ENDOMETRIOSIS

Endometriosis, commonly known as Endometriosis among the public, is a condition where the endometrium, the tissue lining the inside of the uterus, grows outside of the uterus. In this section, you can find detailed information about what endometriosis is, what causes endometriosis, the symptoms it may cause, and treatment methods.

Endometriosis is a condition where the tissue that lines the inside of the uterus, called the endometrium, grows outside the uterus. This tissue, which lines the uterus every month, thickens in preparation for pregnancy due to hormonal changes. If pregnancy does not occur during that cycle, this thickened tissue sheds and bleeds. This shed tissue forms menstrual bleeding.

In endometriosis (Endometriosis), this tissue, outside of the uterus, can be found in various locations such as the fallopian tubes, ovaries, spaces behind the uterus, bladder, intestines, and rarely in distant places such as the eyes, nose, lungs, or surgical scars, leading to symptoms.

When the endometrium tissue is located outside the uterus, it responds to the estrogen and progesterone hormones in the body just as if it were inside the uterus. It thickens, sheds, and bleeds in response to changes in hormone levels in the blood during menstruation. However, since there is no way out for this bleeding tissue, the blood accumulates in the area where the endometriosis tissue is located, causing pain, adhesions, and inflammation in that area.

• Endometriosis is not an infection.
• Endometriosis is not contagious.
• Endometriosis does not turn into cancer.

If the endometrial tissue is found in the ovaries and causes a cyst to form, it is called a Endometriosis. The reason for this name is that the content of the cyst resembles chocolate in consistency and color.

If the endometrial tissue is found in the muscle layer of the uterus, it is called adenomyosis. Adenomyosis is often seen in conjunction with endometriosis.

The exact causes of endometriosis are not fully understood today. There are several theories attempting to explain this. The most widely accepted theory is retrograde menstruation, where menstrual blood flows backward through the fallopian tubes into the pelvic cavity, allowing endometrial tissues to implant and grow. Although retrograde flow occurs in nine out of ten women, endometriosis only develops in about one of every ten women. While normal immune response eliminates the tissue that comes with retrograde flow, in women with immune response abnormalities, this tissue cannot be eliminated, leading to the formation of endometriosis. Another theory explains the disease as the spread of endometrial tissue through blood vessels or lymphatic channels from the uterus to other parts of the body. In recent years, genetic predisposition has also been investigated as a factor in the development of this disease, but no responsible genetic factor has been identified yet.

To distinguish different stages of endometriosis, the American Society for Reproductive Medicine (ASRM) has established a classification system consisting of 4 stages:

• Minimal Disease (Stage 1),
• Mild Disease (Stage 2),
• Moderate Disease (Stage 3),
• Severe Disease (Stage 4).

This staging system is not related to pain but rather to the extent of the endometriosis tissue’s presence in the body. For example, a patient in stage 1 may experience severe pain, while a patient in stage 4 may have no complaints at all.

Who Is at Risk?

Those who start menstruating at an early age

Those who have not given birth

Those with frequent or long-lasting periods

Patients with a completely closed hymen (imperforate hymen) are at increased risk for Endometriosis (endometriosis).

Endometriosis (endometriosis) is one of the most common diseases encountered by gynecologists. It generally occurs in women of reproductive age, especially in women aged 30-40. It has been detected in about 20-25% of young girls who complain of painful periods during adolescence and do not respond to drug therapy. Endometriosis is found in about 25-40% of cases with chronic abdominal pain and in 20-30% of cases with infertility complaints. The likelihood of Endometriosis (endometriosis) is approximately 4-6 times higher in women with severe menstrual pain. The risk is increased in patients with a family history of endometriosis; for example, the risk is approximately 7–10 times higher in those with a family history of the disease.

What Are the Symptoms?

Endometriosis has two main symptoms: infertility and pain (continuous abdominal pain, painful menstruation, and painful sexual intercourse). In women who experience both painful periods and pain during intercourse, Endometriosis (endometriosis) should be considered first. The severity of the pain is not directly proportional to the extent of the disease. The duration and intensity of pain usually increase over time and are often accompanied by lower back pain.

Symptoms of endometriosis:

• Classic symptoms:
  • Painful menstrual periods
  • Infertility
  • Painful sexual intercourse
  • Pain:
  • Painful menstrual periods
  • Pain starting before menstruation
  • Pain during or after intercourse
  • Leg pain
  • Lower back pain
  • Vulvar pain
  • Continuous groin and abdominal pain
• Bleeding:
  • Heavy menstrual bleeding
  • Prolonged periods
  • Pre-menstrual spotting
  • Irregular periods
  • Intestinal and bladder symptoms:
  • Painful bowel movements
  • Pain before or during defecation
  • Rectal bleeding
  • Pain during urination
  • Bloody urine
  • Symptoms resembling irritable bowel syndrome: diarrhea, constipation, colic-like pain
• Other symptoms:
  • Excessive fatigue
  • Tendency to sleep
  • Nausea
  • Depression
  • Recurrent infections
  • Feeling faint or fainting during menstruation

In severe cases, Endometriosis can lead to serious complications such as life-threatening intestinal obstruction, bladder disorders, kidney dysfunction, silent kidney loss (ureteral endometriosis).

Most women with Endometriosis experience some of these symptoms, while some women may have no symptoms at all.

All of these symptoms listed above may have different causes. It is important to rule out underlying conditions.

Reference: Endometriosis UK/ Understanding Endometriosis – Information Pack

How Is Endometriosis Diagnosed?

The diagnosis of endometriosis cannot be made based solely on symptoms, but endometriosis is suspected in patients with painful menstrual periods, pain during sexual intercourse, and chronic lower abdominal pain (pelvic pain).

However, it should also be kept in mind that many patients may have no symptoms at all.

Unfortunately, the diagnosis of Endometriosis is often delayed.

The time from the onset of symptoms to diagnosis averages between 6-10 years. This period is even longer in young patients.

This delay in diagnosis leads to a decrease in the patient’s quality of life, progression of the disease, and financial problems.

Examination

During a gynecological examination, certain findings may suggest endometriosis. These findings include pain during vaginal or rectal examination (rectal palpation), the presence of a painful lump (painful nodule), and the immobility of uterine tissue, which can normally move freely due to adhesions. If your symptoms and examination suggest endometriosis, the definitive diagnosis is made by removing endometriosis foci surgically and sending them for pathology examination.

Ultrasound

Ultrasound performed vaginally or abdominally can reveal Endometriosiss in the ovaries and measure the size of these cysts.

Endoscopic Ultrasound

This is an ultrasound procedure performed to visualize the wall of the colon. It can be used to demonstrate bowel involvement in patients with symptoms of defecation and suspected endometriosis.

Blood tests

Some tumor markers such as CA 125 and CA 19.9 may increase in the presence of Endometriosiss. However, this does not mean that your Endometriosis has turned into cancer. The levels of these blood tests are monitored regularly to follow up on the elevation.

CT and MRI

CT and MRI may be required for the advanced diagnosis of Endometriosiss and deep endometriosis lesions embedded in the tissue.

Laparoscopy

Laparoscopy is a surgical procedure based on inserting a camera into the abdomen through a small incision made either through the navel or just above it. During this procedure, the surgeon has the opportunity to observe the ovaries, uterus, fallopian tubes, and all organs within the abdomen. With this method, endometriosis foci or Endometriosiss within the abdomen can be visually identified and removed if necessary. While some laparoscopies for Endometriosis are short and easy, others may take more time and be challenging. This depends on the organ affected by Endometriosis and the severity of the condition. Additionally, the staging of Endometriosis (endometriosis) is also performed during surgery.

Other Interventional Tests

• These tests are mainly used to exclude diseases that cause symptoms other than endometriosis.
• Cystoscopy (examination of the bladder with a camera)
• Colonoscopy (examination of the colon with a camera)
• Hysteroscopy (examination of the uterus with a camera)
• Proctoscopy (examination of the rectum, the last portion of the large intestine, with a camera)
• Sigmoidoscopy (examination of the sigmoid colon, a portion of the large intestine, with a camera)

While these procedures are rarely useful for diagnosing Endometriosis, they are often very helpful in excluding other diseases that can cause similar symptoms, such as endometriosis. For example, cystoscopy (examination of the bladder with a camera) can help your doctor determine whether you have interstitial cystitis, a bladder condition that often coexists with or causes similar symptoms to endometriosis. Hysteroscopy (not to be confused with hysterectomy), a procedure performed by inserting a camera through the vagina into the uterus, can help identify some uterine abnormalities.

Endometriosis (Endometrioma)

When Endometriosis settles in the ovaries, it causes cysts inside the ovaries.

During each menstrual cycle, the endometrial tissue inside the ovary bleeds due to the effect of hormones, resulting in the formation of cysts, and the blood that remains inside the cyst for a long time gradually turns into a chocolate-like (dark brown) fluid. Therefore, these cysts are called Endometriosiss or “endometriomas.”

If the cyst is not treated and continues to grow, it can twist around itself or rupture, spreading the fluid inside it into the abdominal cavity, often leading to urgent situations that require surgery. Endometriosiss (endometriomas) typically exhibit a characteristic appearance on ultrasound. While simple ovarian cysts disappear within a few months, Endometriosiss usually do not disappear.

Treatment of Endometriosis

Treatment for Endometriosis is selected based on the individual patient. When planning treatment:

• Age
• Severity of symptoms
• Desire for children
• Previous treatments
• Patient’s priorities (pain relief? desire for children?)
• Side effects of medications
• Potential risks

Different treatment approaches are applied, taking into account the duration of treatment.

Surgical treatment, hormone therapy, pain management, nutrition, alternative therapies, and psychological support are among the treatment options for Endometriosis.

Pregnancy and hysterectomy do not treat endometriosis.

Pain

Both medication and surgical treatment are beneficial for painful periods and painful sexual intercourse. In most cases, pain recurs within the first year after treatment. Hysterectomy and oophorectomy may be recommended for cases with severe and recurrent pain and no desire for children. In pain management, birth control pills, progesterone hormone, pain relievers, and some drugs that are structural analogs of GnRH hormone are used. In surgical treatment, laparoscopy is usually preferred.

Infertility

Forty percent of cases presenting with complaints of infertility are diagnosed with Endometriosis. Currently, it is believed that surgical treatment may be beneficial even in mild cases of Stage I-II. After surgical treatment, if there is no pregnancy and there are no significant problems with the fallopian tubes and the quality of sperm in the male partner, intrauterine insemination (IUI) is preferred. In older cases with a low egg count and severe sperm problems, and cases with long-standing infertility problems, in vitro fertilization (IVF) is usually preferred without resorting to IUI.

Does Endometriosis Recur?

Recurrence may occur in approximately 10-30% of cases with endometriosis. As the stage of the disease increases, the likelihood of recurrence after treatment also increases.

Does Endometriosis Cause Cancer?

Directly increased rates of genital or other cancers have not been observed in studies of patients with endometriosis. However, in some ovarian cancers (clear cell carcinoma, endometrioid carcinoma), it has been shown that the frequency of Endometriosiss is increased when the ovaries of these patients are examined.

Can Hormone Therapy Be Administered After Menopause?

In cases of natural menopause with Endometriosis, when hormone therapy is administered, the fact that the patient has had Endometriosis does not make any difference in treatment.

In cases where menopause occurs as a result of surgical operation due to Endometriosis, both estrogen and progesterone hormones are used together in hormone therapy in the first year (in cases without endometriosis, only estrogen is given). However, in patients with Endometriosis, this disease can rarely recur spontaneously after menopause or after treatment.