What You May Not Know About Endometriosis

What Is Endometriosis?

Endometriosis is a condition characterised by the process in which the inner lining of the uterus thickens during the menstrual cycle and is shed through menstrual bleeding also occurring outside the uterus. Endometrial tissue located outside the uterus responds to the menstrual cycle; in other words, it thickens, sheds and bleeds each month in response to hormonal changes. However, this shed tissue cannot be expelled from other areas of the body, which may lead to inflammation, pain and other problems. If the ovaries are also involved in this process, cysts called endometriomas may develop.

Who Is Affected by Endometriosis?

Endometriosis is a condition that generally affects women of reproductive age and may be associated with various risk factors.

Women of Reproductive Age

Endometriosis is generally seen in women between the ages of 15 and 49. It affects approximately 10–17% of women of reproductive age.

Women with Chronic Pelvic Pain

Endometriosis may be identified in 35–60% of women who experience chronic pelvic pain. Pelvic pain may be a symptom of endometriosis.

Risk Factors

Family History

Women with a history of endometriosis in a first-degree relative, such as their mother or sister, have an increased risk of developing the condition. Genetic factors may play a role in the development of endometriosis.

Structural Abnormalities of the Uterus

Structural abnormalities of the uterus may increase the risk of endometriosis. For example, congenital uterine anomalies or abnormal uterine shapes may affect this risk.

Age at First Menstruation and Age at Menopause

The onset of menstruation at an early age, during adolescence, and the onset of menopause at a later age may increase the risk of endometriosis. A longer lifetime exposure to menstrual cycles may affect the risk of endometriosis due to hormonal changes.

Menstrual Cycles

Short menstrual cycles and heavy menstrual bleeding are factors that may increase the risk of endometriosis. More frequent and heavier menstrual periods may affect hormone levels.

Race and Ethnic Origin

The risk of endometriosis may be slightly higher among White and Asian women. Race and ethnic origin are associated with genetic predisposition and environmental factors.

Alcohol and Caffeine Consumption

High levels of alcohol and caffeine consumption may increase the risk of endometriosis. These substances are thought to affect hormonal balance.

Environmental Exposure

It has been suggested that exposure to environmental toxins such as polychlorinated biphenyls and dioxins may increase the risk of endometriosis. These chemicals are thought to have adverse effects on the hormonal system.

Symptoms of Endometriosis (Chocolate Cyst)

Pain

Menstrual Cramps (Dysmenorrhoea)

Severe cramps caused by uterine contractions during the menstrual cycle.

Chronic Pelvic Pain

Persistent pelvic pain that also occurs outside menstrual periods.

Lower Back and Abdominal Pain

Pain experienced particularly during or around the time of menstruation.

Pain During Sexual Intercourse

Deep pain experienced during and/or after sexual intercourse, known as dyspareunia.

Digestive Problems

Bowel Pain

Pain during bowel movements, particularly during menstruation.

Digestive Problems

Digestive symptoms such as diarrhoea, constipation, bloating and nausea.

Bleeding or Spotting Outside the Menstrual Period

Bleeding or spotting that occurs outside the menstrual cycle.

Infertility

Endometriosis may affect the likelihood of pregnancy and may cause infertility. It has been found to cause infertility in approximately 30–40% of women.

Swellings

Painful swellings may develop in areas affected by endometriosis at surgical incision sites.

Symptoms of Deep Endometriosis

Deep endometriosis is a more advanced form of endometriosis, and the severity of pain increases as the disease infiltrates more deeply. Symptoms may include deep pain during sexual intercourse, pain radiating to the rectum, pain during urination and blood in the urine.

Deep Pain During Sexual Intercourse

Deeper and more severe pain during sexual intercourse.

Pain Radiating to the Rectum

Pain that spreads to the anal or rectal region.

Pain During Urination

Pain or discomfort while urinating.

Blood in the Urine

The presence of blood in the urine while urinating, known as haematuria.

Pain Involving Internal Organs

Deep endometriosis may place pressure on organs, causing pain and discomfort.

Fatigue and General Discomfort

Chronic pain and other symptoms may cause fatigue and a general feeling of discomfort.

How Is Endometriosis Diagnosed?

Endometriosis occurs during the reproductive years, and patients may present with groin or pelvic pain, including dysmenorrhoea and dyspareunia, infertility or difficulty becoming pregnant and/or ovarian cysts. After the patient’s symptoms have been discussed and evaluated, an examination is performed based on the preliminary diagnosis.

Examination

During the examination, ovarian cysts or nodular, lump-like structures may be felt behind the uterus. This examination may be painful. Endometriosis tissue located on the peritoneum cannot be detected by palpation.

Evaluation of Symptoms

Endometriosis commonly presents with the following complaints:

• Groin or pelvic pain (dysmenorrhoea): Severe cramps and pelvic pain during menstrual periods
• Pain during sexual intercourse (dyspareunia): Pain experienced during sexual intercourse
• Infertility: Difficulty becoming pregnant
• Ovarian cysts: Particularly symptoms associated with chocolate cysts or endometriomas

The patient’s medical history is obtained and her symptoms are evaluated in consideration of these complaints.

Pelvic Examination

Cysts or nodular, lump-like structures may be felt behind the uterus or around the ovaries. However, endometriosis tissue located on the peritoneum usually cannot be felt during the examination, and the examination may be painful.

Imaging Methods

Following the examination, ultrasonography may be performed to detect and confirm ovarian cysts caused by endometriosis. Magnetic resonance imaging is another imaging method that shows the internal structures of the body and the relationship between organs and lesions.

Medical Treatment

If the patient has signs and symptoms even though no chocolate cyst is detected during ultrasonography, medical treatment may be administered.

Oral contraceptive pills may help reduce pain throughout the menstrual cycle. Gonadotropin-releasing hormone agonists block the menstrual cycle and reduce oestrogen levels by creating a temporary menopausal state. If the pain improves with hormonal medication, the patient may have probable endometriosis.

Laparoscopy

A definitive diagnosis is established through laparoscopy, which is a minimally invasive surgical technique. Surgery is the only way to confirm the presence of endometriosis. A small tissue sample is taken and examined under a microscope through pathological evaluation to establish a definitive diagnosis.

Treatment of Endometriosis (Chocolate Cyst)

Although there is no definitive cure for endometriosis, treatments aim to reduce symptoms and improve quality of life. The appropriate type of treatment depends on the patient’s age, her desire to become pregnant, the extent of the disease and the severity of her symptoms.

Treatment may involve medical treatment, surgical treatment or a combination of both. If the patient wishes to have children, ovarian reserve and the patient’s age are particularly important.

Pain-Relieving Medication

These medications may reduce pain caused by endometriosis.

If Pregnancy Is Not Desired

Hormonal Treatment

Hormonal treatment is used to relieve the symptoms of endometriosis and generally includes the following methods:

Oral Contraceptive Pills

Combined oral contraceptive pills: These may reduce pain by regulating the menstrual cycle and controlling hormone levels. They are frequently used as a first-line treatment to manage pain and control bleeding in women with endometriosis.

Progesterone-Containing Medications

Progesterone tablets or injections: These may reduce the growth of endometriosis tissue by blocking the effects of oestrogen.

Hormonal Intrauterine Device

Levonorgestrel-containing intrauterine device: This hormone-releasing device is placed inside the uterus and may reduce menstrual bleeding and relieve symptoms. However, it may not be sufficiently effective in some patients, and symptoms of endometriosis may continue.

GnRH Agonists

Gonadotropin-releasing hormone agonists: These temporarily stop the menstrual cycle and reduce oestrogen levels, causing endometriosis tissue to shrink. However, long-term use may cause adverse effects such as osteoporosis.

Danazol

Danazol: This is an androgen that inhibits oestrogen production and may relieve the symptoms of endometriosis. Possible adverse effects include weight gain and changes in the voice.

Surgical Treatment

Surgical treatment is performed:

• When a tissue diagnosis of endometriosis is required
• In patients with persistent pain that does not respond to medical treatment
• In cases involving obstruction of the bowel or urinary tract

What Happens If Endometriosis (Chocolate Cyst) Is Left Untreated?

Worsening Pain

Chronic Pain

If endometriosis is left untreated, symptoms such as severe pelvic pain, back pain and abdominal pain before and during menstrual periods may continue and worsen over time.

Pain During Sexual Intercourse

Pain during sexual intercourse, known as dyspareunia, may become more severe and may adversely affect sexual life.

Infertility

Fertility Problems

Endometriosis may cause infertility in approximately 30–40% of women. If left untreated, involvement of the ovaries and changes in pelvic anatomy may reduce the likelihood of pregnancy.

Digestive and Urinary Problems

Digestive Problems

Digestive symptoms such as diarrhoea, constipation, bloating and nausea may continue or worsen.

Urinary Problems

Symptoms such as pain during urination or blood in the urine may become more severe.

Psychological and Social Effects

Quality of Life

Persistent pain and discomfort may lead to psychological stress, anxiety, depression and social isolation.

Daily Life

Pain and other symptoms may adversely affect daily activities and overall quality of life, resulting in loss of productivity and restrictions in social life.

Possible Complications

Ovarian Cysts

Endometriosis may cause cysts such as chocolate cysts or endometriomas. These cysts may grow and place pressure on other organs, resulting in pain and complications.

Adhesions Between Organs

Endometriosis may cause adhesions between organs, which may lead to pain and impaired organ function.

More Serious Conditions

Organ Damage

Long-term endometriosis may damage organs and make surgical intervention more complex.

Cancer Risk

Although rare, endometriosis may increase the risk of cancer involving the inner lining of the uterus and other pelvic organs.

Frequently Asked Questions About Endometriosis

What Is Endometriosis?

Endometriosis is a condition in which the inner lining of the uterus, known as the endometrium, which thickens and is shed through bleeding every month, is located in areas outside the uterus. This causes tissue outside the uterus to behave like the endometrium by thickening, shedding and bleeding.

What Causes Endometriosis?

The exact cause of endometriosis is not fully understood. However, the most widely accepted theory is that menstrual blood flows backwards through the fallopian tubes into the abdominal cavity each month and that inflammation and adhesions develop because the body’s mechanisms are unable to clear this tissue.

Where Does Endometriosis Occur?

Endometriosis is most commonly seen in the ovaries, bowel and the anterior, posterior and lateral regions of the uterus. Endometriosis tissue may also occur on the peritoneum and at surgical incision sites.

What Symptoms Can Endometriosis Cause?

Endometriosis may present with various symptoms:

• Pain: Pain may be experienced during menstrual bleeding, during and/or after sexual intercourse, during bowel movements or while urinating.
• Difficulty becoming pregnant: Endometriosis may cause infertility.
• Chocolate cysts: These are cysts that form as a result of blood accumulating in the ovaries.
• Abdominal gas and bloating: Endometriosis may affect the digestive system.

Does Endometriosis Cause Infertility?

Yes. Endometriosis may cause infertility by impairing egg quality, causing adhesions within the abdominal cavity and disrupting the structure and function of the fallopian tubes.

Does Every Woman with Endometriosis Develop a Chocolate Cyst?

Chocolate cysts do not develop in every patient with endometriosis. Chocolate cysts are present in approximately one to five out of every ten women with endometriosis, corresponding to 17–50%. Therefore, even if you have endometriosis, you may not have a chocolate cyst in your ovaries.

How Is Endometriosis Treated?

There is no permanent cure for endometriosis. However, medical and surgical treatments may be used to relieve symptoms and improve quality of life.

• Surgical treatment: Although removal of the uterus and ovaries may appear to provide a definitive treatment, recent studies have shown that the disease may recur even after these organs have been removed. If surgery is performed, a minimally invasive laparoscopic approach is preferred.
• Medical treatment: Various medications may be used to reduce pain and to stimulate the ovaries in patients experiencing infertility.