Endometriosis, referred to as endometriosis, is a gynecological disease caused by the growth of the endometrium in any part of the body other than the uterine cavity. For example, it occurs in the ovaries, the uterosacral ligament, the plasma layer of the posterior wall of the lower uterus, the pelvic peritoneum of the rectal sockets of the uterus and the sigmoid colon, and also in the myometrium, so clinically endometriosis is divided into extrinsic endometriosis and intrinsic endometriosis. It has been reported that the infertility rate of endometriosis patients is about 40%. Endometriosis is one of the main causes of infertility. Du Baojun, Infertility Center of Xiyuan Hospital, Chinese Academy of Traditional Chinese Medicine
1. Etiology of endometriosis
The causes of infertility due to endometriosis are mainly summarized as follows.
(1) Mechanical factors
During the development of endometriosis, the fallopian tubes are mostly kept open, and adhesions around the ovaries or fallopian tubes are an important cause of infertility.
(2) Abnormal ascites
Ascites is a plasma filtrate, with a normal pelvic fluid volume of less than 5 ml, which increases to 20 ml instantly after ovulation. The volume of ascites (10-20 ml) and the concentration of various hormones and other substances in ascites affect the processes of ovulation, egg collection and delivery of fertilized eggs.
(3) Abnormal ovarian function
Endometriosis may be associated with a variety of ovarian functional abnormalities, such as abnormal peak luteinizing hormone, abnormal follicular development, anovulation, hyperprolactinemia, luteal insufficiency, and luteinization syndrome of unruptured follicles, all of which are more prevalent than in non-endometriosis populations.
(4) Abnormal immune function
Patients with endometriosis may have abnormal cellular immunity, using ectopic proliferating endometrial cells as antigens and producing autoantibodies against normal endometrium. This local reaction activates macrophages and produces various cytokines leading to infertility.
(5) Impairment of fertilization and miscarriage
Endometriosis can affect early embryonic development, with abnormal luteal function and abnormal intrauterine environment, interfering with early embryonic development and implantation, leading to obstructed implantation and miscarriage. Clinically, the miscarriage rate of patients with endometriosis is higher than that of the general population.
2. Clinical manifestations of endometriosis
(1) Infertility
Endometriosis is often caused by pelvic masses and adhesions, blockage of fallopian tubes, poor follicular development or ovulation disorders caused by the lesions. In addition, some cases of habitual miscarriage are caused by endometriosis.
(2) Dysmenorrhea
The clinical characteristic of endometriosis is progressive dysmenorrhea, which is a common and prominent feature. It is secondary to the onset of endometriosis, which can occur before, during and after menstruation. In some cases, dysmenorrhea is difficult to tolerate and requires bed rest or painkillers. The pain often worsens with the menstrual cycle and disappears at the end of menstruation.
(3) Periodic rectal irritation
Progressively increasing symptoms of cyclic rectal irritation are rare in other gynecological diseases and are the most valuable symptoms for the diagnosis of this disorder. The symptoms include swelling and pain in the rectum, anus and vulva, a feeling of urgency and increased frequency of stools. When the lesion gradually worsens, the symptoms become more and more obvious, while they gradually disappear after menstruation.
(4) Irregular menstruation
Patients with endometriosis often have shortened menstrual cycles, increased menstrual flow or prolonged menstrual periods, indicating that the patient has manifestations of ovarian dysfunction. Irregular menstruation can be used as a diagnostic reference, but has no practical value in differential diagnosis.
(5) Painful intercourse
Painful intercourse can occur when ectopic endometrial nodules, rectal trap nodules or adhesions are present in the vaginal vault, or when ovarian adhesions are present in the pelvic floor. When fibroplasia and contraction of the posterior lobe of the broad ligament are evident, they can compress the ureter and make it narrow and obstructed, and urinary symptoms may also occur.
(6) Periodic bladder irritation symptoms
When endometriosis lesions involve the peritoneal reflex of the bladder or invade the muscular layer of the bladder, symptoms such as menstrual urgency and frequency of urination may occur at the same time. If the lesion invades the bladder mucosa (endometriosis of the bladder) there is periodic hematuria and pain.
(7) Periodic lower abdominal discomfort
This symptom is more frequent than dysmenorrhea and is often present in patients with endometriosis without dysmenorrhea. It occurs in patients with mild disease, or in some lesions that are more severe but do not produce dysmenorrhea but only menstrual back pain and lower abdominal cramping discomfort due to individual differences in pain thresholds or other reasons.