What is endometriosis?
Normally, the endometrium is inside the uterine cavity. If the endometrium is found to be growing and developing somewhere other than the uterus, 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, and because the bleeding in the cysts becomes like chocolate paste over time, some people call them “chocolate cysts”. In reality, it is a completely different thing from eating chocolate. The endometrium can also grow in the muscle of the uterus itself, which used to be called “intrinsic endometriosis” and is now called myometriosis.
The condition has been documented in foreign countries since 1860. However, it was not until after the 1920s that it received widespread attention from gynecologists. Now, ectopic disorders have become a common women’s disease worldwide, with an estimated prevalence of 10-15% in the women’s population.
Where does a misplaced endometrium come from?
Ectopic disease is rather strange in that it is benign, yet has some behaviors similar to malignancy. For example, it can infiltrate and grow into surrounding tissues and organs and interfere with their normal function, and can even run away from the uterus to grow in areas far from the uterus, such as the lungs, limbs, skin and belly button, just like cancer. Why does the endometrium grow and develop outside the uterus? Is it the endometrium in the uterus that moves over, or do the cells in these places change on their own? Over the past 70 years, a lot of research has been done on this and no less than 10 hypotheses have been proposed.
The body’s tissues do not remain unchanged. When subjected to some stimuli, some cells can become another kind of cells, a phenomenon medically known as “chemotaxis”. Mayer, a leading foreign authority on pathology, has long believed that if blood enters the abdominal cavity when a woman has her period, the menstrual blood can stimulate the cells on the surface of the ovaries and turn them into the endometrium, causing ectopic disease. Although there is not enough evidence for this hypothesis, the possibility is certainly there.
Drifting downstream: Like cancer, the endometrium can also drift away from the uterus in blood and lymphatic fluid to sites far from the uterus, such as the lungs, nose, limbs, and belly button, causing ectopic disease in these areas. However, all of these ectopias are rare, so this hypothesis can only account for the development of ectopia in these rare sites.
Menstrual seeding: Normal women have 1 menstrual period per month. Menstruation is actually formed by the necrosis and shedding of the endometrium with bleeding. Dr. Sampson was the first to discover that women with deformities or obstructions of the reproductive organs such that the menstrual blood flow was not smooth during menstruation could get severe ectopic disorders at a younger age. Therefore, he proposed the hypothesis of “endometrial implantation by menstrual blood flowing backwards”. He believed that if menstrual blood flows through the fallopian tubes on both sides of the uterus to the pelvis during menstruation, the endometrium in menstrual blood will be seeded to the ovaries and peritoneum, and ectopic disease will occur. Numerous studies have proven that menstrual blood does contain live endometrial cells. Menstrual blood containing live endometrial cells also does flow through the fallopian tubes to the pelvis, and the endometrial cells in it do survive. If the conditions are right, they settle down and multiply, and gradually develop and grow, resulting in endometriosis. The implantation hypothesis was thought to be the most likely cause of ectopic disease compared to the previously mentioned hypotheses.
However, in recent years, it has been found that menstrual blood flow to the abdominal cavity is common in women during menstruation, reaching about 70% to 90%. Why do only 15% of women get ectopic disorders? It has been speculated that there may be other causes, which are cited as follows.
Ovarian endocrine function: ectopic patients are most commonly seen between the ages of 30 and 40. This is also the period when women’s ovaries are at their peak, and it is rare for young girls who have not yet menstruated to get ectopic disease. In women with ectopic disease at a young age, the ectopic disease will gradually subside after menopause. These indicate that there is a close relationship between the endocrine function of the ovaries and the occurrence of ectopic disorders.
Immune factors: Domestic and international studies have found that patients with ectopic disease often have abnormal immune function and imbalance of immune balance. Therefore, it is conjectured that women with abnormal immune function are more likely to have ectopic disease.
Ovarian ovulation abnormalities: Normal women ovulate once a month. The follicles rupture during ovulation and the eggs enter the abdominal cavity. Follicular fluid containing high concentrations of estrogen prevents the growth and development of endometrial cells that enter the abdominal cavity. It has been found that many ectopic patients lack this process of ovulation and certainly do not have follicular fluid flowing into the abdominal cavity, so it facilitates the growth of the endometrial cells that enter the abdominal cavity. Over time, ectopic disorders may occur.
Genetic factors: Both foreign and our studies have found that the immediate family members of ectopic patients are also prone to ectopic disease. And once they get the disease, it is often more severe. We have reported a family of three sisters who all had ectopic disease. It has also been found that the development of ectopic disease may be associated with genetic variations.
Increased intrauterine pressure: If the intrauterine pressure is high during menstruation, the amount of menstrual blood flowing down the fallopian tubes into the abdominal cavity is bound to increase. This will increase the number of endometrial cells entering the abdominal cavity and naturally increase the chance of ectopic disease. Conditions that can cause intrauterine pressure include cervical stenosis, genital tract abnormalities or obstruction, and strong contractions of the uterus (dysmenorrhea). We have also found that these patients are indeed prone to endometriosis.
In conclusion, the causes of ectopic disorders are more complex, and it is likely that many factors are involved and cannot be explained by a single reason.
Why is ectopic disease becoming more common?
The reasons for the increasing number of women with ectopic disease are also multifaceted. First, awareness of ectopic disorders has increased greatly in recent years. For example, for dysmenorrhea, lower abdominal pain, small pelvic masses and infertility, in the past, doctors often thought of pelvic inflammatory disease, etc., but now, doctors think of ectopic disorders first. With a higher level of alertness, there are more chances to detect ectopic disorders. In addition, gynecological laparoscopy and surgery are now widely carried out in China, which has greatly improved the accuracy of diagnosis of pelvic diseases. After laparoscopic examination, people find that what they originally thought to be pelvic inflammatory disease, small ovarian tumors or unexplained infertility is actually quite a lot of ectopic disease. As to whether ectopic disorders are really more prevalent in the women population, it is less clear. Although it is generally believed that the incidence of ectopic disease is significantly higher, this is all based on statistics from hospital gynecological inpatients and does not represent the actual incidence in the women’s population. Many people in China believe that the increased incidence of ectopic disease is related to the widespread use of abortion, but the data from our epidemiological survey and that of Concordia Hospital do not support this hypothesis.
What are the manifestations of ectopic disorders?
Pain is one of the main symptoms of ectopic disorder. Those with dysmenorrhea account for about 70% of cases. Young women can have dysmenorrhea, which is usually the worst on the first day of menstruation and improves quickly thereafter. The pain gradually decreases with age and usually 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 pain gets worse and worse, and many people go to the doctor for this reason. In addition, if the time of menstrual pain has changed, for example, it was the first two days of menstruation, but now it is painful during the whole menstrual period, and in some cases it starts a few days earlier, and the stomach still hurts after the menstruation is clean, you should think about ectopic disease. “Chocolate cysts are also prone to rupture during and around the menstrual period, causing sudden lower abdominal pain, which is sometimes misdiagnosed as appendicitis and operated on in surgery.
In addition, about 1/3 of patients complain of abdominal pain during sexual intercourse, and some are so severe that they are afraid of 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 ectopic nodules growing in the back of the uterus.
Infertility is another major symptom of ectopic disease. About 1 in 3 – 1 in 2 patients are infertile. About 1/3-1/2 of women who are not pregnant have endometriosis.
Menstrual abnormalities . There may be increased menstrual flow, prolonged periods and premenstrual dripping bleeding associated with ovarian dysfunction or concurrent disease. Ectopic disease of the cervix or vagina may cause abnormal bleeding, even heavy bleeding.
A small number of patients have menstrual fever, mostly in patients with ovarian chocolate cysts and more extensive pelvic adhesions.
The uterus is often posterior on gynecologic examination, and hard nodes with marked 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, this suggests a combined ovarian chocolate cyst.
How do I know I have ectopic disease?
The doctor will make a preliminary diagnosis by taking a medical history and performing a gynecological examination. The following ancillary tests will be performed to further clarify the diagnosis of ectopic disease.
Ultrasonography Irregular nodular reflections are seen in the posterior sunken recess of the uterus, sometimes with a small amount of ascites. A typical ovarian chocolate cyst presents as a posterior or lateral aspect of the uterus with a coarse envelope and a dense, fine, strong dot reflection or irregular reflection within.
Blood CA125 measurement Blood CA125 is mostly negative in mild patients and positive in moderate to severe patients. In patients with diagnosed ectopic disease, regular measurement of blood CA125 can be used for efficacy observation.
Laparoscopy is the best method for the diagnosis of ectopic disease. In combination with biopsy, the diagnostic rate of laparoscopy can reach 100%. Typical peritoneal lesions are cinder-like plaques or small dark red vesicles surrounded by spider-like contracture scars. In recent years, it has been found that ectopic lesions can also present as red flame-like, white blister-like, polyps and peritoneal defects or depressions. Ovarian chocolate cysts (see below) can be diagnosed by aspiration through puncture, with ruptured fluid that is either thin or thick and resembles chocolate (see below). However, lesions in the retroperitoneum, especially around the rectum around the cervix may not be visible laparoscopically (they can be palpated).
Under microscopic observation, ovarian chocolate cysts can be divided into two types. Type I (primary) endometriotic cysts are less common and are 1 to 2 cm in diameter in size, containing dark brown fluid, with ectopic endometrial tissue in the walls of the cyst, and are true endometriotic cysts. Type II (secondary) endometriotic cysts are the most common clinically, with a diameter of 3 cm or more. They are formed by functional ovarian cysts such as luteal cysts or follicular cysts together with endometriotic lesions, and are subdivided into three subtypes, IIA, IIB and IIC, according to the relationship between endometriotic nodules and cysts (see figure).
How is ectopic disease treated?
Treatment is divided into expectant therapy, surgery and medication, depending on the patient’s age, the severity of the condition and whether he/she has fertility requirements. Treatment 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. The treatment of ectopic disease is mainly surgical treatment, with medication as an important adjunctive treatment.
I. Expectant therapy
Patients with no obvious discomfort but 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, pain symptoms will disappear and ectopic lesions will gradually shrink or even disappear. Those who are young, do not have severe pain and have fertility requirements are advised to get pregnant as early as possible. Pregnancy and lactation amenorrhea have an inhibitory effect on endoheterosis and can be seen as a natural treatment for ectopic disease.
II. Surgical treatment
It is still the main treatment method today. It is mainly suitable for people with severe conditions such as large chocolate cysts in the ovaries, severe pelvic adhesions, combined uterine diseases such as uterine fibroids and adenomyosis, or those with severe pain for which 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 pain disappears or is significantly reduced after surgery, and about 50-60% can get pregnant. However, the recurrence rate of pain is high, and the possibility of needing another 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, 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 means removal of both ovaries and often of the uterus. It can cure endometriosis radically. It is suitable for women who are older and do not want to have more children.
Studies at home and abroad have shown that laparoscopic surgery (see later for details) is the best method for treating ectopic disease. In recent years, laparoscopic surgery for endometriosis has been widely performed in Japan and abroad. Almost all laparoscopic surgery that can be done with open surgery can be done. Chocolate cysts, although often with some adhesions, are well suited for laparoscopic surgery to peel (see schematic below) and stop bleeding. Fear of laparoscopic surgery because of chocolate cyst adhesions is usually a sign that the surgeon is not yet skilled and experienced enough to try the surgery in such cases, as it is prone to surgical complications such as bleeding, infection and damage to surrounding organs. Laparoscopic surgery has the advantages of less trauma, faster recovery and less postoperative pelvic adhesions, and the postoperative pain relief rate and pregnancy rate can reach that of open surgery, which is well received by patients.
Of course, there are shortcomings of surgical treatment, such as 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 referring to open surgery), which affects pregnancy.