Endomtriosis, popularly known as chocolate cyst, which affects women of reproductive age, especially in the young age group, is a disease that is frequently encountered but for which the level of awareness is low in our country. It is a disease that manifests itself with symptoms of pelvic pain during intercourse, pain during menstrual periods and infertility.
p>It is seen in 5 percent of all women, 10-20 percent in women of reproductive age, and 30-50 percent in women who cannot have babies. The danger increases especially in the 30s. There is a high probability of recurrence after treatment.
The endometrium (the inner layer of the uterus) thickens during each menstrual period and becomes ready for the embryo to settle and develop. . If the egg cell released from the ovaries is not fertilized, the thickened inner layer of the uterus is expelled from the body along with some blood after a certain time.
During the period of bleeding, menstrual blood flows abnormally backwards and some blood is carried to the abdominal cavity. It may be possible. This causes the endometrium cells to settle anywhere on the line where the blood is carried and to behave just like the inner layer of the uterus (by thickening and shedding with some blood every month). Remnants of this bleeding may accumulate over time and cause inflammatory reactions, adhesions or mass formation in the places where they settle.
As a result of endometrium cells settling in the ovary, the inside often resembles melted chocolate in color and appearance. Structures are formed that are filled with a fluid that resembles a cyst and are called chocolate cyst (endometriosis) due to this similarity.
Chocolate cyst often occurs at any time in the chronic pelvic area (in the lower abdomen or in the groin). pain or deep-seated pain during sexual intercourse; It is symptomatic of severe pain during the menstrual period. Pains felt during the menstrual period are pains that cannot be treated with the use of simple painkillers.
Pains occur due to different factors. Due to bleeding caused by endometriosis (the disease that occurs as a result of the inner layer of the uterus settling somewhere outside the uterus) Inflammatory reactions that occur may cause pain. Severe menstrual pains that do not respond to treatment and are felt in every menstrual period are due to these inflammatory reactions.
Pains occur due to the residues formed due to bleeding of endometriosis foci, forming adhesions between the surrounding organs and tissues. may also occur. Chronic pelvic pain or pain felt during sexual intercourse is caused by these adhesions.
The underlying cause of complaints of infertility (infertility or inability to become pregnant) or menstrual irregularity may be a chocolate cyst.
Adhesions caused by bleeding residues may cause blockage of the tubes or disruption of the functions of the fringes of the fallopian tubes. As a result, the egg cell released by the ovary cannot pass into the fallopian tube or cannot progress in the blocked tube. This causes infertility.
- Treatment Approaches to Endometriosis
For women complaining of pain: The most effective treatment for these patients is surgery. are applications. Performing the surgical intervention laparoscopically is considered to be more advantageous in terms of the results obtained and the comfort of the patients, compared to the open surgery performed by opening the abdominal area.
Today, laparoscopy is considered the gold standard in the treatment of chocolate cysts. During the surgical intervention, the chocolate cyst should be removed, any adhesions that have formed should be opened and other endometriosis foci should be eliminated. In order not to damage the patient's ovarian capacity during the surgery, care should be taken to use as atraumatic methods as possible. Deep endometriosis, especially in the rectovaginal septum area, between the back of the uterus and the large intestine, may have been overlooked during the surgery. In this case, even if the patient undergoes surgery, the pain does not go away. For this reason, this area should be carefully reviewed when laparoscopy is performed.
In women who only have a cyst and have no other complaints: In these patient groups, the best treatment approach would be to keep the cyst under observation for a certain period of time without resorting to surgical intervention. ir. However, if blood tests show that the Ca125 value, which is a tumor marker, is high or the diameter of the chocolate cyst exceeds 5 cm, a decision may be made for surgical intervention. Before the surgical intervention, the patient's ovarian capacity should be evaluated by ultrasound and AMH measurement. If, as a result of this evaluation, it is determined that the woman's ovarian capacity is low and the woman is childless, surgical intervention should be avoided as much as possible. In patients with this condition, Ca125 measurements should be taken every 3-6 months. In women who have children or do not want to have children in the future, the cyst should be removed surgically.
In women who complain of not being able to become pregnant: In these patients, the ovarian reserve should first be evaluated. If it is determined that this reserve is sufficient, if the cyst is unilateral, laparoscopy should be performed and then the woman should be expected to become pregnant spontaneously for 6-12 months, depending on the woman's age. In women with poor ovarian reserve, especially those over 38 years of age or if the cyst is bilateral, the best treatment approach is in vitro fertilization. Studies on this subject have found that the results of in vitro fertilization treatment are not different in women with or without chocolate cysts. However, it is recommended not to enter the cyst while collecting eggs during in vitro fertilization treatment. If this is not taken into consideration, that is, if a needle enters the cyst, there may be an increase in the risk of infection and ovarian abscess.
For women who experience repeated failures in in vitro fertilization treatment and have chocolate cysts: There is no consensus on which treatment methods should be applied for these patients. For women who have experienced three or more in vitro fertilization failures, surgical removal of the chocolate cyst may be recommended. Among the patient groups to which this method was applied, spontaneous pregnancy was achieved at a rate of 50% after laparoscopy.
In women who still have cysts after repeated laparoscopies: The complications of laparoscopic surgery are high in such patient groups. If the patient does not complain of pain, then It is recommended to follow closely. For women who do not want to have children and complain of pain, removal of the uterus and ovaries may be necessary. If patients want to have children, in vitro fertilization treatment can be applied. However, patients' tubes should be evaluated before this treatment. Because after repeated surgical interventions, tube obstruction may occur due to adhesions that are likely to form in patients. This factor may cause a woman's chance of pregnancy to decrease even with in vitro fertilization. When obstruction is detected in the tubes, it may be necessary to remove it laparoscopically or close it from the area adjacent to the uterus. If laparoscopy carries a high risk for patients, then hysteroscopic sterilization techniques can be used.
- Treatments used in chocolate cyst
Observation: This treatment approach is performed by closely monitoring the cyst in patients who do not have any complaints. Since there are not many complaints about chocolate cysts, especially in the early stages, the cyst can be surgically removed to prevent the woman's ovarian reserve from being negatively affected.
Drug treatments: In this treatment, the patient's pain is tried to be reduced. When painkillers recommended to reduce painful menstrual cramps are not useful, other treatments are started.
Hormone therapy: Externally administered hormones in patients may be effective in reducing or eliminating the effects of endometriosis. Due to the increase and decrease in hormone levels during each monthly menstrual cycle, endometrial tissue thickens, sheds and bleeds. The growth of this tissue can be slowed down or new formations can be prevented with external hormone medications. However, this approach to chocolate cyst treatment is not a permanent solution for patients. Because after stopping hormone therapy, the patients' discomfort begins to recur.
Surgical treatments: This treatment can be applied mostly to patients with severe pain complaints. Laparoscopic surgery is preferred instead of open surgery. To apply this method, the patient's age, whether he wants a child or not, the severity of his complaints and the condition of the cyst are taken into account. hope is taken into account. Although the most effective treatment for chocolate cyst is surgery, this treatment cannot definitely prevent the cyst from reoccurring.
Combined treatments: In these treatments, patients are given both drug treatment, surgical treatment and other treatments together.
Removal of the uterus and ovaries: In cases where the chocolate cyst has severe effects on the patient, if the patient does not want to have children again, the removal of the uterus and the ovaries is used. In this way, the quality of life of patients is regulated. Recurrence of chocolate cysts is not possible after treatment.
Assisted reproductive methods such as in vitro fertilization treatment: These treatments are applied before surgical treatment if women want to have children. Because surgery may cause a decrease in ovarian capacity.
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