What is Endometriosis?
Endometriosis (Chocolate Cyst Disease) is an unusual disease that is often seen in the reproductive age, sometimes in the form of a chocolate cyst that is detected only by chance without causing any complaints, and sometimes it may not be very relieved despite many medical treatments and operations. It is one of the important examples of the phrase “there is no disease, there is a patient” that we use in medicine. It is seen in 1 out of 10 women of reproductive age. it is the placement of the lining of the uterus (endometrium) in the extra-uterine organs. İt is most common in 65-70% of the ovaries (ovaries). Apart from this, the organs seen in the abdomen are the peritoneum, tubes, vagina, intestines, bladder, ureter, umbilicus (navel), old operation suture areas, lungs, diaphragm, spinal canal, brain, eye, breast tissue, heart, arms, and hands. reported as the spleen.
Why and how does endometriosis occur?
İt is a disease that was first described in 1860, but its cause and treatment are still debated. Various theories have been put forward to explain why. It is not known exactly why this disease affects women and by what factors it occurs. One of the most widely accepted theories is that endometrial tissue flows back into the peritoneal cavity, namely the abdominal cavity, through the tubes during menstruation, and new endometriosis foci are formed. In recent years, it has been investigated that genetic predisposition may play a role in the development of this disease, but a direct genetic factor responsible has not been found yet. As a result of the insufficient immune response, it suggests that this retracting endometrial tissue causes endometriosis foci in the peritoneal membrane surrounding the abdominal cavity and in the genital organs such as ovaries and tubas. According to another theory, some changes (metaplasia) occur in peritoneal and ovarian cells in response to effects such as increased estrogen, and endometriosis develops. Another theory suggests that endometrial tissue spreads with blood and lymph vessels and thus endometriosis occurs. Some scientists have also suggested that some environmental factors (a toxin such as Dioxin, which is an intermediate product in the chemical industry, PVC, and paper production), are effective in the formation of it. In other words, different theories are explaining the occurrence of It and endometriosis continues to be a disease with many unknown facts. The resulting endometriosis foci grow and bleed according to the changes of the estrogen hormone in the menstrual cycle, spread deeper, resulting in pain and adhesions in the areas where they are located. While the immune system cells try to eliminate the endometriosis foci, an inflammatory condition occurs with it, resulting in scar tissue and serious adhesions.
What is the frequency of endometriosis?
İt is a reproductive age disease and is most common in the 30s. It is seen in 70% of women with painful menstruation, painful intercourse, and chronic groin pain. It is seen in 30-40% of women with infertility problems. It is generally seen in one in 10 women of reproductive age (15-49 years). Although endometriosis is not common in the 13-19 age group, which we call adolescents, the frequency of it is 70% in young girls who have severe menstrual pain and do not respond to painkillers.
What are the risk factors for endometriosis?
- Frequent, excessive, and long periods,
- Early start to menstruation,
- Entering late menopause,
- The white race,
- Congenital uterine anomalies,
- Having a family member affected by endometriosis (it is 3 times more common in women with endometriosis in their family),
- Eating fatty foods,
- Excessive meat consumption,
- Excessive caffeine consumption,
- Thin and tall stature,
- Being blond and auburn
- It is counted among the risk factors.
What are the symptoms of endometriosis?
- Painful menstruation
- Chronic groin pain
- Painful sexual intercourse (pain hitting the anus and groin)
- Infertility (infertility)
- Diarrhea and constipation
- Rectal bleeding, bloody stools
- Menstrual irregularity, premenstrual spotting
- Painful and bleeding urination
- Some women with endometriosis may have no symptoms, the diagnosis is made by ultrasound or by seeing during surgery.
How is endometriosis diagnosed?
First of all, the patient’s complaints and personal history are taken. Here, it is definitely discussed with the patient whether there are some special complaints about endometriosis. Then, ultrasonography is performed together with a gynecological examination and examination. During the pelvic examination, tenderness, pain expression, limited movement of the uterus and ovaries may suggest endometriosis. Occasionally, blue-purple nodular lesions can be seen behind the cervix (cervix) during speculum examination, this simple finding indicates the presence of Deep Infiltrative (surrounding, moving around) Endometriosis in the deep tissues of the pelvis. Therefore, pelvic examination with a speculum is very important for diagnosis.
Yet another auxiliary method is blood tests, the most frequently requested Ca 125 and Ca 19-9. However, the sensitivity of these tests in detecting endometriosis is low and they are only requested as additional tests.
The most informative of the auxiliary methods in diagnosis is Ultrasonography. In ultrasonography, chocolate cysts, which we call endometrioma in the ovary, serious adhesions between the ovaries and the uterus, and sometimes endometriotic nodules in the intestine, rectum, bladder, around the ureter (the tube that carries urine from the kidney to the bladder) can be seen.
Magnetic Resonance Imaging (MRI), which is an advanced imaging method, is especially useful in cases where endometriosis, which we call deep endometriosis, involves deep pelvic tissues. Standard MRI is not enough here. This MRI must be able to shoot very precisely and special equipment should be used to increase the image quality in the relevant region during shooting. These features are available in a very limited number of viewing centers. Also, the Interpreting Radiologist must be experienced in these matters.
The definitive diagnosis of it is made by laparoscopy and tissue biopsy. During laparoscopy, endometriosis can be evaluated as mild (stage 1-2) and severe (stage 3-4).
In another classification, it is evaluated in 3 groups as peritoneal endometriosis, ovarian endometriosis, and deep endometriosis. Although it is easy to detect it in the peritoneum and ovary during laparoscopy, deep endometriosis can be overlooked during the operation because it involves deep pelvic tissues.
Is There a Special Blood Test Requested in the Diagnosis or Follow-up of Endometriosis?
Especially Ca 125, Ca 19-9 and Human Epididymis Protein 4 (HE4) may be desired. They are not routinely asked from every patient. However, the sensitivity of these tests in detecting endometriosis is low and can only be requested as an additional examination. It can be requested in special cases. Another possible blood test is HE4. It is especially used to distinguish it from malignant ovarian masses.
How is the Definitive Diagnosis of Endometriosis Made?
The definitive diagnosis of it is made by tissue biopsy by laparoscopy or laparotomy. During laparoscopy or laparotomy, endometriosis can be evaluated as mild (stage 1-2) and severe (stage 3-4). In another classification, it is evaluated in 3 groups as peritoneal endometriosis, ovarian it, and deep endometriosis. Although it is easy to detect it in the peritoneum and ovary during laparoscopy, deep endometriosis can be overlooked during the operation because it involves deep pelvic tissues. In the presence of It, the experience of the physician is extremely important in both diagnosis and treatment management.
How is Endometriosis Treated?
İt is not a disease that can be treated and eliminated completely. The stage and severity of the endometriosis disease affect the treatment approach. Two important determining factors in treatment are pain and infertility (child desire). There are two basic approaches in the treatment of it: Medical Treatment (drug use) and Surgical Treatment.
What is Used in Drug Treatment?
The purpose of treatment with medical drugs is to suppress endometriosis lesions by creating a low estrogenic condition, to reduce inflammation, and to stop the progression of endometriosis lesions. Drug treatment includes painkillers, birth control pills, progesterone-containing drugs specific to endometriosis treatment (also available in our country), intrauterine progesterone-containing tools (spiral), monthly or 3-month needles that we call GnRH analogs, and aromatase inhibitors. There is a difference between them in terms of side effects and price. Regardless of drug treatment, 50% of endometriosis can recur after treatment.
In Surgical Treatment
Purpose in surgical treatment; To maintain normal anatomy, to open adhesions, to remove ovarian cysts with minimal damage to the remaining ovarian tissue, to burn or cut out the endometriosis foci in the peritoneum with cautery, and to remove deep endometriosis nodules, if any. In the treatment of it, surgery should be in the form of preventive surgery, only endometriosis foci should be eliminated. Surgery should be avoided at an early age, unless necessary, because symptoms return within a year in half of the women after surgery, and a repeat operation may be required in half of the cases within 5 years after surgery. Medical drug therapy after surgery may delay the recurrence of symptoms.
In Which Cases, Surgical Treatment Is Not Considered In The Foreground?
- Those who do not have children,
- In adolescents
- Those with very low ovarian reserve
- Those with double-sided chocolate cysts
- In patients who have previously undergone recurrent operations
If the pain complaint is at the forefront, medical treatment or surgical treatment may be recommended. However, one of the most important points to be known for treatment is that surgical treatment is the most effective method for pain. Here, fertility and the age of the woman gain importance. While there is no limitation regarding surgery in women with children, surgical treatment is not considered in the foreground in those who have no children, those with bilateral chocolate cysts, and those who have undergone previous operations.
it is suitable to do. While medical treatment is not required after surgery in early-stage It, medical treatment after surgery is useful in preventing recurrence in advanced-stage endometriosis.