Nov, 30 -0001

Chocolate Cyst (Endometriosis)


Fatih Şendağ, Associate Professor of Gynecology and Obstetrics, states that chocolate cyst is an insidious disease and says, "Do not underestimate your menstrual cramps that do not go away with simple painkillers." However, pain is not the only determinant. Chocolate cysts are found in a significant portion of women who apply to the doctor only with the complaint of menstrual irregularity or the complaint of not having a child. Assoc. Dr. Fatih Şendağ answered our questions about the chocolate cyst.
What is a chocolate cyst? Endometrium cells, located in the upper layer of the uterus, which we call the endometrium, can spill into the abdominal cavity and some of the menstrual bleeding may pass into the abdominal cavity. These cells are at any point in the abdomen; they can settle on the ovaries, on the uterus, on the peritoneum, and there just as in the menstrual cycle; Just as the layer we call "endometrium" thickens, sheds and bleeds, they imitate the menstrual order in the region where they settle.
As a result of these cells settling in the ovary, a "chocolate cyst" is formed. We call it a "chocolate cyst" because the endometrium cells penetrate into the ovary and accumulate as a chocolate-like and colored liquid inside the ovary.
What is the incidence?
Chocolate cyst occurs in 10 percent of women of reproductive age. In women with infertility problems, the incidence increases even more and is 20-40 percent.
What are the causes of chocolate cyst formation? Are there any of these that we can avoid? Unfortunately, we do not have a cure to prevent this. A direct link cannot be established for reasons such as any food, diet or obesity. More genetic reasons are at the forefront. The risk is also increased in women who smoke. These can be said as risk factors. But in reality, what is under the disease and how it occurs has not been clearly revealed yet. That's why we call it the "sickness of theories".
The reason is not clear yet. The most accepted theory; the backward flow of menstrual blood and the attachment of these cells to the abdominal cavity and their development there.
What are the symptoms of a chocolate cyst?
Chocolate cyst causes two main complaints:
■ Pain (groin pain during menstruation)
■ Infertility
How does the mechanism of the disease that causes pain work?
As long as a woman's menstrual cycle continues, the endometrial cells, which settle in another spot outside the uterus, multiply, shed and bleed during menstrual periods. This situation pulls the tissues together and sticks them.
For example, the intestines stick on the uterus or on the ovaries. The urinary tract may be affected. The pain caused by the disease in this way may not affect women in a very wide spectrum, from very mild pain to very severe.
Menstrual pain is a common problem for many women. Can we understand whether this pain is a symptom of a chocolate cyst?
Here we can make the following caveat. There are simple menstrual pains and they go away when 1-2 simple painkillers are taken. This is not a huge problem. But if there are very serious menstrual pains, if these pains do not go away despite the painkillers taken, if they prevent going to work, if they disrupt the comfort of life, then the underlying cause must be investigated.
Can a chocolate cyst be seen even if there is no pain complaint?
Yes, it can be seen. In many of our patients, this discomfort also causes menstrual irregularity. The patient has no pain and comes for menstrual irregularity. You see, there is a chocolate cyst. Or "I have no complaints, but I've been married for so many years, I can't have children" and you see, there is a chocolate cyst. Looking at the figures, 22 percent of the patients do not have any complaints.
How is the diagnosis made?
Chocolate cyst can be seen 90-95% of the time very easily with ultrasound. After the diagnosis, "Is the pain or the desire for a child in the foreground?" Treatment is planned by answering the question.

Does the treatment differ between women who want to have a baby and women who only complain of pain?
Yes. If pain is at the forefront, we try suppressive drug treatments first. Birth control pills are most commonly used in these treatments. Since birth control pills reduce hormone levels, they suppress pain and reduce complaints.
Another form of treatment is the creation of a false pregnancy in the patient. If you create a false pregnancy by interrupting the menstrual period, endometriosis will regress. But this is not a very practical approach. After all, how long will she not menstruate? With some needles, we can stop the patient from menstruation for 6 months. Cutting it for longer is risky anyway. Because it causes osteoporosis and it may not be possible to regain these losses. For this reason, it is necessary to use the needle treatments for 6 months and cut them off. But at the end of the treatment, the complaints may come back again. Birth control pills are more practical and we can give these pills longer. If the patient does not want a child, drugs will provide birth control during the treatment and the quality of life will increase as the pain is reduced and relieved. Of course, we do not give birth control pills to a patient whose desire for a child is at the forefront. If there is a complaint of infertility, the patient should be operated.

When does surgery come into play in the treatment? Let's take a patient with pain. He may have pain from the first menstrual period, this pain may appear in later ages... Things change according to the age of the patient. We primarily consider drug treatment in unmarried women and try to solve it with drugs in young girls. But if we are not successful with drug therapy, if the patient's life comfort is deteriorating due to pain, then we recommend surgery.

"Gold Standard Closed Surgery"
The gold standard in the surgery of the chocolate cyst is closed surgery. (Laparoscopic surgery). Imagine a young lady, that the operation was performed by cutting 10-15 cm with the open method. Think about it, this lady will marry in the future, will give birth to a child, if the adhesions increase during the operation, if the ovarian channels are blocked, it may be difficult to have a child. Laparoscopy has an advantage in these aspects. You do not open the stomach, it does not come into contact with the open atmosphere. You perform the surgery through a one-centimeter incision. The patient can go home without any incisions and can stand up the next day.

Post-operative pain is less common. Return to daily activities is faster. In open surgery, you cut the skin in seven layers and stitch it in seven layers. Each layer you cut comes back to you as pain later on. Therefore, when we consider these, laparoscopic surgery is very advantageous.
What is the satisfaction level of the patients after the operation? Can the disease be completely eliminated?
Unfortunately, endometriosis is not a disease that can be completely eliminated. There is still no definitive treatment. Since the exact cause is not known, treatments are also made for the complaints of the patients. If the treatment of a disease is not known exactly, it means that the treatment is not known for sure. There are many treatments and theories for chocolate cyst, but the most realistic treatment at the moment is surgery anyway.
If the chocolate cyst cannot be completely treated, how long do patients feel comfortable after the operation?
The technique applied in the surgery is important. The aim is to remove the cyst with minimal damage to the ovaries. If this is well implemented, the chance of recurrence of the disease is less than 5 percent. But there are some techniques, and in those techniques, the surgeon simply enters the cyst and empties it with a needle. We call this aspiration. In other words, the cyst wall remains as it is, or is partially removed. In these techniques, the risk of recurrence of the cyst is 70-80%. In techniques in which the cyst wall is completely removed by performing a complete cyst excision, the chance of recurrence of the disease decreases to 5 percent.


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