Endometriosis is a common disease that affects women of reproductive age. It is the presence of the membrane layer that normally covers the inside of the uterus anywhere other than where it should be.
Endometrium tissue is sensitive to the increases and decreases in estrogen and progesterone levels during the menstrual cycle, whether inside or outside the uterus. The tissue, which grows and thickens under the influence of hormones, may bleed with the decrease in hormones. Unlike the endometrial tissue inside the uterus, there is no outflow of blood originating from this misplaced tissue. The resulting blood may accumulate and form a cyst or settle in the surrounding tissues. Endometriosis is a disease that is completely dependent on the estrogen hormone.
Incidence
Since the diagnosis of endometriosis is made surgically, it is not possible to determine the actual incidence. The accepted rate today is 5-10%. It is most commonly seen in the ovaries. In 75% of the cases, the lesion is in the ovaries, then they are seen in the space of the abdominal membrane behind the uterus (Douglas pouch), in the ligaments that hold the uterus in place, in the tubes, intestines, bladder, cervix, vagina, external genital organs, surgical wounds, and incisions made during birth with stitches. . Rarely, it can be seen in distant organs such as the belly button and nasal membranes. It has been reported in the literature that it can also be seen in men. The resulting lesions may be microscopic and invisible to the naked eye, or they may reach very large diameters such as 10-15 centimeters. Although it is generally seen in women of reproductive age, it can be detected in all age groups. From time to time, the diagnosis of endometriosis is overlooked in very young patients due to the age of the patient. However, autopsies show that endometriosis may also occur in newborns and menopausal women.
Is endometriosis a malignant disease?
Endometriosis itself is not a malignant disease. However, studies have found an increase in the incidence of breast, ovarian and some circulatory system cancers in endometriosis patients, but the relationship between these cancers and endometriosis is not clear. According to some researchers, this disease is the reason why certain types of cancer are more common in endometriosis patients. It could be the medications he is using. Similarly, because endometriosis patients are under close follow-up, cancer that develops independently of the disease may be detected at an earlier stage.
Cause
Although the exact cause is not known, many theories are advanced. is being driven. It is the most accepted theory of retrograde menstruation. Accordingly, menstrual blood escapes from the tubes into the abdominal cavity and the endometrial tissues it contains settle there and maintain their vitality. This theory is inadequate to explain endometriosis seen in men. In addition, while every woman's menstrual blood leaks into the abdominal cavity in greater or lesser amounts, this theory cannot explain why endometriosis develops in some and not in others. Another theory about the development of endometriosis is its spread through blood, but this theory has not received sufficient support in scientific circles. One of the suggested ways of formation is that some cells in embryonic life may turn into endometrial cells over time. This theory may explain endometriosis cases in men, but there is not enough evidence on the subject. Another theory that has attracted attention recently is that some disorders in the immune system may cause this condition.
Pathology
The lesions in the early period are small, not swollen from the surface, blue, black, powdery. These are burn-like formations. These implants may remain unchanged, disappear on their own after a while, or they may cause a reaction where they are located and attract the normal tissue around them, causing adhesions. The resulting adhesions disrupt the anatomical integrity and cause complaints. Endometriosis located in the ovaries bleeds during each menstrual period and forms a cyst, and the blood accumulated in this cyst becomes brown, thick and sticky over time. Endometriosis located in the ovaries is called endometrioma or chocolate cyst.
Clinical
The most common complaint in endometriosis patients is extremely painful menstruation. There is an increasing pattern in the severity of pain. The cause of the pain is the contractions that occur in the uterus under the influence of some substances called prostaglandins secreted from the endometriosis chambers. However, the severity of pain There is no relationship between the degree of endometriosis and the degree of the disease. A mild degree of endometriosis may cause severe pain, while in a case of advanced endometriosis, very mild menstrual pain may be observed or even there may be no pain. However, if the pain starts earlier and lasts longer, it may indicate that the stage of the disease is advancing. Pain typically begins a few days before menstruation, reaches its peak with menstrual bleeding, and continues throughout bleeding. In fact, sometimes these pains may not respond to painkillers.
Apart from menstrual pain, endometriosis may also cause chronic groin pain and lower back pain. These pains may also spread to the legs. Endometriosis can cause pain during sexual intercourse. This condition is called dyspareunia. Most patients with endometriosis do not have a bleeding disorder. However, bleeding in the form of brown spotting before menstruation is typical for endometriosis. The majority of endometriosis patients consult a doctor because of their inability to have children. In general, approximately 10-20% of women suffering from infertility have varying levels of endometriosis. The relationship between endometriosis and infertility is not fully understood. It is controversial whether especially mild and moderate endometriosis causes infertility.
However, the most commonly accepted theory is that endometriosis causes a type of inflammation in the pelvic cavity, leading to the release of certain substances, and these substances have negative effects on follicle and egg development. that it has effects. It is suggested that these substances secreted from the abdominal membrane may have negative effects on the union of egg and sperm, tubal function, and even the implantation of the fertilized egg into the endometrium.
Another idea is that mild endometriosis does not cause infertility. The main cause of infertility in these patients is another known pathology such as poor sperm quality, ovulation disorder, or unknown causes such as unexplained infertility cases. Endometriosis is just an additional pathology that accompanies the picture. On the other hand, severe endometriosis is a known cause of infertility. The resulting adhesions and anatomical disorders disrupt the normal function of the reproductive system. They cause fertilization problems by disrupting the sperm. Even if there is no adhesion, chocolate cysts can disrupt normal ovulation and cause infertility.
Diagnosis
The diagnosis of endometriosis is made by directly seeing the lesions and examining them pathologically. So surgery is necessary for a definitive diagnosis. If endometriosis is suspected in the history and there is an infertility problem, diagnostic laparoscopy should be performed. During laparoscopy, all intrapelvic structures such as the peritoneum, uterus, Douglas cavity, and tubes are observed and the presence of small endometriosis foci is investigated, while in severe cases, adhesions are observed.
Ultrasonography is one of the most important diagnostic tests in the diagnosis of endometriosis. However, while ultrasonography is useful in identifying chocolate cysts located in the ovaries, it is insufficient in providing information about pelvic endometriosis. Endometriomas located deep within the ovary may be overlooked during laparoscopy, but these masses can be easily noticed with a careful ultrasonographic examination. In ultrasonography examination, in cases where endometrioma is suspected, checking a marker called Ca12-5 in the blood is important to support the diagnosis.
This tumor marker, secreted in some cancers originating from the ovary, also increases in the presence of endometriosis, but its blood level does not increase as much as in malignant diseases. Stages Endometriosis is staged according to the area where the disease is located, its spread, depth and size. Stage 1 means minimal disease, stage 2 means mild, stage 3 means moderate, and stage 4 means severe endometriosis. There is no direct connection between the stage of the disease and the complaints it causes.
Treatment
There is no definitive and permanent treatment for endometriosis. The aim of the treatments is to relieve pain and eliminate infertility. Medical and surgical treatments can be applied for this purpose. Medical treatments are based on the principle that endometriosis is an estrogen-dependent disease. Pregnancy and menopause are two natural conditions that prevent the formation of endometriosis. The aim of hormonal treatments is to imitate these two natural conditions. In both cases, since the effect of estrogen on the endometrium will disappear, the endometrial tissue located in the wrong place is expected to be suppressed.
The hormonal state seen during pregnancy. While birth control pills are used to mimic menopause, drugs called danazol or GnRH analogues are used to mimic menopause. In this treatment, which lasts 3-6 months, blood estrogen levels drop to very low levels, as in natural menopause. GnRH analog therapy, which is usually administered as injections once a month, is a very expensive form of treatment. Since long-term use of GnRH analogues may cause post-menopausal complaints such as osteoporosis and hot flashes, they can be given together with estrogen-containing drugs. This situation, called add-back treatment, may seem like an oxymoron. However, the aim is to keep the blood estrogen level in a range low enough to suppress endometriosis and high enough not to cause osteoporosis.
Studies show that medical treatments applied in endometriosis are effective in relieving pain, but do not have a positive effect on infertility. For this reason, medical treatment is not recommended for patients presenting with infertility. The preferred treatment approach in severe endometriosis cases is surgery. Especially the developments in laparoscopic surgical techniques allow these patients to be treated effectively. For example, 50% of patients whose chocolate cysts are removed become pregnant within 6 months without the need for treatment.
Restoring the anatomical order is extremely important in both relieving pain and increasing reproductive potential. Assisted reproductive techniques If a woman treated for infertility cannot become pregnant within 6 months after surgery, the next option is assisted reproductive techniques. If the tubes are open, vaccination can be attempted. In cases where insemination fails, the last alternative is in vitro fertilization. In this group of patients, a decrease in ovarian reserve can be expected, especially if a large chocolate cyst has been removed. Additionally, due to some unknown reasons, low fertilization rates may be observed in these endometriosis cases.
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