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Endometrioma, colloquially called chocolate cyst, and endometriosis, a condition that involves endometrioma, is manifested by certain symptoms, such as difficulty in getting pregnant, ovarian cysts and abdominal distension. As the disease affects many women at reproductive age, it is crucial to follow up the patient for lifetime through personalized treatment plan and regular follow-up visits. Associate Professor Şadıman Kıykaç Altınbaş from Gynecology and Obstetrics Department of Güven Hospital informs about diagnosis and treatment methods of endometriosis.
What is endometriosis?
Endometriosis is a condition characterized by growth of the endometrium – the lining inside the uteus –, which thickens every month and is excreted through menstrual bleeding if conception does not occur, outside the uterus. Endometriosis is a chronic disease that requires a lifetime management plan, where medical treatments should be prioritized, while repeated surgical procedures should be avoided.
What is incidence of endometriosis and who are in the high-risk group?
It affects 10-17% of women at reproductive age and 35-60% of women with chronic pelvic pain.
The people with high-risk include:
• Individuals with endometriosis in a first-degree relative
• People with structural abnormality in the womb
• Women who give the birth beyond the age of 30 years and women with no history of delivery
• Adolescents with early menarche (the first menstrual bleeding) and women with late menopause
• Women with menstrual cycle of 27 days or shorter and women with heavy menstrual bleeding
• Very lean women
• White race and Asian women
What are causes of endometriosis?
The exact cause of endometriosis is not known yet. The most commonly acknowledged theory is as follows; the blood that usually flows out every month turns back into the abdominal cavity through the Fallopian tubes and an inflammation emerges that result in adhesions and infection when the protective mechanisms of the body cannot remove the accumulated blood.
What are symptoms of endometriosis?
Endometriosis is more commonly seen in ovaries, peritoneum, intestines and incision scars as well as anterior, posterior and lateral parts of the womb. Symptoms will vary depending on the location. The most common symptoms of the chocolate cyst – endometriosis that involves the ovaries – are dysmenorrhea (severe menstrual pain), dyspareunia (genital pain during or after intercourse), dysuria (painful urination), pain induced by intestinal peristalsis, pelvic and lower back pain, infertility (difficulty in getting pregnant) and abdominal distension.
How is endometrisis evaluated? How is it diagnosed?
Patients with endometrisosis are usually women at reproductive age who are 25 to 35 years old. Patients usually visit a doctor with pelvic pain, difficulty in getting pregnant and/or symptoms of ovarian cyst. Questioning and reviewing these complaints, the doctor will examine the patient in accordance with provisional diagnosis and suspicion. Although findings of physical examination may vary, endometriotic implants (the lesions of endometriosis) may be manifested by nodules on the posterior wall of the womb, ovarian cysts and pain induced by the examination. Imaging tests, primarily an ultrasound and magnetic resonance imaging, when required, may be used to visualize the chocolate cysts and the nodules located on the posterior wall of the womb and in the urinary bladder. Final diagnosis is based on the laparoscopic evaluation of the abdominal organs and biopsy by inserting an optic camera through a hole created in and around the bellybutton. Spread of endometriosis and adhesions are visualized with this surgical procedure and it can enable both diagnosis and treatment of the condition.
What are treatment methods for endometriosis?
Treatment of endometriosis may vary depending on the spread of the disease, its level, symptoms and whether the patient has future conception plans. Medication treatment, surgery or both methods can be considered. If the patient has future pregnancy plans, treatment is planned in the light of age and ovarian capacity. Patient- and disease-factors dictate the answers of which treatment, for whom and how long.
What are indications of surgery in endometriosis?
Following conditions require surgical management of the endometrisosis:
• A persistent pain that does not respond to the medication treatment,
• Patients with severe symptoms that limit the vital functions,
• Conditions that require histopathologic diagnosis of the endometriosis,
• Obstruction of the intestines and the urinary tract.
What are surgical methods used for treatment of endometriosis?
If a surgical procedure will be performed, laparoscopy – the closed method – should be the first option. Laparoscopy – one of the minimally invasive surgeries – requires only small incisions, measuring 0.3 to 1 cm in length, and uses an optical camera that is inserted through the belly button. Smaller skin incisions allow quicker recovery, milder postoperative pain, less requirement of medication and shorter hospital stay. Considering those advantages, laparoscopic approach is superior to the open surgery in selected patients.
• Peritoneal endometriosis – a form of endometriosis that involves the membrane of the abdominal cavity may be detected during the closed surgery in patients with pain, which is refractory to the medication treatment. In this case, the implants located on the peritoneum are either excised or burned (ablation).
• If surgical management is decided for the chocolate cyst, usually the cyst wall is excised while ovary is tried to be spared. Medication treatment is also started to prevent the postoperative recurrence, as chocolate cysts may relapse over time, even if a surgery is performed.
• Surgery is planned for deep infiltrative endometriosis (the form of disease associated with nodules in nerves and ligaments of the womb as well as deep adhesions in intestinal wall and the urinary bladder), if there is no response to the medication treatment. The surgery intends to remove all nodules to restore the normal anatomy and to eliminate pain and complaints of the patient.
The initial procedure plays a very crucial role in endometriosis surgery, because endometriosis is a chronic disease associated with adhesions in abdominal organs. Each procedure is challenging and causes occurrence of an extra adhesion. Endometriosis surgery should be performed by gynecologist & obstetricians who are experienced in minimally invasive procedures and endometriosis surgery in relevant healthcare centers.
What are considerations for postoperative period of the endometriosis surgery?
Medication treatment may be started to prevent the postoperative recurrence. Medication treatment may last 6 to 24 months and the treatment should be personalized for each patient. Oral contraceptives that contain estrogen and progesterone, pills that contain only progesterone or intrauterine devices that secrete hormone are among the treatment options. This challenging disease can be managed, if the treatment decided by the doctor is maintained along with follow-up visits at certain intervals.
How long does it take to return to work and social life?
It takes shorter time to return to normal life following the laparoscopic procedures comparing to the open surgery. The period of time may vary from 7 days to 15 days depending on the actual surgical procedure or the pain threshold of the patient. A doctor who is experienced in endometriosis will guide the process and plan the most suitable treatment according to patient- and disease-factors.
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