Endometriosis

Endometriosis is a very common disease. Endometriosis is seen in 2-18% of women with no complaints, 5-21% of women with back and groin pain, 50% of women with severe groin and menstrual pain, and 10-90% of women who present with infertility. In the United States, endometriosis is the third most common disease among all women hospitalized and operated on for gynecological problems.

General information

The epithelium lining the uterine cavity is called the endometrium. The endometrium, also called the uterine cervix, lining the inner wall of the uterus in a thin layer. The endometrium tissue is prepared for a possible pregnancy every month. During menstruation, the endometrium tissue breaks down and is shed and excreted as menstrual blood through the cervix and vagina. However, in a significant proportion of women, some of the blood shed during menstruation passes through the tubes and into the abdominal cavity. The blood and fragmented endometrial tissue that passes into the abdominal cavity are eliminated by the “macrophage” cells of the body’s immune system. Endometriosis is the appearance of endometrial tissue, which forms the inner wall of the uterus (fallopian tubes), in organs other than this region. The areas where endometrium tissue is located outside the uterine cavity are called ‘endometriosis foci’. Endometriosis foci may be few in number or widespread in severe forms.

It is not known for certain how the endometrium tissue, which is normally found only in the intrauterine layer, settles in other areas. It is known that the passage of menstrual blood into the abdominal cavity by ‘redistribution’, i.e. retrograde flow, plays an important role. However, although it is known that menstrual blood passes into the abdominal cavity in a significant number of women, it is not known why only some women develop Endometriosis. The inadequacy of the immune system, which is supposed to break down and destroy the endometrial tissues in the abdominal cavity, is blamed. As a result, the indestructible endometrial tissue attaches to the outer surface of the uterus, ovaries, tubes, peritoneum and intestinal surfaces. Although the redocrat current is the strongest hypothesis for the formation of endometriosis foci, many other mechanisms are thought to play a role (such as familial affinity).

Frequency of occurrence

Since endometriosis can be found even in women with no complaints, the exact prevalence of this disease is not known. Since the definitive diagnosis can only be made laparoscopically or surgically, different rates are reported. However, the prevalence of endometriosis in women of childbearing age is estimated to be about 10%. It is seen in 2-18% of patients with no complaints, 5-21% of those with back and groin pain, 50% of women with severe groin pain and menstrual pain, and 10-90% of women who present with infertility. In the United States, endometriosis is the third most common disease among all women hospitalized and operated on for gynecological problems.

Factors that cause endometriosis

Retrograde mesturation: During excessive menstrual bleeding, some blood passes through the tubes into the abdominal cavity. It is claimed that endometrial cells in the blood adhere to the organs and cause endometriosis. Hormonal effects are thought to cause endometriosis. This disease is most common in women of childbearing age. Endometriosis occurs in young girls who do not menstruate and in menopausal women.

Immune system dysfunction can also lead to endometriosis. Many studies have shown that the body’s natural defense system (macrophages, T-lymphocytes, natural killer cells) responds differently. Metaplasia theory: it is suggested that endometriosis occurs when some cells in the body transform into uterine cells. Smoking and alcohol have also been found to play a role. It is less common in women who do gymnastics or sportive women. It has also been hypothesized that air pollution and dioxin, which passes into the air from cigarette smoke, play a role in the formation of endometriosis. The risk of endometriosis in first-degree relatives is increased by 5-7%.

Where and how are foci of endometriosis seen?

Endometriosis causes various types of lesions in the abdominal cavity and genital organs. According to the extent of these lesions, it is classified as Stage I-II-III-IV. This classification is based on the location and extent of the lesions during laporoscopy. It is not possible to predict the diagnosis and stage of endometriosis without laporoscopy. In minimal-mild or Stage I-II, endometriosis is more limited and in the initial phase. In moderate-severe or Stage I-II, the foci of endometriosis are more diffuse and there are adhesions and chocolate cysts. Although not always the case, the patient’s complaints (groin pain, severe menstrual cramps, pain during intercourse, inability to have children, etc.) usually increase in proportion to the stage of endometriosis. However, very advanced endometriosis may not have severe symptoms, while very mild forms may have severe and unbearable symptoms.

Endometriosis foci are most commonly found in the ovaries, followed by the peritoneal membrane covering the Douglas cavity behind the uterus, the ligaments holding the uterus in place, the tubes, small and large intestines, bladder, cervix, vagina and external genital organs. Rarely, non-genital organ locations such as the eyes and lungs are also seen. Endometriosis foci are small, dark red-blue-black colored, gunpowder burn-like lesions. These foci may remain unchanged or may progress, causing a reaction where they are located and attracting and adhering to surrounding normal tissues (for example, the uterus and bowel may adhere to each other). They can cause adhesions between organs in the pelvis in the form of thin to thick fibrous bands. These adhesions can be found without causing any complaints and infertility, or they can cause infertility, especially when they are found between the tubes and ovaries.

Dense adhesions can prevent the egg that hatches each month from passing through the tubes. The pulling, adhesions and displacement of organs can lead to disruption of normal anatomical integrity, which can cause severe pain continuously or during intercourse. Foci of endometriosis that start on the surface of the ovaries sometimes bleed into the ovarian tissue during each menstrual period, leading to the formation of a chocolate cyst (endometrioma). Just as the endometrium tissue in the uterus sheds with hormonal changes during each menstrual period, foci of endometriosis in the ovary also bleed, causing the cyst to grow over time. Sometimes there are chocolate cysts in both ovaries, which can be up to 10 cm in diameter. Ultrasound examination has typical images of chocolate cysts.

What symptoms does endometriosis cause?

– The most common complaints are as follows:

– Groin and lower back pain (long-term)

– Excessive menstrual pain (dysmenorrhea)

– Painful sexual intercourse (dyspareunia)

– Inability to conceive (infertility)

– Irregular menstruation

– Pain in the anus

Endometriosis treatment

In particular, whether the woman is single or married, whether she wants to have children, her age and the severity of her complaints are important in terms of treatment selection and timing. In addition, if a married woman wants to have children, the course of action should be determined after evaluating the spermiogram results of her husband. There are different treatment options depending on the extent of the disease and the symptoms.

1.Medical (medication) treatment

Medications with hormonal effects such as birth control pills, GnRH analogs, danazol and progestins are used in drug treatment. These medications aim to regress endometriosis foci and relieve pain. However, it is not possible to completely eliminate endometriosis foci with medication and patients benefit to a limited extent from medication. The most effective medications are injections called GnRH analogs (GnRH-a). The effect of GnRH-a suppresses the pituitary gland and thus the ovaries and a ‘false menopause’ occurs. Since endometriosis foci develop under hormonal influence, suppression of ovarian hormones leads to regression of these foci and pain reduction. GnRH-a is usually used in the form of injections given once a month or every 3 months for 3-6 months. It is recommended to use these medicines for longer than 6 months. Birth control pills or progestins can be used for longer periods. Today, drug treatment is used as an adjunct to surgical treatment for 3-6 months after surgery.

2.Surgical treatment

Surgical approach is the most effective treatment for endometriosis. In every stage of endometriosis, laparoscopic surgery should be the first choice treatment method. Laparoscopic surgery has many advantages over conventional operations. Especially for patients who want to have children in the future, laparoscopic surgery should be performed by experienced teams. The aim of laparoscopic surgery is to remove or destroy endometriosis foci as much as possible, to remove adhesions, to remove chocolate cysts (endometrioma) in the ovaries and to normalize the distorted anatomy again.

Electrical energy or a laser is used to destroy foci of endometriosis. Especially in the presence of widespread endometriosis, the laser has a clear advantage over other methods. Measures should be taken to remove adhesions between the intra-abdominal and genital organs and to prevent these adhesions from recurring. Various surgical techniques are used in laparoscopy for the treatment of chocolate cysts. However, laparoscopic cystectomy (removal of the cyst) is the most effective treatment method. In cases such as only aspirating the cyst (draining the fluid inside), procedures performed without removing the cyst wall or incomplete removal of the cyst during lapoeoscopy, the possibility of cyst recurrence within 6 months to 1 year is quite high.

It is extremely important to preserve intact ovarian tissue very carefully when removing a chocolate cyst. Especially in young women or women who want to have children in the future, unnecessary and incorrect removal of intact ovarian tissue with the cyst or complete removal of the ovary with the cyst should be avoided. This reduces the woman’s egg reserve and fertility potential and can lead to early menopause. In women with chronic pelvic pain, i.e. long-lasting groin and lower back pain, heavy menstruation or painful intercourse, additional procedures are performed to relieve pain during laparoscopy. With LUNA (laparoscopic uterine nerve ablation) or sacral nerve ablation, the nerve endings that provide pain sensation are destroyed. There is a significant improvement in pain sensation after this procedure.

In patients with inability to conceive, the patency of the tubes should be checked in the same session. If there is adhesion, obstruction or stenosis in the tubes, they should be corrected with laporoscopic laser surgery and normal anatomy should be ensured. In women who wish to have a child, if another treatment (IVF, etc.) is required after surgery, the highest chance of conception is in the first 1 year. In our center, this rate is 60% in stage endometriosis (Stage I-II) and 40% in middle and advanced stages (Stage III-IV). Patients who cannot conceive within 1 year after surgery should be offered other treatment (IVF) options.

LUNA OPERATION : For the treatment of severe pain, the sacro-uterine ligaments (*), where the nerve endings are located, are destroyed with a laser.

Factors affecting success after treatment:

– Endometriosis stage and degree of anatomical disturbance

– Success of the operation (experience of the surgical team performing the operation and having the necessary technology)

Female age

– The presence of additional problems in the woman (myoma in the uterus, etc.)

– Presence of sperm problems in the male

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