It is necessary to briefly mention the endometrial tissue and its changes that occur in each cycle to understand the endometriosis (chocolate cyst) disease:
The epithelial layer lining the uterine cavity is called the endometrium tissue (uterus). Endometrial tissue lays the inner walls of the uterus as a thin layer. This tissue, consisting of endometrial cells and connective tissue (stroma) cells, undergoes cyclic changes monthly in preparation for pregnancy. During the menstrual period, the endometrium tissue is broken down and shed, and it is excreted through the cervix and vagina with menstrual blood. However, in a significant portion of women, menstrual blood passes through the tubes and passes into the abdominal cavity in a small amount. The fragmented endometrium tissue, which passes into the abdominal cavity with the reflux of menstrual blood (retrograde), is eliminated by the "macrophage" cells of the body's immune system.
Endometrial tissue goes cyclically through regeneration and shedding phases. These cyclic changes are due to the effect of hormones secreted from the brain and ovaries. While the endometrium layer is thin (3 to 5 mm) in the postmenstrual period, it gradually thickens up to 9 to 15 mm in the following days due to hormonal effects. With the end of menstruation, the endometrial tissue regenerates and gradually thickens. Embryo reaches the uterine cavity nearly 5 to 6 days after egg hatching. These days the endometrium should be ready for pregnancy; otherwise, the embryo cannot settle in the endometrium and pregnancy does not occur.
Endometriosis (chocolate cyst) is the settlement of endometrium cells that make up the inner tissue of the uterus in places outside this region. The areas where the endometrium cells are located outside the inner region of the uterus are called 'endometriosis focus'. Although endometriosis foci may be few in number, they are very common in severe forms.
It is not known exactly how the endometrium tissue, which is normally found only in the inner layer of the uterus, is located in other areas. It is known that the "retrograde" flow of menstrual blood into the abdominal cavity plays an important role as described above. However, while a significant proportion of women have retrograde flow, it is not known why only some of them develop endometriosis. The insufficiency of the immune system, which must break down and destroy the endometrial tissues reaching the abdominal cavity, is blamed. As a result, the endometrium tissue, which cannot be destroyed, settles on the outer surface of the uterus, ovaries, tubes, lower abdominal cavity membranes (peritoneum), intestinal surfaces. Although retrograde flow is the strongest theory in the formation of endometriosis foci, other mechanisms (metaplasia theory, hematogenous spread, etc.) are also thought to play a role.
Incidence
The exact incidence of endometriosis in women is not known since the disease can also be found in women who have no complaints and who could conceive without treatment. Reported rates vary, as the diagnosis is made by laparoscopy or surgery. However, the incidence in women of childbearing age is estimated to be 10%. While this rate is low for women who do not have a pregnancy problem (1 to 5%), this rate increases to 20-40% for women who apply due to infertility.
Where and how are endometriosis foci seen?
Endometriosis causes very different types of lesions in the abdomen and on the genital organs. It is classified as Stage I-II-III-IV according to the extent of these lesions.
This classification is made according to the location and extent of the lesions detected during laparoscopy. It is not possible to estimate the diagnosis and stage of endometriosis without laparoscopy. While the disease is more limited and in the initial stage in Minimal-Mild (Stage I-II) endometriosis, endometriosis is more common in Moderate-Severe (Stage III-IV) forms. In stage III-IV, there are usually severe adhesions and chocolate cysts in the abdomen. Although not always valid, the patient's complaints (groin pain, severe menstrual pain, pain in intercourse, inability to have a child, etc.) increase with the stage of endometriosis. However, severe symptoms may not be present in very advanced endometriosis, and in very mild forms, the complaints may be serious and intolerable.
Endometriosis foci are small, dark red-blue-black colored formations like gunpowder burns. These foci may remain unchanged or progress, cause a reaction where they are located and adhere to the surrounding normal tissue by retracting them (for example, the uterus and intestines may adhere tightly to each other), or they may cause adhesions in the form of thin-thick fibrous bands between organs. These adhesions may not cause any complaints or infertility, but on the other hand, intense adhesions, especially between the tubes and ovaries, may make it difficult to get pregnant or completely prevent pregnancy. These adhesions may prevent the egg to be taken into the tubes and their journey in the tubes, as well as increase the risk of ectopic pregnancy. In addition, disruption of normal anatomical integrity, retraction, adhesions and displacements in organs can cause severe pain. These pains may disturb the woman in certain periods (menstrual period, during intercourse) or may be continuous.
Endometriosis foci located on the surface of the ovaries can sometimes bleed into the ovarian tissue during each menstrual period, causing the formation of a chocolate cyst (endometrioma). Just as the endometrium tissue in the uterus sheds with hormonal changes in each menstrual period, the endometriosis foci in the ovary also bleed, and cause the cyst to grow over time. Sometimes there are chocolate cysts in both ovaries grown up to 10 cm in diameter. On ultrasound examination, chocolate cysts have typical appearances.
With which complaints endometriosis (chocolate cyst) patients apply to the doctor:
The most common complaints for admission are severe pain and infertility (inability to conceive). The patient's pain may be periodic or continuous. While there may be typical complaints such as severe groin and/or low back pain (chronic pelvic pain), excessively painful menstruation (dysmenorrhea), painful sexual intercourse (dyspareunia), or pain in the anus, the patient may also express the pain with atypical complaints. Endometriosis can also cause complaints such as irregular menstruation, constipation, bowel obstructions. Besides, a chocolate cyst can be detected during routine gynecological and ultrasound examination in a patient without any complaints.
Relationship of endometriosis and infertility
Infertility (inability to conceive) is an important problem affecting endometriosis patients. Although these patients can become pregnant without treatment, they are usually assisted by surgery or infertility treatments, especially in the advanced stages of the disease. For the treatment of infertility, firstly ovulation induction and vaccination should be applied in the first stage. When this treatment cannot get results, IVF is applied to patients in the next step. Patients who underwent laparoscopy or surgery for chocolate cyst or endometriosis are recommended to conceive in a natural way following 1 year after surgery. In vitro fertilization method is applied to patients who cannot become pregnant naturally within this period or who have advanced problems that will prevent them from getting pregnant during the operation.
The main reasons for endometriosis (chocolate cyst) disease to cause infertility are:
- Development of adhesions between organs (especially between the uterus, tubes, ovaries and intestines)
- May cause blockages in the tubes
- Chocolate cysts reduce the healthy tissue in the ovaries or affect the reserve of the ovaries.
- Follicle development in the ovaries is disrupted, it causes hormonal irregularities (luteal phase failure)
- It impairs the healthy development and attachment of the embryo. It causes changes in the immune system.
Treatment of Endometriosis
The treatment of endometriosis (chocolate cyst) is usually done for 3 reasons:
- Pain
- Infertility
- Chocolate cyst
A significant number of patients have more than one cause together. Whether the woman is single or married, or she has children or does not want children in the future, her age and the severity of the complaints are important in terms of the choice of treatment and the way to be followed. In addition, if there is a desire for children, the sperm analysis of the spouse should also be evaluated.
What are the types of treatment?
Types of treatment vary from person to person:
- Medical treatment
- Surgical treatment
- Medical + Surgical treatment
- IVF procedures
- Medical treatment (with medication):
Medical treatment is used especially for the relief of pain. Hormonal drugs such as birth control pills, GnRH analogues, danazol and progestins are used. Suppression of endometriosis foci and relief of pain are aimed with these drugs. However, it is not possible to completely resolve endometriosis foci with drugs, and patients benefit from drug therapy to a limited extent.
One of the agents used in the treatment is GnRH analogues. Under the influence of GnRH analogues, the pituitary gland and thus the ovaries are suppressed and a "false menopause" condition is created. Since endometriosis foci develop under hormonal influence, these foci regress and pain decreases as a result of suppression of ovarian hormones. These drugs are usually used before or after surgery for 3 to 6 months. They are in the form of monthly or quarterly injections. These drugs are not recommended to be used for longer than 6 months because of their side effects. Birth control pills or progestins can be used for longer periods. Usually, the symptoms start again after the drugs are stopped.
Today, it has been determined that drug therapy is not beneficial for infertility. These drugs do not have any effect on the pregnancy and cause a waste of time.
- Surgical treatment:
Surgical treatment is considered as the last option in our endometriosis patients. Today, the general approach is to avoid surgery as much as possible. However, surgical intervention can be considered in the presence of severe pain, the presence of very large cysts, the risk of rupture of the cyst, and the presence of conditions that prevent egg collection during IVF.
When surgical treatment is decided, laparoscopic surgery should be the choice for every patient. If laparoscopy is not possible or the surgeon's experience is not sufficient, open surgery can be used to treat endometriosis. Laparoscopic surgery has many advantages compared with conventional open surgery. Laparoscopic operation should be performed by highly experienced teams especially in patients who want to have children in the future.
The aim of the surgical treatment of endometriosis (chocolate cyst) disease is to cauterize or destroy the endometriosis foci as much as possible, remove the formed adhesions, remove the chocolate cyst (endometrioma) in the ovaries, and restore the deteriorated anatomy to normal. Electrical energy or laser is used to destroy endometriosis foci. Laser has a clear advantage over other methods, especially in the presence of extensive endometriosis. Necessary measures should be taken to remove the adhesions formed between the abdominal and genital organs, and to prevent the recurrence of these adhesions.
Various surgical techniques are applied for the surgical treatment of chocolate cyst with laparoscopy. However, the cystectomy technique (complete removal of the cyst) is the most effective treatment method.
In laparoscopy, the risk of recurrence of the cyst increases significantly in 6 months to 1 year postoperatively, in cases when only cyst aspiration (emptying the fluid inside) or applications in which the cyst wall is burned without removing have been performed, or when the removal of the cyst is incomplete. The chance of recurrence of chocolate cyst is very low after a successful surgical treatment. If the patient does not have any complaints, it is recommended to the chocolate cysts below 3 cm should be followed and removed surgically if only they grow. Medical treatment of chocolate cysts is unsuccessful. Drugs are only used to shrink the cyst before surgery and make the surgery easier or to relieve pain in the postoperative period.
It is extremely important to protect the intact ovarian tissue and not to damage it while removing the chocolate cyst. Especially in women who are young or who want to have children in the future, removing the intact ovarian tissue with the cyst unnecessarily and incorrectly or complete removal of the ovary with the cyst should be avoided. In these cases, a woman's ovarian reserve and fertility potential decreases, thus early menopause can occur. Today, in some selected patients, in addition to surgical treatment, drug therapy is used to reduce chocolate cysts before surgery or for 3-6 months after surgery.
Chronic pelvic pain is defined as the pain persisting for more than 6 months. Additional procedures are also performed to relieve pain during laparoscopy in women with severe inguinal and low back pain, severe menstrual pain or painful intercourse. The nerve endings carrying pain sensation are destroyed with laparoscopic LUNA (laparoscopic uterine nerve ablation) or presacral nerve ablation. After these procedures, there is a significant improvement in the pain of the woman.
The period with the highest chance of conceiving after surgery in infertility patients is the first year. Other treatment options should be offered to patients who cannot become pregnant within 1 year after surgery. All causes of infertility should be removed during laparoscopy. By using laser, endometriosis foci should be destroyed, adhesions should be removed if any, and the tubal obstruction should be resolved, chocolate cyst (endometrioma) in the ovaries should be removed, and the deteriorated anatomy should be brought back to normal. In women who want to become pregnant, other infertility treatments should be started in cases where results are not obtained within a period of 1 year postoperatively. If the woman's partner has a sperm disorder, then the choice of treatment may be different.
Factors affecting success after treatment:
- Stage of endometriosis
- Successful operation (preoperative and postoperative status)
- Age of woman
- Presence of additional conditions in a woman (myoma uteri, etc.)
- Sperm disorders in male
