The appearance of the endometrium in other parts of the body outside the uterine cavity is called endometriosis. The appearance and growth of the endometrium in the muscular layer of the uterus is called adenomyosis. The two diseases may be present in combination.
The incidence of endometriosis.
has increased significantly in recent years; it is a common gynecologic disease. About 10% of women of childbearing age suffer from this disease, and 30 million people in China suffer from endometriosis! Of these women, 20-90% are unable to get pregnant or have abdominal pain.
Age of onset.
Onset at childbearing age, mostly 25-45 years old. The onset of endometriosis is related to the cyclical changes of menstruation. Girls before menarche and older women after menopause generally do not suffer from this disease.
Lesion-prone sites.
Ovaries, posterior wall of the uterus, ligaments, peritoneum between the vagina and rectum and pelvic cavity. Other: abdominal cavity and other parts of the body, such as the navel, bladder, kidneys, lungs, breasts, and even on the hands, arms, and thighs, but very rarely.
How does endometriosis develop?
It is a benign lesion, but behaves much like a malignant tumor, with the ability to metastasize and implant distantly, making eradication very difficult. The cause of its onset is unknown and there are various theories. It is currently believed that endometriosis is a genetic disorder; an immune disorder; an inflammatory disorder; a disorder due to bleeding; an organ-dependent disorder and a hormone-dependent disorder.
Pathological changes of endometriosis.
The lesions bleed periodically, with increased fibrous tissue and adhesion formation, and the lesions grow in the ovaries as cysts filled with thick chocolate-like fluid – chocolate cysts. Endometriosis is generally rarely malignant, with only about 1%.
Staging.
We classify the disease into four stages: Stage I: very mild; Stage II: mild; Stage III: moderate; Stage IV: severe.
Manifestations of endometriosis.
Dysmenorrhea and plain lower abdominal pain; menstrual irregularities; infertility; deep pelvic pain during sexual intercourse. Abdominal pain, diarrhea or constipation, periodic blood in the stool if the bowel is invaded; painful menstrual urination and frequent urination if the bladder is invaded; menstrual back pain and hematuria if the ureter is invaded; rupture of the chocolate cyst causes sudden onset of severe abdominal pain with nausea, vomiting and anal swelling; sometimes an abdominal mass can be felt; pain is increased when the cyst ruptures; the patient feels pain when the physician performs a gynecologic examination.
Further examination of the suspected patient.
B-mode ultrasonography can identify chocolate cysts; Ca-125 (glycoconjugate antigen) values may be measured elevated; laparoscopy directly observes pelvic lesions and is currently the best method for diagnosis.
Treatment principles.
It is considered comprehensively according to different situations such as the patient’s age, symptoms, site and extent of lesions and requirements for fertility. In principle, patients with mild symptoms should be treated with expectant therapy and actively strive for pregnancy; ② patients with fertility requirements should be treated in a “three-step” process, with the first step being laparoscopic examination to confirm the diagnosis and appropriate surgery. The first step is laparoscopic examination to confirm the diagnosis and appropriate surgery. Mild patients can try to get pregnant after surgery; the second step is pharmacological treatment after surgery for more severe lesions; the third step is treatment to help pregnancy by artificial insemination or in vitro fertilization. ③Severe patients without fertility requirements can be treated with surgery and medication; ④Patients without fertility requirements who have severe symptoms and lesions can be considered for radical surgery. Treatment goals: remove lesions; reduce pain; increase the chance of pregnancy; delay recurrence as much as possible. Both surgical and pharmacological treatments have a high recurrence rate.
Surgical treatment.
We generally prefer laparoscopic surgery. (i) conservative surgery for young and fertile patients, removing only the lesion; (ii) semi-conservative or semi-radical surgery for moderately severe patients who do not need to have children, i.e., preserving at least one ovary or part of the ovary to maintain female endocrine function. (iii) For patients who do not need to have children and for severe cases, radical surgery is feasible, with removal of the uterus and both ovaries.
Drug treatment.
① short-acting contraceptive pills; ② contraceptive ring treatment, for patients with severe dysmenorrhea and unwilling to remove the uterus and ovaries, a progestin-containing contraceptive ring (Mannedol) can be used, which can significantly reduce or “eliminate” dysmenorrhea, but is not effective for ovarian chocolate cysts; ③ Danazol (oral or suppository); ④ progesterone (endometrium); ⑤ gonadotropin-releasing hormone agonists (GnRH-a) (Inhibiton, Dabigat, Norelide, Daphylline, etc.). All of these drugs are designed to lower the estrogen level in the blood, causing the endometriosis lesions to shrink and achieve the stage of treatment.
Assisted conception treatment.
Assisted reproduction techniques such as natural cycles or pharmacological ovulation promotion + intrauterine insemination after washing of the husband’s semen; ovulation promotion + in vitro fertilization and embryo transfer (IVF) techniques. Moderately severe or recurrent endometriosis is a reason for IVF treatment.