Endometriosis means that endometrium, i.e. intrauterine tissue, is located in other areas as well as its localization in the uterus. Endometrium tissue is normally inside the uterus so it is an intrauterine tissue, when pregnancy occurs it is where the gestational sac is located. In the absence of pregnancy, it is excreted out of the uterus every month with menstruation. If it is located in the muscular wall of the uterus it is called endometriosis interna (adenomyosis), if it is located in the distant organs outside the uterus it is called endometriosis externa. It is a progressive process and was first described in 1800.
Frequency of Endometriosis
It is seen in 3-10% of women of child-bearing age and 25-35% of women who cannot have children.
In laparoscopy performed to ligate the tubes of women who had children before, endometriosis was found randomly between 6-40%.
Locations of Endometriosis
The most common areas are the peritoneal membrane (abdominal membrane) covering the surfaces of the abdominal organs and intestines. The most common in this area are the back of the uterus, ovaries, the ligaments of the uterus, especially the sacro-uterine ligament, the bladder, intestinal surfaces, tubular, side walls of the pelvis. More rarely, it can be in the nasal mucosa, rectum mucosa, cervix, vagina, lungs, spine, stomach and breast. Endometriosis foci can be observed in episiotomy sites in abdominal surgeries and vaginal deliveries due to surgical implantation of endometrial tissue.
Development of Endometriosis
Endometriosis is a completely estrogen-sensitive disease. Endometriosis is no longer a problem in pregnancy and menopause.
These areas, which are fully sensitive to hormonal changes to which the endometrium is sensitive. When the uterus is bleeding with the menstruation, they bleed in the area they are. However, since they cannot be ejected like menstruation, they can form a cyst with the blood accumulated wherever they are located. If this area is located in the ovaries, it forms the ovarian cyst called endometrioma, which we frequently see. The old blood accumulated in the cyst over time creates a cyst content of “melted chocolate” as a qualitative and therefore it is also called “chocolate cyst”.
Many theories have been proposed for the mechanism of the formation of endometriosis. In every woman, some of the menstrual blood flows from the tubes back into the abdomen during menstruation. In some women, while doing endometriosis, most women are completely absorbed and destroyed from the peritoneum. Therefore, back flow from the tuba is not revealing for every woman. It has been suggested that the endometrum spreads through blood and lymph, but it has not been widely accepted. One of the most commonly accepted theories is that the peritoneum (abdominal membrane) turns into endometrial tissue from time to time (metaplasia = transformation of a completely mature epithelium into another epithelium). It is also known that women with endometriosis have a high rate of immunological factors in the abdominal fluids, and it is mentioned that immunological dysfunction and existing inflammation may prevent the egg and sperm from joining and the zygot to settle into the intrauterine tissue.
Diagnosis of Endometriosis
In the early period of endometriosis, foci such as blue black and gunpowder can be observed on the peritoneum. These foci can remain as they are formed, or may pull the surrounding tissue to itself, causing disruption in adhesion and anatomical integrity. Adhesions in the tubes are related to bleeding and adhesions occurring every month. If the focus of endometriosis is located on the surface of the ovaries, the bleeding area formed on the surface of the ovary will turn into an endometrioma cyst (chocolate cyst) containing old blood by forming a capsule. If an endometrioma cyst has formed, ultrasonography can be very helpful in diagnosis. However, the diagnosis of endometrioma is made only by surgery.
Classification of Endometriosis
Although there is a classification and scoring system determined by the evaluation during the operation performed by the American Fertility Society (AFS), it does not help us much in the clinic and in advising the woman. However, depending on the severity, the stage can be staged from 1 to 4 in minimal, mild, moderate and severe endometriosis.
Complaints and findings of Endometriosis
The most common complaint of women with endometriosis when applying to the clinic is pain.
Reflection of the severity of pain to the clinic may not always be directly related to the severity of the disease. In mild endometriosis, the woman can apply with severe pain, and the woman who comes with 10-15 cm endometrioma can be diagnosed by ultrasonography without any pain. However, it is still a typical definition if the severity of menstrual pain that does not occur after the first menstruation and starts later, increases in severity over time. Pain during menstruation is defined as “dysmenorrhea”. The pain starts a few days before menstruation and increases much during menstruation and decreases towards the end of menstruation. Apart from this, the woman may also have constant pain in her groin and lower back (chronic pelvic pain). Pain during menstruation is related to the fact that prostaglandins released from endometriotic foci cause uterine contraction. However, as the severity of endometriosis increases, the pain may be expected to increase with adhesions and the growth and pressure effect of the endometrioma.
The woman may experience pain in sexual intercourse. The pain is related to the endometriotic foci in the space behind the uterus called “cul de sak” and in the ligaments of the uterus, primarily the sacrouterine ligament. In some positions, pain may be more pronounced. Pain felt during sexual intercourse is defined as “dyspareunia”.
In both cases, the severity of pain is related to how deep the lesions penetrate rather than the prevalence.
A common situation is that couples apply because of not having children. This may be because adhesions affect the tubes or ovulation (ovulation) cannot be achieved due to endometriomas in the ovaries. However, inflammation and immune mechanisms occurring within the peritoneum change the character of the peritoneal fluid. The joining of sperm and egg, the ideal movement of the tuba and the embryo settling in the endometrium can be implanted. There is often a consistency between the severity of infertility and the severity of endometriosis, and as the severity of the disease increases, the frequency of not having children increases. However, in severe endometriosis, the woman may become pregnant easily, and mild endometriosis may not become pregnant and assisted reproductive techniques may be required. However, the generally accepted common view is that minimal and mild endometriosis does not affect pregnancy rates much. The main problem discussed here is severe endometriosis. The number of women conceiving spontaneously in minimal and mild endometriosis is quite high.
Intermediate bleeding is not a very common condition in endometriosis. Spotting before and after menstruation can be seen. Bleeding problems are more common in adenomyocysts.
Acute abdomen picture; that is, the rotation of the endometrioma from the ovarian root (torsion) and cyst rupture are also very rare.
However, it should not be forgotten that in endometriosis, the disease can be detected entirely randomly on ultrasonography without any complaints, or it can be detected incidentally in the abdomen during any operation.
Apart from gynecological examination and ultrasonography, magnetic resonance (MRI) examination can also help in diagnosis. As may be required in the differential diagnosis of endometrioma, it is very useful in other organ endometriosis such as the bladder bowel and in determining the endometriotic nodule.
Treatment in Endometriosis
Treatment can be arranged medically or surgically depending on the indication, but it should be remembered that endometriosis does not have a permanent and definitive solution.
The logic in medical treatment is to stop estrogen support by creating an environment such as pregnancy or menopause based on the fact that endometriosis is an estrogen-dependent disease. Birth control pills suppress ovulation and create an environment that mimics pregnancy and is very successful in pain management. In the meantime, the woman should be reminded to control her weight and not to smoke. Another option is to use GnH analogues to create a dummy mimosa. This treatment, whose effectiveness is between 2-4 weeks, is continued for 6 months (injections every month or every 3 months). It is quite expensive and can cause severe flushing and mild osteoporosis. Applying low-dose contraceptive pills called add-back therapy will resolve these issues while delivering GnRH analogues. This option is also successful in pain management. However, in recent years, this treatment option has been applied much less frequently. Bek I practically never apply it in my own practice.
Also, in recent years, a progesterone treatment that includes dienogest and is planned only for endometriosis has been adapted to daily practice. This treatment, which is effective in suppressing endometriosis and even shrinking endometriomas, can be used continuously (every day) or 7 days a month, such as birth control pills. The woman can be provided with this treatment with regular follow-up to control the progression of the disease until the pregnancy request.
Surgical treatment should be preferred in severe endometriosis, if the pain is too much, in endometriomas exceeding 6 cm and in special cases such as rectovaginal endometriotic nodules. In the treatment of pain, removal of endometiotic focus, endometritic nodule and endometriosis is very successful. However, surgery should be performed in experienced hands and laparoscopically. Pregnancy rates for the first 6 months after the operation are quite high in couples who cannot have children and should be evaluated well. Since it is well known that surgery can reduce the ovarian reserve during removal of the endometrioma, the cases to be operated on should be carefully selected. In many women with endometriosis or endometriosis, successful results can be obtained in assisted reproductive techniques (IVF) without surgery. In young women, if the operation is mandatory, the preference of egg freezing must be presented to the patient and information must be given.
Removal of ovaries and uterus may be the definitive solution in women who do not have an expectation of children, who have advanced pain and severe pain due to endometriosis. Knowing that endometrioid type ovarian cancers cause 7-fold increased risk in endometriomas, it may be necessary to follow up with regular ultrasonography and tumour markers and to apply surgical treatment if necessary. Here, the method and results of the operation should be explained to the woman very well and the decision of surgery should be made together.