Endometriosis, with a simple definition, is the situation where a tissue that is very similar to the endometrium (inner lining of the uterus) but has some differences, settles and develops outside the uterus (uterus). Where endometriosis is present, it causes the development of scar tissue, resulting in adhesions and inflammatory changes in the intra-abdominal, especially in the pelvis, where the female reproductive system is located (the lowest part of the abdominal cavity, which is formed by the pelvis bones and where the female reproductive system organs are located). Endometrioma, on the other hand, is the condition where the endometrial tissue in the uterus is often found in the ovary, sometimes on the ovary, to form a cyst. It is the most common form of endometriosis disease. Between 15% and 45% of endometriosis patients have endometriomas.
Endometriosis often develops inside the ovaries. Here it forms cysts filled with a brown-black fluid. These cysts, which occur in very different shapes in terms of size, are called endometriomas. They are also called ‘chocolate cysts’ due to the color and consistency of the fluid inside. It can develop between the vagina and the rectum (deep infiltrative endometriosis). The endometriotic tissue that settles in these areas develops with the effect of estrogen and progesterone hormones, just like the endometrium (uterine lining), causing symptoms such as painful menstruation and pain during intercourse. These changes, which the disease shows under the constant influence of hormones, can cause adhesions in many parts of the female reproductive system, including the tubes, and affect the possibility of pregnancy development and cause infertility. In addition, toxic substances such as abnormal cytokines and interleukin secreted from endometriomas can affect both the attachment of the embryo and the development of a potentially healthy embryo by causing changes in the healthy uterine lining. In addition, endometriomas can potentially cause premature ovarian failure, decreased ovarian reserve, and abnormal ovulation processes.
Endometriomas can increase the likelihood of developing ovarian cancer in women of reproductive age, can negatively affect normal ovulation processes, and cause pain during sexual intercourse and menstrual periods. Although most endometriomas are considered to be benign structures, surgical removal of endometriomas may be required to confirm that there is no malignancy in rapidly growing cases with changes in shape, content and appearance on follow-up ultrasonography. Again, surgery can be performed in couples who have severe menstrual pain and difficulties in conceiving a child. In the case of an endometrioma located in the ovary, the egg reserve and egg quality on that side can be seriously affected.
Treatment
The basic approach is based on suppressing the woman’s ovulation cycle. Generally, it is preferred to use birth control pills or drugs containing only progesterone without interruption first, or to suppress ovulation with agents that act on the hypothalamus (the region of the brain that regulates the menstrual cycle) with other drugs if it is insufficient. The side effects of long-term use of drugs that act at the hypothalamic level, such as bone loss and bone pain, weight gain, hot flashes, due to low estrogen levels occur sooner or later; In this respect, care should be taken and estrogen should be added to the treatment at low doses if necessary. In cases of persistent groin and low back pain, the use of painkillers can provide relief for patients for a short time. However, all these approaches provide only temporary relief and do not make endometriomas disappear/disappear, although they may prevent their growth or sometimes partially shrink them.
In a significant part of the patients, it may be sufficient to follow up the endometriomas at regular intervals (every 6 months) if they do not have symptoms. However, the patients followed should be informed that endometriomas can impair ovarian functions and egg quality, and decrease ovarian reserve in the longer term. If there is no desire to have a child yet, and ovarian reserve is decreasing, and if surgical treatment for endometriomas is on the agenda, patients should be informed about fertility-preserving treatments such as “egg freezing” before surgery. If pregnancy does not develop even after 1 year in married couples who want to have children, after evaluating the size, location and condition of the tubes before a possible surgery, you can learn about options such as vaccination, in vitro fertilization or embryo freezing that will increase the pregnancy rate and ensure pregnancy development with assisted reproductive techniques. Couples should be informed. As can be seen, extra effort is required to be very meticulous in patients with endometrioma/endometriomas and to protect fertility with correct guidance. Because, if the surgical stage is reached for treatment, all kinds of approaches must be applied in order to preserve fertility beforehand. Everything that can be done before surgery should be applied, with repetitive egg retrieval and freezing treatments, or with repetitive egg retrieval and embryo freezing treatments. It is also known that a significant portion of endometrioma cases become pregnant spontaneously and achieve a healthy live birth. Again, pregnancy can be achieved by vaccination and in vitro fertilization for couples planning pregnancy. All these treatments are correct and possible approaches in line with the patient’s or couple’s condition and wishes at the time of application.
However, sometimes patients may present with both large endometriomas (greater than 5 cm) and diffuse deep infiltrative endometriosis and associated intense complaints and decreased ovarian reserve. Again, some patients, mostly young patients who do not have any complaints and therefore do not need a gynecological examination (abdominal ultrasonography in single patients are often sufficient alone) may experience a sudden onset of pain in the lower abdomen and groin, with the ovary turning around itself. It may present with a clinic called ‘ovarian torsion’ in which self-feeding is impaired. If it is intervened in the early period, the ovary can be preserved and the endomtrioma can be removed. In delayed cases, the affected ovary can be removed completely.
Surgical approach to endometrioma cases is laparoscopic (closed) excision and opening of intra-abdominal adhesions, if any. In very rare cases, open surgery may be required. In both cases, the germinal tissue (germinal epithelium) of the ovary, which ensures the fertility of the woman around the endometrioma, should be preserved by being very careful during the surgery. Therefore, the operation should be performed by experienced gynecologists and obstetricians. Although fertility can be established in surgical interventions performed properly, in some of the cases, the removal of healthy tissue with endometrioma or the deterioration of blood flow to the healthy ovarian tissue despite great care, the patient’s ovarian reserve may be impaired. Strategies such as collecting eggs and freezing them if they are married, or trying to get pregnant with fresh embryos with IVF treatment if pregnancy is not achieved after 3 vaccinations, and/or freezing as many embryos as possible and freezing them after the operation can be followed. Everything is shaped after an evaluation is made by considering many factors such as the patient’s complaints, the duration of the disease, the condition of the tubes, the condition of the ovarian reserve, whether there is a desire for pregnancy or not. After discussing the pros and cons of the current situation, the method that will provide the most benefit from assisted reproductive technologies such as medical treatment, surgical treatment and vaccination, IVF and egg/embryo freezing should be selected. It should be noted that 5%-20% of endometriomas recur after surgery.
Today, endometrioma and endometriosis cases are handled with a multidisciplinary perspective. Just like in vitro fertilization centers, endometriosis/endometrioma centers have started to be established in which experts from many fields of medicine work jointly. It is obvious that in such centers, the patient and the couple will have a high chance of getting rid of the disease with maximum efficiency and preserving their fertility.
What is endometrioma? How should it be followed and treated? approach to cases in the light of basic and current principles
