Normally, the endometrium is inside the uterine cavity. When endometrial tissue with growth function appears in other parts of the uterine cavity other than the overlying mucosa, it is called endometriosis. It is commonly found in the ovaries and pelvic peritoneum, etc. It is mostly purple-blue or dark red nodules in appearance that are not found in other gynecological conditions. These misplaced endometrium, like the endometrium in the uterus, bleed and shed during menstruation, but because they cannot be discharged, the blood accumulates locally and accumulates over time, forming blood-containing cysts. Ectopic diseases that grow on the ovaries often form these cysts because the bleeding in the cysts becomes like chocolate paste over time, so some people call them “chocolate cysts”. The endometrium can also grow in the muscles of the uterus itself, called uterine adenopathy. In recent years, its prevalence has increased and it has become a common gynecological condition. The prevalence is estimated to be 10-15% higher in the women’s population. Etiology of ectopic disease Endometriosis is a hormone-dependent disease and is therefore mainly seen in women of childbearing age. The causes of ectopic disease are complex and are likely to involve many factors together, such as menstrual seeding, abnormal ovulation, abnormal immune function, and genetic factors, which cannot be explained by a single reason. Symptoms of ectopic disorder 1. Pain is one of the main symptoms of ectopic disorder. Those with dysmenorrhea account for about 70%. Young women can have dysmenorrhea, which is usually the heaviest on the first day of menstruation and gets better soon afterwards. The pain level gradually decreases with age and generally disappears after marriage or after having children. If you do not have dysmenorrhea and it starts after a few years or after having children, or if you have dysmenorrhea and it gets worse afterwards and does not get better after having children, you may have ectopic disease. Another great feature of ectopic dysmenorrhea is that the more painful it is, the worse it gets, and many people go to the doctor for this reason, even affecting their studies and work. In addition, women who used to have dysmenorrhea should think of ectopic disorder if the timing of the dysmenorrhea has changed, for example, it used to be on the first or second day of menstruation, but now it hurts throughout the entire menstrual period, or in some cases it starts a few days earlier, and the stomach still hurts after the menstruation clears. In addition, about 1/3 of patients complain of pain in the abdomen during sexual intercourse, and some of them are very severe, thus fearing intercourse. Another 1/3 of women have frequent lower abdominal pain on one or both sides, which may be related to “chocolate cysts” or pelvic adhesions. Typical symptoms of ectopic disorders include anal cramps, stabbing pains or throbbing pains, in mild cases only during menstruation, in severe cases always during the week. In a few cases, the pain also radiates to the thighs or vulva. Another strange phenomenon in ectopic disease is that there is no significant relationship between the degree of stomach pain and the severity of the disease. We have encountered “chocolate cysts” larger than a child’s head in which the patient had no abdominal pain. In some cases, the pain is unbearable when there are only a few ectopic nodules growing in the back of the uterus. The mechanism of pain in endometriosis is still difficult to determine. However, it is believed that there are three major mechanisms: 1. the action of inflammatory factors in the abdominal cavity; 2. the direct or indirect effect of bleeding from the ectopic implantation lesion; and 3. the involvement or infiltration of the pelvic floor nerves. 2, Infertility is another major symptom of ectopic disease. Approximately 1/3 – 1/2 of patients are infertile. About 1/3-1/2 of women who are not pregnant have endometriosis. 3. Abnormal menstruation . There may be increased menstrual flow, prolonged menstrual periods and premenstrual dripping bleeding, which are related to ovarian dysfunction or concurrent diseases. Ectopic disease of the cervix or vagina may cause abnormal bleeding or even heavy bleeding. 4. Few patients have menstrual fever, mostly in patients with ovarian chocolate cysts and more extensive pelvic adhesions. Diagnosis of ectopic disease 1. Ask for medical history and do gynecological examination. The uterus is often posterior on gynecological examination, and hard nodes with obvious tenderness can be palpated in the isthmus of the posterior wall, the uterosacral ligament or the posterior sunken recess. If a poorly mobile mass can be palpated on the lateral posterior aspect of the uterus, it suggests a combined ovarian chocolate cyst. 2.Ultrasound examination . 3.Blood CA125 measurement Blood CA125 is mostly negative in mild patients and positive in moderate to severe patients. For patients with diagnosed ectopic disease, regular measurement of blood CA125 can be used for efficacy observation. 4.Laparoscopy is the best method for diagnosis of ectopic disease. Combined with biopsy, the diagnosis rate of laparoscopy can reach 100%. Treatment of ectopic disease Treatment methods are mainly divided into expectant therapy, surgical treatment and drug treatment, which are considered according to the patient’s age, the severity of the disease and whether there is a requirement for fertility. The treatment method varies from person to person. In recent years, more and more experts believe that ectopic disease should be treated like cancer, with early detection and early treatment. Surgery is the main treatment for ectopic disease, and medication is an important adjunct to treatment. 1.Expectant therapy Patients with no obvious discomfort and only suspicious endoheterotopic nodules in the pelvis found during physical examination can be re-examined every 3-6 months. Patients who are close to menopause can wait for observation. After menopause, painful symptoms will disappear and ectopic lesions will gradually shrink or even disappear. Those who are young, do not have heavy pain and have fertility requirements are recommended to get pregnant as early as possible. Pregnancy and lactation amenorrhea have an inhibitory effect on endometriosis and can be seen as a natural treatment for ectopic disease. 2.Surgical treatment is still the main treatment method today. It is mainly suitable for those who have serious conditions such as large chocolate cysts in the ovaries, serious pelvic adhesions, combined uterine diseases such as fibroids and adenomyosis, or those whose pain is severe and medication is ineffective. There are three types of surgery. (1) Conservative surgery Only the endometriosis lesion is removed and the ovaries and uterus are preserved, thus preserving the reproductive function. It is suitable for those who are young and want to preserve their reproductive function. Most of the postoperative pain disappears or is significantly reduced, and about 50-60% can become pregnant. However, the recurrence rate of pain is high and the possibility of needing a second surgery is about 10%. (2) Semi-radical surgery Removing the ectopic lesion while removing the uterus and preserving part of the ovaries can cure dysmenorrhea radically, and recurrence is rare after surgery. It is rarely necessary to operate again. However, the removal of the uterus means that the patient cannot have children, so it is suitable for those who have already had children, are over 35 years old, and have persistent pain or are accompanied by uterine lesions. (3) Radical surgery, in which both ovaries are removed and the uterus is often removed. It can cure endometriosis radically. It is suitable for older women who do not want to have any more children. Of course, there are shortcomings in surgical treatment, such as the risks and complications of surgery; surgery removes obvious visible ectopic lesions, and tiny invisible lesions are not cut off naturally; surgery cannot prevent recurrence of ectopic disease; surgery may also increase pelvic adhesions (mainly refers to open surgery) and affect pregnancy. 3.Medication Commonly used and effective drugs for the treatment of ectopic disease include Danazol, progesterone, gonadotropin-releasing hormone analogues or agonists, progestin-like drugs and oral contraceptive drugs.