This explains why some patients experience gastrointestinal symptoms, urinary problems, or even chest pain that appears only during menstruation.

Endometriosis is a progressive disease.
When identified early, medical therapy and appropriate monitoring may help slow progression. If surgery becomes necessary, treating disease before extensive scarring develops often leads to better long-term outcomes.
Early diagnosis may also preserve fertility, reduce chronic pain, and prevent repeated surgeries later in life.

No.
Many patients respond well to hormonal suppression and careful medical management.
However, when symptoms persist, fertility is affected, or deep infiltrating disease develops, expert laparoscopic excision surgery remains the preferred surgical approach because it removes disease while preserving normal anatomy whenever possible.

Painful periods that interfere with school, work, or everyday life are not something patients should simply accept.
Awareness leads to earlier diagnosis.
Earlier diagnosis leads to earlier treatment.
Earlier treatment offers the best opportunity to prevent advanced disease and improve quality of life.
Most importantly, patients should know that endometriosis is treatable, and with appropriate care many women go on to live healthy, active lives.