I. What is endometriosis?
Endometriosis is a disease caused by the endometrium, which normally grows in the uterine cavity, growing in other parts of the uterus outside the cavity. Originally, the endometrium is a layer of epithelium covering the inside of the uterine cavity with a strong regenerative and transformative capacity that undergoes cyclical changes under the regulation of estrogen and progesterone. It is either shed periodically and mixed with menstrual blood and excreted from the body, or it becomes a breeding ground for the development of fertilized eggs. Some of the “rebellious” endometrium escapes from the uterine cavity headquarters and sets up camp in the pelvic peritoneum, ovaries, uterine surface, uterosacral ligament, intestines, bladder, ureter, and even nasal mucosa and respiratory tract, causing pain, masses, abnormal bleeding, infertility, and a series of symptoms in the affected organs, collectively called uterine Endometriosis (referred to as endometriosis).
Clinically, endometriosis is classified into: peritoneal, ovarian and deep nodal according to the location and severity of the lesion.
Is endometriosis a malignant lesion?
Endometriosis is pathologically uncompromisingly benign. However, clinically, it has the behavioral characteristics of malignant tumors such as invasion to surrounding tissues, distant metastasis and easy recurrence after treatment. Therefore, it is called the “benign cancer” of gynecology. This reference may seem contradictory, but it succinctly reflects the complexity of endometriosis and the difficulty of treatment.
What are the clinical manifestations of endoheterosis?
(a) Chronic pelvic pain, 80% of patients have different degrees and types of pelvic pain
(1) Dysmenorrhea: It is a common and prominent symptom. Some patients have primary dysmenorrhea, that is, abdominal pain and abdominal cramps from the beginning of menarche. Most patients have secondary dysmenorrhea, with normal menstruation at menarche and periodic abdominal pain from a certain period, which can occur during, before or after menstruation, requiring bed rest or medication for pain relief in severe cases, affecting the patient’s life, study and work.
(2) painful intercourse: if the endoheterosis lesion occurs in the posterior vaginal fornix and uterosacral ligament area, it will thicken and shorten the sacral ligament, sclerosis, adhesion of the pelvic floor peritoneum to the surrounding tissues or involve the nerves, and pain will be felt during intercourse, affecting sexual life.
(3) Painful stool: Patients often feel painful when passing stool through the rectum during menstruation, which is a typical symptom of utero-rectal fossa, vaginal-rectal compartment and endorectal anomalies. If the lesion invades the rectum, it will cause narrowing of the intestinal lumen and symptoms of urgency, constipation and obstruction, and if the lesion invades the rectal mucosa, there will be blood in the stool during menstruation. Often misdiagnosed as rectal cancer.
(4) Periodic urinary frequency, painful urination, and blood in urine, which are symptoms of endocele of the bladder.
(5) Periodic localized mass enlargement and pain around the incision in the case of endoheterosis at the abdominal wall caesarean incision and perineal incision scar.
(6) Acute abdominal pain: ovarian endometriotic cysts during menstruation or late menstruation often increase in size and are prone to rupture, resulting in sudden onset of severe lower abdominal pain with anal cramping.
(ii) Menstrual disorders: endometriosis is often associated with ovarian dysfunction, resulting in increased menstrual flow and prolonged periods.
(3) Infertility: The causes of infertility due to endometriosis include: adhesions around the fallopian tubes that affect the picking up of oocytes or lead to incompetence of the fallopian tubes; ovarian chocolate-like cysts that affect ovulation; increased inflammatory factors in the pelvis that affect conception.
How do I know if I am suffering from endometriosis and can ultrasound confirm the diagnosis?
If women of childbearing age have the above symptoms, they should go to the hospital promptly for gynecological pelvic examinations, and if necessary, the doctor will recommend the following tests to assist in the diagnosis.
1.B ultrasound: to clarify the presence, source and nature of cysts in the pelvis. Endometriosis often invades or compresses the ureter, leading to hydronephrosis and even loss of kidney function due to atrophy. Ultrasound of ureter of both kidneys should be done if necessary. Rectal ultrasound can clarify the invasion of the rectum. However, ultrasound cannot confirm the diagnosis of endometriosis. Ovarian cysts found for the first time should also exclude the possibility of physiological cysts, which need to be rechecked at an interval of 2-3 months.
2, CA125: not a specific indicator for cancer, but can also be elevated in endometriosis and adenomyosis.
3.Nuclear magnetic: for endoheterosis with extensive and severe lesions, it can help identify malignant tumors, tuberculosis and inflammatory masses.
4. cystoscopy: for those with periodic painful urination, frequent urination and blood in the urine
5, rectal colonoscopy: those with periodic blood in the stool and painful defecation
6.Laparoscopy is the most effective method to diagnose endoheterosis. Not only can the diagnosis be clarified, but also the lesion of endoheterosis can be removed. Of course the most accurate diagnosis depends on the postoperative pathological examination to achieve.
V. How to treat endo if clinically suspected? Can drugs cure endoheterosis?
The cause of endo is unknown, and there is no drug to cure it. Since endo is a hormone-dependent disease, the main objectives of drug treatment are to suppress ovarian function, cause pseudo-pregnancy or pseudo-menopause, reduce the activity of endo lesions as well as reduce the formation of adhesions, relieve pain, suppress residual lesions after surgery, prevent recurrence, and shorten the interval between recurrences. Fertility promotion.
There are four main types of drugs available and the main side effects are as follows.
1. oral contraceptives: continuous or cyclic use for 6 months, with fewer side effects, which may include gastrointestinal symptoms or abnormal liver function.
2.Progestins: mainly breakthrough bleeding, breast distension, weight gain, gastrointestinal symptoms and abnormal liver function
3, progesterone: mainly androgen-like effects, such as increased hair, thickening of voice, facial acne, weight gain, and abnormal liver function
4, GnRHa: young patients who need to have children prefer this drug for 3-6 months, the side effects are mainly due to hypoestrogenemia causing hot flashes, vaginal dryness, decreased libido, insomnia and depression, etc. Long-term application can cause osteoporosis.
5.Chinese medicine has a long history and Chinese medicine has its unique efficacy in relieving the symptoms of endometriosis.
6.What cases need surgery?
For those who have no pelvic tenderness nodules or adnexal masses and only mild dysmenorrhea, pain medication, oral contraceptives and progesterone treatment can be chosen and followed up regularly. Laparoscopic surgery if it is ineffective.
Surgery is preferred for patients with pelvic tenderness nodules, adnexal masses and infertility to clarify the diagnosis. Experimental drug treatment is not advocated. Postoperative pharmacologic adjuvant therapy and adjuvant fertility treatment.
For patients with extensive and severe lesions that make surgery difficult, they can also be treated with GNRH-a for 3 months before surgery to shrink the lesions, reduce intraoperative bleeding, and decrease the difficulty of surgery.
Objectives of treatment: reduction and elimination of lesions, relief of pain and other symptoms, improvement and promotion of fertility, reduction and avoidance of recurrence.
VII. What are the methods of surgical treatment?
(1) For young patients who require fertility. Because coarctation of the ovary has a considerable chance of combining with other types of ovarian tumors and a 1% chance of malignancy, and it responds poorly to drug treatment, it should be diagnosed and treated early. The pelvic adhesions can be separated under laparoscopy to restore the normal anatomical structure, remove the lesions visible to the naked eye as much as possible, relieve pain, increase the pregnancy rate and improve the quality of life.
For patients with unexplained infertility, after comprehensive examination and exclusion of other infertility factors, early laparoscopic examination should be performed for the presence of endometriosis. Because there are few positive signs of endo in the early stage, laparoscopy can make a clear diagnosis. Surgery can significantly improve the pregnancy rate. In patients with mild endoheterosis, natural conception can be expected for six months after surgery, and assisted reproductive technology should be actively used to assist pregnancy in moderate to severe cases.
(2) For those who have no fertility requirements but wish to preserve ovarian function The uterus and the lesions of endometriosis can be removed. The intrauterine device, Mannedal, i.e., it can prevent contraception and the recurrence of endometriosis, and is a new option for younger patients who have completed fertility.
(3) For those who are older, have no fertility requirements, have heavy symptoms or multiple treatments are ineffective. Total hysterectomy/biaxial resection for radical treatment is recommended.
(4) Complete surgical excision and pathological examination of lesions in the abdominal wall cesarean incision and perineal incision as far as possible.
What preparations are needed before surgery?
Complete all routine laboratory tests in the outpatient clinic
After admission, patients and their families sign an informed consent form to fully understand the risks of surgery (severe pelvic and abdominal adhesions in endometriosis, surgery may easily damage the surrounding organs)
For lesions involving the rectum, intestinal preparation is required, including semi-liquid diet two days before surgery, liquid diet one day before surgery, clean bowel washings, oral antibiotics, and indwelling gastric tube on the day of surgery.
If the lesion involves the urinary system, a ureteral stent should be placed.
If hysterectomy is required, vaginal douching should be performed for two days before surgery.
What about recurrence after treatment of endometriosis?
The recurrence rate of endometriosis is 30-40% 5 years after surgery, and 12% of them need to be operated again. Treatment is more difficult after recurrence. Surgery and postoperative medication are still available for ovarian endometriosis cysts, but there is a possibility of premature ovarian failure. Ovarian cysts of small size can be assisted with ultrasound-guided puncture, but they are prone to recurrence.
X. Can endometriosis become malignant?
The incidence of malignancy in endometriosis is about l%. Patients should have regular checkups and be alerted to malignant changes if cysts are found to increase significantly within a short period of time; if ovarian cysts increase after menopause; if imaging suggests the possibility of malignancy; and if serum CA125 is significantly elevated.
XI. What is meant by adenomyosis?
Adenomyosis refers to the growth of endometrium in the uterine cavity into the myometrium, causing periodic bleeding within the myometrium. The ectopic endometrial tissue stimulates the proliferation of myometrial fibers to form a poorly defined, diffuse lesion, which is called adenomyoma if it forms locally as a tumor. Common clinical manifestations include secondary, progressively worsening dysmenorrhea, which in severe cases causes non-menstrual pelvic pain, lower limb pain, and low back pain. Excessive menstruation often leads to anemia, infertility, miscarriage, and uterine enlargement. The pathogenesis of endometriosis and adenomyosis are extremely similar and often occur simultaneously.
Twelve, how to treat adenomyosis?
(1) Expectant treatment: those without symptoms and without fertility requirements can be observed regularly.
(2) surgical treatment: for those without fertility requirements in the perimenopause, total hysterectomy is the main treatment to eradicate this disease.
(3) Adjuvant fertility treatment: for infertile patients, GnRH-a treatment can be used to assist pregnancy; for patients with adenomyoma of the uterus, adenomyoma can be surgically removed first, and postoperative GnRH-a treatment can then be used to assist pregnancy.
(4) Medication: same as for endometriosis.
(5) Intrauterine device – Manuelle: suitable for patients with no fertility requirements, small uterine size and excessive menstruation, not only for contraception, but also for controlling the symptoms of adenomyosis. Manuelle is valid for 5 years.
(6) Interventional treatment: mainly for reducing the blood supply to the uterus, reducing the volume of the uterus and relieving pain.
XIII. How is endometriosis caused?
Endometriosis is a disease of unclear etiology, which may be 。。。。。。
It is currently believed that menstrual blood reflux is the main cause. The endometrium is like a seed that is sent into the pelvis with the menstrual blood through the fallopian tubes. Under normal circumstances, the menstrual blood that flows backwards into the pelvis is destroyed and cleared by the pelvic immune cells. However, in a few cases pelvic immune cells are unable to recognize or attack the refluxed endometrial cells, and over time a nuisance lesion is formed. However, this doctrine is difficult to explain all types of endoheteropathy. It may also be associated with hematologic or lymphatic metastases, immunodeficiency, and endocrine disorders. Endoheterozygosity tends to have familial aggregation and is likely a polygenic genetic disorder. Early menarche, short cycles, heavy periods, and strenuous activity during menstruation are also risk factors for morbidity. Primary dysmenorrhea may increase the risk of later onset, so young women are advised not to take dysmenorrhea lightly.
XIV. How to prevent endometriosis?
1, pay attention to adjust their emotions, maintain an optimistic and cheerful state of mind, pay attention to their own warmth, avoid catching cold, so that the function of the body’s immune system and endocrine system remains normal.
2.Prohibit strenuous sports and heavy physical labor during menstruation. Avoid overexertion. If ovarian cysts have been detected, the tension in the cystic cavity will rise during menstruation leading to rupture of the cystic wall resulting in acute abdominal disease.
3. Do family planning and try to avoid abortion and scraping to reduce the chance of menstrual blood reflux.
4.Be sure to abstain from sexual intercourse during menstruation. Avoid unnecessary vaginal examinations.
5. congenital or acquired diseases such as hymenal atresia, vaginal atresia, cervical stenosis, uterine malformation (especially stumpy uterus), extreme retroflexion of the uterus, etc., can cause poor drainage or retention of menstrual blood, resulting in the development of endometriosis due to retrograde flow of menstrual blood into the pelvis. Therefore, these diseases should be diagnosed and treated as early as possible.
6. Surgery of the reproductive tract such as tubal lavage, hysterosalpingography, cervical surgery and other operations should be chosen within 3-7 days after menstruation to avoid causing endometrial implantation.