Endometriosis (Chocolate Cyst Disease)

Endometriosis (Chocolate Cyst Disease): is an unusual disease that is often seen in reproductive ages, sometimes in the form of a chocolate cyst that is detected only by chance without causing any complaints, and sometimes as a disease without much relief despite many medical treatments and operations. It is one of the important examples of the phrase "treating the patient, not the disease" in medicine. It is seen in 1 out of every 10 women in reproductive age. Endometriosis is the presence of the endometrial (the lining of the uterus) tissue outside of the uterus. Endometriosis most commonly involves the ovaries (in 65-70% of cases). Other organs that have been reported to be affected include the abdominal peritoneum, fallopian tubes, vagina, bowel, bladder, ureters, umbilicus (naval), suture sites of previous operations, lungs, diaphragm, spinal canal, brain, eyes, breast tissue, heart, spleen, arms and hands.

In  chocolate cyst disease, while a lesion as small as a needle tip may affect the quality of life significantly in some women, a lesion as big as a walnut or even a lemon may be asymptomatic in others.

Especially in our country, women can look for alternative remedies from the people around them or on the internet for their problems such as heavy menstrual bleeding or painful sexual intercouse. Thus, they might be late to seek medical advice. This may lead to a waste of time which causes the problem to grow and the danger to increase.

One of those dangers is kidney loss! Chocolate cyst disease, which is histologically benign but may be behaviourally malign, can narrow the pipe that transports urine to the urinary bladder and lead to silent loss of function in kidneys.

Symptoms:

• Chronic fatigue
• Painful menstruation
• Painful sexual intercourse (pain in the anus and groin)
• Infertility
• Diarrhea and constipation
• Bleeding from the anus, bloody stool
• Menstrual irregularity, premenstrual spotting
• Painful urination and blood in the urine
• Some women with endometriosis may have no symptoms and the diagnosis is made by ultrasonographic examination or during surgery.

Assessment of the patient's complaints and taking a detailed medical history at first is mandatory. It must be discussed with the patient whether there are some special symptoms regarding endometriosis. Then, physical, ultrasonographic and gynecological examinations are performed. Tenderness, pain and decreased uterine mobility during pelvic examination may suggest the presence of endometriosis. Occasionally, bluish-purple nodular lesions can be seen behind the cervix during speculum examination. This simple finding indicates the presence of Deep Infiltrative Endometriosis in the deep tissues of the pelvis. Therefore, pelvic examination with a speculum is very important in making the diagnosis.

Another auxiliary method is blood tests, and Ca 125 and Ca 19-9 are most commonly requested ones. However, these tests have low sensitivity in recognizing endometriosis and are ordered only in some cases as additional tests.

Ultrasonography is one of the most informative methods for diagnosis. Ultrasonography can show chocolate cysts called endometrioma in the ovary, serious adhesions between the ovaries and the uterus and occasionally endometriotic nodules around the ureter (the pipe that carries urine from the kidney to the bladder), intestines, rectum and bladder.

The definitive diagnosis of endometriosis is made by laparoscopic biopsies (tissue sampling). During laparoscopy, endometriosis can be assessed as mild (stage 1-2) or severe (stage 3-4).

Endometriosis is not a disease that can be definitively treated and completely eliminated. The stage and severity of the disease affect the treatment approach. Two important determinants of treatment are pain and the patient's desire for a child. There are 2 main approaches to the treatment of endometriosis: Medical Treatment (medication) and Surgical Treatment.

If pain is the chief- complaint, both medical and surgical treatment may be considered. However, we know that surgical treatment is the most effective approach for pain. The fertility history and age of the woman are important while making the decision for surgery. While there is no limitation regarding surgery in women who have children, surgical treatment is not considered as first choice in women who do not have children, in patients with bilateral chocolate cysts or who have had previous surgeries.