Endometriosis

CHOCOLATE CYSTS AND ENDOMETRIOSIS

Chocolate cysts, or more generally endometriosis, are subjects that are very frequently discussed, written about in books spanning hundreds of pages, and widely debated in scientific platforms. Although many studies have been conducted regarding endometriosis, it is still a condition that medicine cannot fully explain, and therefore a definitive treatment cannot yet be clearly stated. Let us try to better understand this interesting condition through questions and answers:

What are Endometriosis and Chocolate Cysts?

The condition in which the inner lining of the uterus, called the endometrium, is located anywhere outside the uterus is medically referred to as Endometriosis. If this condition appears in the ovaries in the form of a cyst (a fluid-filled sac), it is called a Chocolate Cyst (Endometrioma) because it contains a melted chocolate-colored and chocolate-like fluid. 

How does Endometriosis occur?

Although there are many theories about how endometriosis develops, there is still no single theory that fully explains its formation mechanism.  The currently accepted view is that menstrual blood containing cells from the uterine lining flows backward into the abdominal cavity, and due to certain deficiencies in the immune system responsible for clearing these cells, the uterine lining cells settle within the abdomen. Another important factor known in the development of endometriosis is the central role of estrogen in the body through certain internal mechanisms. Studies have shown that endometriosis lesions can produce their own estrogen, thereby continuing to grow and cause clinical symptoms.

How common is Endometriosis?

There are very different data regarding the frequency of endometriosis. Rates ranging from 2–18% in women without any symptoms (incidentally detected), 5–21% in women with lower abdominal and groin pain, and 5–50% in women experiencing difficulty becoming pregnant have been reported. On average, it is accepted to occur in approximately 6–10% of women.

At what ages is Endometriosis seen?

Although endometriosis is generally considered a disease of the reproductive years, it may also be detected in teenage girls and in women many years after menopause. The age group in which it is most commonly diagnosed is accepted as 25–35 years. With the more liberal use of laparoscopy, cases have been reported as early as age 11 and as late as age 78.
 

Where is Endometriosis found?

Apart from the ovaries, endometriosis may occur in many places imaginable, such as the membranes covering the organs just outside the uterus (peritoneum), the pouch behind the uterus (Douglas pouch), the intestines, the area between the vagina and the final part of the large intestine (rectovaginal septum), as well as the skin (normal birth suture areas or cesarean incision sites), lungs, liver, brain, eyes, and more. The most important organ where it has not been demonstrated to date is the spleen. 

What are the known risk factors for Endometriosis?

Research conducted in communities indicates that endometriosis is more frequently seen in certain individuals. These risk factors include;

• Genetics: Studies have shown that individuals whose first-degree relatives (mother, sister) have surgically confirmed endometriosis are at 4–8 times greater risk of endometriosis. It has also been reported that when endometriosis exists in the family, it tends to be more severe. However, no single gene or gene fragment alone can fully explain endometriosis. Studies on this subject are ongoing.
• Presence of uterine abnormalities (double uterus, uterine septum, etc.)
• Early age at first menstruation (11 years or younger)
• Never having children
• Short menstrual cycles (having periods every 27 days or less)

What conditions reduce the risk of Endometriosis or do not increase the risk?

• Having children reduces the risk.
• Breastfeeding reduces the risk.
• Birth control pills reduce the risk.
• Intrauterine devices do not affect the risk.
• Tampon use does not affect the risk of endometriosis.

What clinical complaints can Endometriosis cause?

• Pain 
  • Very severe menstrual cramps, 
  • Pain during intercourse,
  • Persistent groin pain, 
  • Pain during bowel movements
• Difficulty becoming pregnant (subfertility)
• Spotting-type vaginal bleeding before menstruation (premenstrual spotting)

Why does Endometriosis cause difficulty becoming pregnant?

• Ovulation disorders and incomplete release of the egg may occur.
• It may cause insufficiency in certain hormones that should be released after ovulation.
• It may lead to adhesions, causing blockage of the fallopian tubes or disrupting the healthy interaction between the tubes and ovaries.
• Some substances released may negatively affect reproductive cells such as eggs and sperm.
• Some substances secreted from endometriosis lesions may create fertilization problems.
• Again, some released substances may negatively affect implantation of the fertilized egg into the uterus.
• Painful intercourse may lead to avoidance of sexual activity.

How is Endometriosis diagnosed?

The complaints mentioned above may suggest endometriosis for diagnosis. During the physician’s examination, deep pain, a painful mass between the rectum and vagina, or a palpable painful lump or cyst may be detected. Ultrasonography is useful especially in diagnosing chocolate cysts, although it has no role in endometriosis involving the peritoneum. Endometriosis may also be detected through laparoscopy (examination by entering the abdominal cavity with a camera) or incidentally during abdominal surgeries. Today, laparoscopy is considered the gold standard for diagnosis. Although definitive diagnosis is established by microscopic examination of tissue samples, biopsy is recommended in suspicious cases.

What treatment options are available for Endometriosis?

Since endometriosis has still not been fully clarified today, it would be incorrect to speak of a complete cure. In addition, the exact natural course of endometriosis is also not entirely clear — whether some cases progress while others regress spontaneously. Therefore, treatment options for endometriosis are generally aimed at relieving symptoms. 

• Medical treatment: There is no complete cure with medication. However, suppression of endometriosis may reduce symptoms. Medications used for this purpose include birth control pills, progestins, drugs inducing temporary menopause (GnRH analogues), danazol (although less preferred today due to side effects), and in difficult or previously operated cases, a group of medications called aromatase inhibitors that block estrogen production. These are among the medical treatment options.
• Surgical treatment: In the presence of chocolate cysts in the ovaries, surgery (open or laparoscopic) is generally recommended if the cyst is 4 cm or larger. Studies have reported that the recurrence rate of chocolate cysts may reach up to 50% within 5 years after surgery. Although there is a risk of losing ovarian reserve while completely removing the cysts, the currently preferred surgical method that reduces recurrence is removal of the cyst together with its capsule. It has been shown that removing the cyst with its capsule decreases the likelihood of recurrence. In women presenting with pain complaints, surgical procedures involving cutting nerves responsible for transmitting uterine pain (LUNA, presacral neurectomy) may help reduce groin and menstrual pain.  In cases with difficulty conceiving, surgical elimination of endometriosis lesions (burning or excision) may increase the chances of pregnancy. In women who have completed childbearing, removal of the uterus and ovaries is considered a final surgical option for endometriosis-related complaints. However, it should not be forgotten that surgical treatment of endometriosis also carries certain surgical risks.
• New treatment options: According to studies, medicated intrauterine devices reduce recurrent pain related to endometriosis. Many treatment options such as selective estrogen receptor modulators, selective progesterone modulators, aromatase inhibitors, and immune regulators (pentoxifylline, TNF-alpha blockers, PPAR-gamma) are still in the experimental stage.

Is there a screening or prevention method for Endometriosis and Chocolate Cysts?

Unfortunately, there is currently no screening or prevention method available for endometriosis.

In conclusion, endometriosis is a condition with an unknown cause that generally leads to pain and difficulty becoming pregnant, does not yet have a complete medical cure, and may recur even after surgical treatment. For more detailed information regarding the condition, individual complaints, and the most suitable treatment option, it is essential to consult a specialist in Obstetrics and Gynecology.

Endometriosis

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