Endometriosis is a gynecological disease that occurs when endometrial tissue in the uterus settles and develops in areas outside the uterus. This tissue develops and sheds within 28 days, according to the hormonal changes that occur in women on a monthly basis. In the first 14 days of this period, the tissue thickens in preparation for a possible pregnancy that may occur in the woman. In the month when pregnancy does not occur, the tissue thins and sheds with bleeding. The hormones estrogen and progesterone are the cause of these changes. Therefore, it is a disease that affects women of reproductive age.
Although endometriosis is in a different location than the uterus, it responds to hormones just as it does in the uterus, growing, thickening and shedding on a monthly basis. Areas where the tissue can settle outside the uterus are:
Ovaries
Tubes
Outer surface of the uterus
Abdominal cavity behind the uterus
Urinary bladder
Intestinal surface
Rectum area of the large intestine
To the peritoneum
There are reports that these tissue cells are very rarely located in the lungs and eyes. In the ovaries, where the tissue is most commonly located, a chocolate cyst called endometrioma is formed in parallel with the development of the tissue. The bleeding that occurs in these tissues every month causes adhesions in the organs in the abdomen and the pelvic cavity over time. In advanced stages, an intense adhesion that cannot be separated is observed in the ovaries, tubes, uterus and surrounding intestines.
This disease can be seen in women who menstruate in their thirties, but it can also be seen in women of any age who menstruate. Women who have relatives with endometriosis, such as mothers and sisters, are at greater risk. Three-quarters of women with chronic pelvic pain have this disease.
What are the symptoms of endometriosis?
The most common symptom of the disease is chronic pelvic pain. The effect of the pain is especially felt during urination, bowel movements, before and during menstruation. Endometriosis can also cause patients to not be able to conceive. There is no connection between the severity of the pain in patients and the severity of the course of the disease. Most patients who have difficulty conceiving may not have any complaints of pain. However, it is a known fact that approximately one third of endometriosis patients have problems with not being able to conceive. The pain gradually increases and cannot be treated with medication. It has been determined that if endometriosis patients can conceive, most of their complaints decrease. Therefore, in drug treatments applied to patients, some drugs show the hormonal effects of pregnancy and reduce symptoms.
Although it is known that endometriosis causes infertility in women, the exact cause of this has not been determined. While endometriosis is detected in 25-50% of women with infertility problems, this is 6-8 times higher in infertile women compared to women who give birth. While the probability of getting pregnant within a month is 15-20% in healthy couples, the rate is 2-10% in those with endometriosis.
The Relationship Between Endometriosis and Infertility
Pelvic integrity disruption: Adhesions in this area may prevent the release of eggs from the ovaries and their passage to the tubes.
Functional changes in the abdominal wall: The inner lining of the abdomen, the peritoneum, is among the areas affected by endometriosis. Here, the volume of peritoneal fluid and the cells called peritoneal macrophages increase. These cells intervene in the event of inflammation. In addition, there is an increase in cytokines that regulate the functioning of the cells. These changes can be effective in the relationship between the egg and sperm, the movement of the sperm and their survival.
Changes in hormonal and cellular functions: An increase in IgG, IgA and lymphocytes is observed in the endometrial tissue of patients. Therefore, abnormalities may occur in the implantation of the embryo into the uterus.
Endocrine and ovulation disorders: Compared to the normal menstrual cycle of women, the follicular phase is shorter. The egg development phase, that is, the first half of the period, is shortened. The LH peak decreases, estradiol decreases. In endometrial biopsies, progesterone and the luteal phase are normal. In patients with severe adhesion, the ovary is coiled. Even if the hormone parameters are normal, the ovary cannot release an egg, and they remain in the ovaries as cysts.
Implantation failure: In women with endometriosis, changes in the endometrium prevent the egg from attaching to the endometrium during the implantation phase.
In women, the monthly cycle begins with the onset of puberty and the first menstrual bleeding. In this cycle, endometrial tissue develops every month due to the effect of hormones and is shed vaginally at the end of the month if there is no pregnancy. When women have endometriosis, this blood flow is into the abdomen through the tubes. This inflow causes chronic inflammation, which in turn causes adhesion, tissue change and the reproductive organs to not function properly. Since the tissue around the disease focus shrinks, pain occurs due to lack of oxygen.
If there is an adhesion in the abdomen, it prevents the egg from being held in the tubes, transported to the tubes, and prevents the egg from meeting with the sperm and being fertilized. In this case, the risk of ectopic pregnancy in women increases 6 times more than normal.
As endometriosis progresses, it causes the tissue to spread and the surrounding tissue to die. The chances of these women getting pregnant decrease to 12-36%. The pregnancy rate is not affected much in mild cases when the anatomy is not damaged in the long term. Studies have determined that there is no change in the pregnancy rates of patients when these are treated. In cases where fertility is affected, it has been suggested by some researchers that the body creates antibodies against the endometrial tissues that are incorrectly placed in the woman's body and that this effect increases the spontaneous miscarriage rate by 3 times. Meanwhile, up to 70% of patients have been able to get pregnant spontaneously within 3 years without any treatment. Getting pregnant causes the disease to regress and its effects on the woman to decrease.
In the treatment of endometriosis, the woman's age, the stage of the disease, the types of treatment previously applied to the woman and the length of time the woman has been unable to conceive are important. In this case, the patient is given;
Waiting to see if you get pregnant
Application of ovulation induction and intrauterine insemination
Application of in vitro fertilization ( test tube baby ) treatment
While treatment is planned for patients with early-stage endometriosis with a 1-year observation period, the first-stage treatment for patients with advanced-stage endometriosis may be to immediately choose in vitro fertilization.
The disease foci can be removed with surgery performed by laparoscopic or open methods. In this way, the symptoms can be relieved or the woman can be allowed to get pregnant. In laparoscopies performed for infertility , endometriosis was determined at a rate of 21-48%, and in laparoscopies performed for non-infertility purposes, endometriosis foci were determined at a rate of 1.3-5%. After the surgical treatment applied to the patients, the pregnancy rate in patients within 15 months was 70-80% in mild cases, 55-60% in moderate cases, and 40-45% in severe cases. The general average of these is between 55-65%.
Since the blockage that may occur in the tubes due to the disease is a possible cause of infertility, a hysterosalpingogram may be taken. When the woman is of appropriate age, the blockage in the tubes may be attempted to be opened with a laparoscopic method. In this way, the pregnancy rate in women will increase. If pregnancy does not occur within 3 months, it will be appropriate to treat the disease and switch to other treatment methods to achieve pregnancy. When the woman is under 35 years of age and has not been able to conceive for 2 years, pregnancy can be achieved through ovulation treatment and insemination treatment. These treatments should be planned carefully by evaluating the patient's condition. If necessary, the woman's ovarian reserve should be evaluated. Because healthy ovarian tissue may also be affected in surgical treatments.
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