Endometriosis

Kadın Hastalıkları

Endometriosis is endometrium (womb’s inner layer causing bleeding) tissue covering inside the uterus (womb) to be found out of the place that should be found normally and to show function. It can response hormonal changes. It is encountered in women in reproductive ages. The inner layer of the womb is the tissue ejected through bleeding at the end of cycle by thickening in each menstrual period. Endometrium tissue, which is located out of the uterus, thickens at each menstrual period and is tried to be removed. These tissues are most frequently seen in ovaries (75%), abdominal cavity, tubes, and intestines. In addition, they are seen in the ligaments holding the womb on its place, bladder, cervix, vagina, external genital organs, and episio site opened during cesarean and birth. Eye, belly-button, and nasal membrane are the sites where they are located very rarely.

Extra-uterine localizations cause adhesions in adjacent tissues and function disorders by bleeding in menstrual periods. They can cause inguinal pain, painful menstruation, infertility, and ovarian cyst (chocolate cyst).

CAUSES

Its final diagnosis is made surgically. Its exact cause is unknown; various theories were developed. Although it is an estrogen-dependent disease, it can be encountered at all age groups. It is seen mostly depending on the hormonal treatment after menopause.

  • Retrograde menstruation theory (regurgitation of menstrual blood)
  • Lymphatic and vascular (through vessels) spread
  • Coelomic metaplasia (transformation of tissues to endometrial tissue with a different stimulation)
  • Residual embryonic cell theory
  • Iatrogenic spread (to be formed along operation site after operations such as hysterectomy, cesarean)
  • Metaplastic transformation theory
  • Immunologic and genetic factors (this can be seen by 7% in first degree relatives)

It is most frequently seen in ovaries. As related to menstrual period, bleeding into the lesion develops in the ovary, so cystic structures which cause adhesion in adjacent tissues and grows in ovaries. Following bleeding into the cyst, its color and consistency is similar to chocolate. Therefore, it is called as chocolate cyst.

CLINIC AND DIAGNOSIS

These patients usually come to us with complaints of waist pain, inguinal pain, painful menstruation, painful sexual intercourse, and infertility. Dysmenorrhea (painful menstruation) is severe, sometimes does not response to painkillers. Endometriosis can be encountered in 15-25% of infertile women. Mechanic factors (the tips of tubes can be congested depending on adhesions in abdominal cavity), disorders in ovulation, immunologic disorders are among the causes of infertility in endometriosis. The risk of abortion is high in people with endometriosis when they become pregnant.

TREATMENT

The treatment should be planned intended for infertility and pain problems. Because pregnancy rates obtained without any treatment in minimal and mild endometriosis are the same with pregnancy rates obtained after medical treatment, 6-9 months should be waited in these patients before initiating a medical treatment.

The final diagnosis is made by confirmation of endometriosis focuses seen during surgery with pathology. Painful focuses can be felt as fixed during physical examination. Solidities, nodules can be palpated in ligaments holding the uterus. In examination with speculum, dark brown, blue lesions may be encountered in cervix, vulva. Ultrasound and MRI are helpful for diagnosis. Ca 125 may be seen higher in the blood but this elevation is not unique to endometriosis.

MEDICAL TREATMENT

The treatment is planned by giving hormonal therapy, and by including the person into the environment of false pregnancy or menopause. Effects begin to be seen about 2 months later. DANAZOL or GnRH ANALOGUES are used for the treatment of false menopause. For the treatment of false pregnancy, birth control pills or progesterone hormones are used. Medical treatment is not so much useful for the treatment of minimal or mild endometriosis. In cysts, too, seen in ovaries over 3 cm, medical treatment is not so much effective.

SURGICAL TREATMENT

Surgical treatment is planned according to diffuseness of disease, age, and expectations. Conservative treatment should be applied for people planning a child. To remove endometriosis focuses, to open adhesions, and to make appropriate for normal anatomy are the objective. There is the risk of development of endometriosis again in a person whose single-sided ovary is excised because estrogen hormone is released from remained ovary. Presacral neurectomy is rarely used in order to decrease pain. It can be performed as surgical laparoscopy or open surgery. Use of GnRH analogue before surgery is controversial.

Excision of cyst capsule, vaporization/coagulation of cyst capsule, or emptying cyst can be performed in surgery of chocolate cyst (endometrioma). Drainage only is not preferred so much. It has the possibility of 70% to recur. Pregnancy rates are observed by 40-50% in infertile women after operation. Method of in vitro fertilization also is among preferences in those who are unable to be pregnant within 12 months after the operation of endometrioma. But these methods also depend on age of the patient, duration of infertility, and no another accompanying risk factor.