The Treatment of Chocolate Cyst

Painkillers (non-steroidal anti-inflammatory drugs: such as ibuprofen or naproxen sodium) are frequently used to help relieve pelvic pain and menstrual cramps. These painkillers have no effect on endometriotic implants (foci of chocolate cyst that settle on the organs or on the lining of the bowel) or on the progression of endometriosis. At the same time, they reduce the production of the prostaglandins that cause pain, and therefore they also reduce the pain.

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In many women who have complaints due to endometriosis (one of the foremost complaints of these women is pain), painkillers are frequently used in treatment before a definite diagnosis is made. In such situations, NSAIDs are frequently used as first-line (given at the outset) empirical treatment (treatment believed to be beneficial). If they are effective in controlling the pain, there is no need for any other medical treatment or procedure. If the painkillers used are not effective, further assessment and treatment will be needed.

Because endometriosis emerges during the reproductive years, most of the medical treatments for endometriosis are based on stopping the normal cyclical hormone production of the ovaries. These drugs include GnRH analogues, oral contraceptive pills and progestins.

One of the points we know well about chocolate cyst disease is that the disease is highly dependent on oestrogen, also called the female hormone. While endometriosis is typically encountered frequently during the most active periods of reproductive age, this disease is very rarely seen before menstruation begins and after the menopause.

Artificial Menopause Injections (GnRH analogues) are used effectively to reduce pain and to shrink the size of endometriosis implants (foci). These drugs suppress the production of oestrogen by the ovaries by preventing the release from the pituitary gland of the hormones that stimulate the ovaries. As a result, after treatment the menstrual periods stop, imitating the menopause. GnRH agonists are available in nasal and injection (shot) forms.

The side effects, as a result of oestrogen deficiency, are;

By adding a small amount of progesterone in pill form, the unwanted side effects due to oestrogen deficiency can be avoided. This form of administration is called "add back therapy". It is a term referring to this modern method of administering GnRH agonists together with progesterone in order to eliminate most of the unwanted side effects of GnRH treatment and thus make it suitable.

Oral contraceptive pills (a combination of oestrogen and progesterone)  are also used in the treatment of endometriosis. Sometimes women with severe pain are asked to take oral contraceptive pills, in particular continuously (normally, when the packet of birth control pills is finished, they are not used for 1 week and then a new packet is started). Continuous use in this way suppresses menstruation considerably.

In endometriosis in particular there are 2 important areas of use; they are used in the treatment of pain due to the disease and in reducing the risk of the disease recurring after surgery. As side effects, weight gain, breast tenderness, nausea and, particularly somewhat more frequently, irregular bleeding (these are small amounts of spotting; significant bleeding is not expected with birth control pills) may be seen. Oral contraceptive pills are generally well tolerated by women with endometriosis.

Progestins (for example, medroxyprogesterone acetate, norethindrone acetate, norgestrel acetate) are used in treatment. Dienogest, which is licensed specifically for endometriosis, is widely used in symptomatic patients (patients who have complaints) both worldwide and in our country. Although in the past progesterones were more likely to come to mind in patients who could not take the birth control pill or who did not respond to painkillers, dienogest in particular is used far more widely than OCs in symptomatic patients.

Its common side effects are;

The cessation of menstruation (amenorrhoea) caused by high-dose depot progestins (long-acting) may last for several months after treatment is stopped. Therefore these drugs are not recommended for women who plan to become pregnant immediately after treatment is stopped.

Danazol is a synthetic drug that prevents the effect of oestrogen on egg production and ovulation by creating a hormonal environment of high androgens (the dominant hormones in men) and low oestrogen. In 80% of the women who use this drug the pain decreases and the endometriotic implants shrink. However, in as many as 75% of the women who use danazol, significant drug-related side effects are seen.

Apart from the deepening of the voice, all of these side effects are reversible after the drug is stopped. In some cases it may take months for the side effects to pass. Danazol should not be taken by women with certain liver, kidney or heart conditions. This drug is rarely used today.

A more recent approach to the treatment of endometriosis involves the use of drugs known as aromatase inhibitors (for example, anastrozole and letrozole ). These drugs act by interfering with the local formation of oestrogen in the endometriosis implants. They also prevent oestrogen production in the ovarian and fatty tissue.

Research is continuing in order to assess the effectiveness of aromatase inhibitors in the treatment of endometriosis. Aromatase inhibitors can cause significant bone loss with long-term use. In pre-menopausal women they have to be used together with other drugs because of their effects on the ovaries.

Today, Intrauterine Devices (IUDs) are typically used for birth control purposes. There are also types of these coils that continuously release progesterone (in our country it is sold by the pharmaceutical company Bayer under the name Mirena®). In particular, they ensure that a high dose of progesterone is present inside the uterus. Pain located in the midline within the pelvis may respond to this treatment. They can be used in particular in adenomyosis and in pelvic pain accompanied by heavy, irregular bleeding. They can also be used in deep infiltrating endometriosis in the pelvis, but in this case the chance of success is not very high.Today, Intrauterine Devices (IUDs) are typically used for birth control purposes.

There are also types of these coils that continuously release progesterone (in our country it is sold by the pharmaceutical company Bayer under the name Mirena®). In particular, they ensure that a high dose of progesterone is present inside the uterus. Pain located in the midline within the pelvis may respond to this treatment. They can be used in particular in adenomyosis and in pelvic pain accompanied by heavy, irregular bleeding. They can also be used in deep infiltrating endometriosis in the pelvis, but in this case the chance of success is not very high.

Surgical treatment for endometriosis can be beneficial when the symptoms are severe or when medical treatment is inadequate. Surgery is the preferred treatment method when there is an anatomical disruption in the pelvic organs or when there is an obstruction of the bowel and urinary tract. Generally the conservative method, in which the uterine and ovarian tissue is preserved (only the surgical removal of the endometriotic tissue), is preferred. But less often, in patients who do not wish to have children in the future and who have undergone repeated endometriosis surgery, a more radical hysterectomy (removal of the uterus) with or without removal of the ovaries may be performed.

The surgery for Deep Infiltrating Endometriosis is quite different and will be discussed separately. The most important point in endometriosis surgery is that the doctor’s having the necessary knowledge and experience in this surgery is essential for a successful result. If this operation is performed by a doctor who does not have sufficient experience, it will be accompanied by a high rate of complications during the operation (bleeding, vascular injury, injury to the urinary tract and the bowel and  fistula) and by recurrence of the disease at an early stage after the operation.

In fact, this is due to incomplete surgery rather than to recurrence of the disease. With successful surgery, the ability to conceive spontaneously when desired, a pain-free life and a low rate of recurrence of the disease will be seen. Both endometriosis surgery and Deep Infiltrating Endometriosis surgery will also be discussed in more detail.