I. General rules of treatment
1.Objectives of treatment: to reduce and eliminate lesions, to reduce and eliminate pain, to improve and promote fertility, and to reduce and avoid recurrence.
2. Basic considerations for treatment: The treatment plan is based on the following factors.
(1) age.
(2) Fertility requirements.
(3) severity of symptoms.
(4) history of previous treatment.
(5) extent of the lesion.
(6) Patient’s wishes. Treatment measures should be individualized. The treatment of pelvic pain, infertility and pelvic masses should be treated separately.
3. Treatment methods: can be divided into surgical treatment, drug treatment, interventional treatment, herbal treatment and adjuvant treatment (such as assisted reproductive technology treatment), etc.
II. Surgical treatment
(A) The purpose of surgical treatment
The purpose of surgical treatment is to remove the lesion and restore the anatomy.
(2) Types of surgery and selection principles
1.Conservative surgery: that is, lesion excision. To preserve the patient’s reproductive function, surgery is performed to remove as many foci as possible that are visible to the naked eye, to remove ovarian endometriosis cysts and to separate adhesions. It is suitable for younger patients or those who need to preserve their reproductive function. Laparoscopy is preferred for conservative surgery.
2. Hysterectomy and bilateral adnexal resection: removal of the whole uterus, bilateral adnexa and all lesions visible to the naked eye. It is suitable for those who are older, have no fertility requirements, have heavy symptoms or have recurrence and have failed conservative surgery or drug treatment.
3.Hysterectomy: Removal of the whole uterus and preservation of the ovaries. It is mainly suitable for those who do not have fertility requirements, have severe symptoms or recurrence and have been treated with conservative surgery or medication, but are younger and wish to preserve the endocrine function of the ovaries.
4. Nerve block surgery: such as uterosacral ligamentotomy (LUNA), anterior sacral neurectomy (PSN). Due to the less than ideal therapeutic effect of surgery and the risk of surgery, it is no longer the main procedure for the treatment of pain associated with endometriosis.
(C) Pre-surgical preparation
1.Adequate preoperative preparation and evaluation.
2. Adequate understanding, cognition and informed consent of the risks of surgery, the possibility of surgical injury especially to the urinary system as well as to the intestinal tract.
3.For patients with DIE, adequate bowel preparation should be done.
4. In patients with vaginal rectal septal endometriosis, preoperative imaging should be performed, and if necessary, colonoscopy and biopsy should be performed to exclude lesions of the intestine itself. For those with obvious deep infiltrative lesions in the parametrium, the ureter and kidney should be routinely examined for fluid retention before surgery. If there is ureteropelvic fluid, the site and degree of fluid retention and renal function should be clarified.
5. Assistance from urology and general surgery if necessary.
(D) Key points of surgical implementation
1, fully expose the surgical field. If there are pelvic adhesions, pelvic adhesions should be separated first to restore anatomy.
2. Try to remove or destroy the lesion for the purpose of reduction of peritoneal type endoheterosis. Cautery, vaporization or excision may be performed. Cyst excision is preferred for ovarian endometriosis cysts. During surgery, the adhesions to the surrounding area should be separated, the chocolate like fluid in the cyst should be aspirated, and the cyst wall should be flushed out and then peeled away. The trauma is hemostatic with low-power electrocoagulation or sutures. The anatomical level of the tissues should be taken care of during surgery to protect the normal ovarian tissues as much as possible.
3., DIE management is more difficult. If the lesion does not invade the rectal or colon wall, try to remove the lesion; if there is intestinal wall infiltration but no intestinal stricture, it is generally not advocated to remove the intestinal wall or intestinal segment, and lesion reduction is appropriate. If the lesion is large and causes intestinal stenosis or even intestinal obstruction or periodic blood in the stool, resection of the intestinal wall plus suture of the intestinal wall or resection of the intestinal segment plus anastomosis will be performed as appropriate.
4.If ureteral obstruction is caused by ureteral endometriosis, adhesiolysis or partial ureteral resection and anastomosis can be performed according to the lesion and the degree of ureteral obstruction. A double J tube should be placed in the ureter before surgery as an indication.
5. Endo-ureteral disease of the bladder should be performed mainly by resection of the lesion.
6.In case of combined infertility, hysteroscopy and tubal lavage can be performed at the same time.
7. Repeatedly flush the pelvic and abdominal cavity after the surgery. Apply anti-adhesion preparations to the surgical wound to prevent adhesions.
Drug treatment
(I) Objectives of treatment
To inhibit ovarian function, stop the development of endometriosis, reduce the activity of endometriosis lesions and reduce the formation of adhesions.
(B) Selection principles
1. It should be used in cases with basic diagnosis, and long-term “experimental treatment” is not recommended.
2. There is no standardized program.
3.The efficacy of various programs is basically the same, but the side effects are different, so the side effects of drugs, the patient’s wishes and economic ability should be considered when selecting drugs.
(iii) Available drugs
They are mainly divided into five categories: non-steroidal anti-inflammatory drugs (NSAID), oral contraceptives, highly effective progestins, androgen derivatives and gonadotropin-releasing hormone agonists (GnRH-a).
(iv) Commonly used drug treatment options, mechanism of action and side effects
1.NSAID.
Usage: Apply as needed, at intervals of not less than 6 h.
Mechanism of action.
(1) inhibit the synthesis of prostaglandins.
(2) Inhibition of lymphocyte activity and differentiation of activated T-lymphocytes, reducing stimulation of afferent nerve endings.
(3) Direct action on injurious receptors, preventing the formation and release of pain-causing substances.
Side effects: mainly gastrointestinal reactions, occasionally abnormal liver and kidney functions. Long-term application should be alert to the possibility of gastric ulcer.
2.Oral contraceptives.
Usage: continuous or cyclic medication, lasting 6 months and more, can be used for a longer period of time.
Mechanism of action: inhibition of ovulation.
Side effects: Less frequent, with occasional gastrointestinal symptoms or abnormal liver function. patients over 40 years of age or with high-risk factors (such as diabetes, hypertension, history of blood clots and smoking), be alert to the risk of blood clots.
3. Highly effective progestin.
Usage: Continuous use for 6 months.
Mechanism of action: Synthetic high-efficiency progestin can cause endometrial metaplasia-like changes, eventually leading to endometrial atrophy, and at the same time, can negatively feedback inhibit hypothalamic-pituitary-ovarian axis.
Side effects: mainly breakthrough bleeding, breast swelling and pain, increased body mass, gastrointestinal symptoms and abnormal liver function.
4. Pregnant Trienone.
Dosage: 2.5 mg, 2 to 3 times/week for 6 months.
Mechanism of action: Pregnatrienone is an androgen derivative, a synthetic 19-nortestosterone derivative, and an anti-progestational steroid hormone. The main mechanism of action is to reduce ER and PR levels, lower blood estrogen levels, and lower sex hormone-binding globulin levels.
Side effects: androgen-like effects such as increased hair, mood changes, and coarsening of the voice. In addition, it may also affect lipoprotein metabolism, and there may be liver function damage and increased body mass.
5. GnRH-a.
Usage: Depending on the different preparations there are subcutaneous injection or intramuscular injection, once every 28 days for a total of 3 to 6 months or longer.
Mechanism of action: Down-regulation of pituitary function, resulting in temporary drug depot and low estrogenic state in the body. It can also bind to GnRH-a receptors in the periphery to inhibit the activity of in situ and ectopic endothelial cells.
Side effects: Mainly perimenopausal symptoms caused by hypoestrogenemia, such as hot flashes, vaginal dryness, decreased libido, insomnia and depression. Long-term application is associated with the possibility of bone loss.
6. GnRH-a+ reverse addition regimen.
Theoretical basis: “Estrogen window dose theory” says that different tissues have different sensitivity to estrogen, and that maintaining the level of estrogen in the body in a range that does not stimulate ectopic endothelial growth and does not cause perimenopausal symptoms and bone loss [estradiol levels between 146 and 183 pmol/L (i.e., 40-50 pg/ml)] will both stimulate ectopic endothelial growth and cause bone loss. ml)], the therapeutic effect is not compromised and side effects are reduced.
Reverse add-back regimen.
(1) Estrogen and progestin regimen: Estrogen and progestin are administered in a continuous combination. Estradiol valerate 0.5-1.5 mg/d, or combined estradiol 0.3-0.45 mg/d, or estradiol patch releasing 25-50 μg daily, or estradiol gel 1.25 g/d applied transdermally; progestins are mostly used in the form of dydrogesterone 5 mg/d or medroxyprogesterone acetate 2-4 mg/d. Compounded estradiol drospirenone tablets, one tablet daily, may also be used.
(2) Progestin regimen alone: 1.25 to 2.5 mg of norethindrone acetate daily.
(3) Continuous application of tibolone, 1.25 to 2.5 mg/d recommended.
Considerations for reverse addition.
(1) There is no definite conclusion on when to start reverse addition.
(2) Application of reverse addition may prolong the duration of GnRH-a use. The therapeutic dose should be individualized and estrogen levels should be monitored if available.
(7) Combined regulation: short-term application of GnRH-a within 3 months, only for the need to relieve symptoms, can also be used botanicals, such as black asclepias isopropyl alcohol extract, asclepias ethanol extract, twice a day, each time 1 tablet.
(E) promising drugs
These include aromatase inhibitors, gonadotropin-releasing hormone antagonists and selective PR modulators (SPRM), which are new drugs for the treatment of dysmenorrhea that deserve further research.
D. Treatment of dysmenorrhea
1. Treatment principles.
(1) For those with combined infertility or adnexal masses, surgery is preferred.
(2) For those who do not have combined infertility and adnexal masses, drug treatment is preferred.
(3) Surgery can be considered if drug treatment is ineffective. The consultation and treatment process of pain related to endometriosis is shown in Figure 1.
2. Empirical drug treatment: For patients with dysmenorrhea without obvious pelvic masses and infertility, empirical drug treatment can be chosen. First-line drugs include NSAID, oral contraceptives and highly effective progestins (such as medroxyprogesterone acetate). Second-line drugs include GnRH-a, levonorgestrel intrauterine delayed release system (LNG-IUS). First-line drug therapy is not effective change to second-line drugs, if still not effective, surgical treatment should be considered.
Some medications are associated with a high recurrence rate of pain after discontinuation of medication. Dysmenorrhea can also be considered herbal treatment.
3. Surgical treatment.
Indications.
(1) Ovarian endometriotic cysts ≥ 4 cm in diameter.
(2) Combined infertility.
(3) Dysmenorrhea is not treated with medication. Laparoscopy is preferred for surgery. Careful preoperative evaluation and preparation, good surgical equipment, reasonable surgical approach, skilled surgical technique, and an appropriate postoperative management plan should be available. Surgical excision of endo-herpetic lesions, especially DIE, can be effective in relieving symptoms. The recurrence rate of symptoms after surgery is high, with an annual recurrence rate of up to 10%. Therefore, adjuvant medication and long-term management should be provided after surgery.
Preoperative medication: not recommended. However, for those with more severe lesions and estimated surgical difficulties, preoperative brief application of GnRH-a
for 3 months, which can reduce pelvic congestion and decrease the size of lesions, thus reducing the difficulty of surgery to some extent and improving the safety of surgery.
In patients with ovarian endometriotic cysts, cyst excision should be preferred. Current evidence from evidence-based medicine shows that cyst excision has a lower recurrence rate and a higher pregnancy rate than cyst puncture and intracapsular wall electrocoagulation.
For DIE, pain recurrence rates are high in those with incomplete lesion excision, but complete excision of the lesion may increase the risks of surgery such as bowel and ureteral injury. Surgical procedures for DIE invading to the colorectum include lesion excision, dissection and intestinal segment excision with anastomosis.
4. Postoperative drug therapy: First-line or second-line drug therapy can be chosen according to the condition. Postoperative medication and long-term management can effectively reduce the recurrence of ovarian endometriosis cysts and pain. It is worth noting that medication is only effective during the treatment period and symptoms will reappear soon after discontinuation of medication.
V. Treatment of infertility
1. Treatment principles.
(1) For patients with endometriosis combined with infertility, a comprehensive infertility examination should first be performed according to the infertility treatment pathway to exclude other infertility factors.
(2) Simple drug treatment is not effective for natural pregnancy.
(3) Laparoscopy is the preferred surgical treatment modality. Surgery requires assessment of the type, stage and EFI score of endometriosis, which allows assessment of the severity of the endometriosis lesion and evaluation of the prognosis of infertility, and patients are given fertility guidance based on the EFI score.
(4) Young patients with mild to moderate endoheterosis and high EFI score can expect a natural pregnancy for 6 months after surgery and be given fertility guidance; those with low EFI score and high-risk factors (age over 35 years, infertility for more than 3 years, especially primary infertility; severe endoheterosis, pelvic adhesions, incomplete excision of lesions; incompetent fallopian tubes) should actively undergo assisted reproductive technology for pregnancy. GnRH-a should be used as pretreatment before assisted conception, usually for 3-6 months.
GnRH-a should be used for 3-6 months.
(5) In cases of recurrent endometriosis or decreased ovarian reserve function, assisted reproductive technology is recommended as the first choice. The diagnosis and treatment of endometriosis combined with infertility.
2. Impact of treatment on pregnancy and factors to be considered.
(1) Current studies show that surgery increases the postoperative pregnancy rate for ASRM stages I-II; there is no evidence-based medical evidence on the effect of surgery on postoperative fertility in patients with endometriosis III-IV.
(2) Ovarian endometriosis cyst removal surgery inevitably results in loss of ovarian tissue, destruction of ovarian function by endometriosis itself and inflammatory response to ovarian trauma after surgery, all of which can cause a decrease in postoperative ovarian reserve function. Therefore, before laparoscopic surgery in infertile patients, the impact of surgery on ovarian reserve function should be thoroughly evaluated and considered. For recurrent cysts, repeated surgery is not recommended; studies have shown that the pregnancy rate after reoperation is only 1/2 of the initial treatment, so cystocentesis and assisted reproductive technology treatment are recommended as the first choice. If the pain symptoms are severe, the cyst is gradually increasing in size, puncture is ineffective or impossible, or assisted reproductive technology treatment has repeatedly failed, surgery should be performed, but surgery does not significantly improve the postoperative pregnancy rate.
(3) DIE surgery has no significant effect on pregnancy rate, so in vitro fertilization-embryo transfer (IVF-ET) is preferred for patients with DIE combined with infertility who have insignificant pain symptoms, and surgery is used as second-line treatment for IVF-ET failure.
(4) Intraoperative tubal lavage can be performed at the same time to understand the patency of the fallopian tubes; hysteroscopy can also be performed at the same time to understand the condition of the uterine cavity.
(5) Adenomyosis is an independent factor affecting postoperative pregnancy. For diffuse adenomyosis, drug therapy should be preferred to reduce the size of the uterus for natural pregnancy or assisted reproductive technology; if drug therapy is ineffective, wedge hysterectomy is feasible. For limited adenomyoma, surgical excision is feasible. Wedge resection for adenomyosis and adenomyomectomy cannot completely cut out the lesion, and the recurrence rate is high after surgery, and there is a risk of uterine rupture in pregnancy after surgery.
3.Assisted reproductive technology treatment: including super ovulation (COH)-intrauterine insemination (IUI) and IVF-ET, which are chosen according to the patient’s specific situation.
(1) COH-IUI: Indications: mild or moderate endometriosis; mild male factor infertility (mild oligozoospermia, etc.); cervical factor and unexplained infertility with patent fallopian tubes. The single-cycle pregnancy rate is about 15%; if 3 to 4 cycles are unsuccessful, the treatment modality of assisted reproductive technology should be adjusted.
(2) IVF-ET: IVF-ET is preferred for patients with severe endometriosis, advanced infertility and tubal incompetence. IVF-ET should be considered for those who have failed other methods (including natural pregnancy, ovulation induction, artificial insemination, after surgical treatment.) GnRH-a should be pretreated for 3-6 months before IVF-ET to help improve the pregnancy success rate (pregnancy rate can be increased by 4 times). The duration of drug use is adjusted according to the severity of the patient’s endometriosis and ovarian reserve function.
VI. Treatment of DIE
1. Main features.
(1) Typical clinical symptoms such as dysmenorrhea, painful intercourse, painful defecation and CPP; invasion of colon, rectum, ureter and bladder, causing gastrointestinal and urinary system related symptoms.
(2) Signs: posterior vaginal vault or posterior uterine tenderness nodules.
(3) Lesion distribution: most DIE lesions are located in the posterior pelvis, involving the uterosacral ligament, the utero-rectal sulcus and the vaginal rectal septum.
2, diagnosis: according to the clinical symptoms and signs of DIE can make a preliminary diagnosis, histopathological findings are the basis for confirming the diagnosis. mri examination has a high diagnostic value for DIE, transrectal ultrasonography has a high sensitivity and specificity for the diagnosis of rectal DIE.
3.Treatment.
Indications for DIE surgery.
(1) painful symptoms and ineffective drug treatment.
(2) Combined ovarian endometriosis cysts and/or infertility.
(3) Invasion of the intestine, ureter and other organs causing obstruction or dysfunction. For young patients who need to preserve their reproductive function, conservative focal resection with preservation of the uterus and bilateral adnexa is the mainstay. For patients who are older, have no reproductive requirements, or have severe disease especially recurrence, hysterectomy or hysterectomy and bilateral adnexa can be performed.
4. Key points of DIE surgery.
(1) For suspected intestinal DIE, preoperative sigmoidoscopy or proctoscopy can be performed, the main purpose of which is to exclude the possibility of intestinal tumors. For patients with suggestive pelvic adhesions, ultrasonography of both kidneys should be performed to exclude pelvic ureteral effusion and intravenous pyelogram (IVP) if necessary.
(2) Adequate exposure of the surgical field. If pelvic adhesions and ovarian cysts are present, the pelvic adhesions should be separated first and the cysts should be removed to restore anatomy.
(3) The surgery should try to cut the lesion. The current surgeries for intestinal DIE mainly include intestinal wall lesion chipping, saucer resection and intestinal segment resection with anastomosis. Without intestinal stenosis, surgery is appropriate to reduce the lesion and try to ensure the integrity and function of the intestinal wall. The best surgical option for intestinal DIE is still controversial. The surgical decision is made by weighing surgical safety against surgical outcome.
5. Special types of DIE.
(1) Ureteral DIE: Less common, referring to ureteral dilatation or hydronephrosis associated with endoleptic disease. Clinical features.
(i) insidious onset and non-specific clinical manifestations.
(2) Symptoms do not parallel the degree of lesion, and early diagnosis is difficult.
Diagnosis.
①Diagnosis is based on the history of endoleptic disease and imaging examinations, and excluding other causes of ureteral obstruction.
② Imaging examinations are mainly used to evaluate the degree of ureteropelvic effusion and the site of stenosis. Urological ultrasonography is the preferred tool for imaging diagnosis. IVP, CT, CT reconstruction of the urinary system (CTU), MRI, and MRI angiography of the urinary system (MRU) can provide clearer imaging images and more definite sites of obstruction.
(iii) Preoperative renal hemogram can evaluate renal function on both sides separately.
Treatment.
①The treatment of ureteral endothelia is based on surgical resection, and preoperative and postoperative medication can be used as an adjunct.
②Surgery is mainly aimed at removing lesions, restoring anatomy, preserving and improving renal function as much as possible, and removing lesions of endoheterosis in other parts of the pelvis as much as possible to reduce recurrence.
(③) Drug therapy after conservative surgery can effectively reduce recurrence.
(2) Bladder DIE: It refers to ectopic endometriosis involving the bladder forced urinary muscle, which is less common. It is mostly located in the posterior wall and top of the bladder.
(1) Typical clinical symptoms are bladder irritation, hematuria is rare, and may be combined with painful symptoms of different degrees.
②The diagnosis relies on ultrasound, MRI and cystoscopy. Preoperative cystoscopy is mainly to exclude bladder tumors and to determine the relationship between the lesion and the ureteral opening.
(③Treatment is based on surgical resection. Focal resection is the current DIE of the bladder
The treatment of choice is focal resection. The key to surgery is to cut the lesion as much as possible, and the difficulty of surgery is closely related to the size and location of the lesion, especially the relationship with the ureteral opening. Special attention should be paid to the relationship between the lesion and the ureteral opening during surgery.
④ Postoperative ureteral patency is the key to ensure healing of the bladder incision. It is advocated to use a thicker ureter, keep it continuously open and leave it in place for 10-14 d after surgery. if other pelvic endoheteropathies are combined, postoperative drug treatment is recommended.
VII. Recurrence and uncontrolled endoheterosis
It refers to the reappearance of clinical symptoms after the symptoms of endometriosis have been relieved by surgery and/or medication, and they return to the pre-treatment level or worsen or reappear as endometriotic cysts.
1.Treatment principle: basically follow the principle of primary treatment, but should be individualized.
2.Treatment of endometriotic cysts: those who are young and need to preserve reproductive function can undergo surgery or ultrasound-guided puncture, postoperative medication or assisted reproductive technology. For those who are older or whose imaging suggests a solid part in the cyst or significant blood flow, surgery is appropriate.
3.Treatment of dysmenorrhea: if the dysmenorrhea recurs after surgical treatment, it can be treated with medication first, and still ineffective, surgery should be considered. In case of older age, no fertility requirement and heavy symptoms, hysterectomy or hysterectomy and bilateral adnexal resection can be considered.
4. Treatment of combined infertility: If combined with endometriosis cysts, ultrasound-guided puncture is preferred and IVF-ET is performed after 3-6 months of GnRH-a. Repeated surgery may further reduce ovarian reserve function and risk of premature ovarian failure. The pregnancy rate of IVF-ET in recurrent patients is 2
(40%, 20%, respectively). For those without combined endometriosis cysts, IVF-ET should be performed after 3-6 months of GnRH-a administration.
VIII. Endometriosis malignancy
The rate of endometriosis malignancy is about 1%, and the main malignant site is in the ovary, mostly called endometriosis-associated ovarian malignancy (EAOC), while other sites such as vaginal-rectal compartment, abdominal wall or perineal incision endometriosis malignancy is less common. The current study suggests that endometriosis increases the risk of ovarian epithelial carcinoma (ovarian cancer) such as ovarian endometrioid carcinoma and clear cell carcinoma, but not high-grade plasmacytoma and mucinous carcinoma of the ovary.
1. Diagnosis: Sampson proposed the diagnostic criteria in 1925.
(1) The coexistence of cancerous tissue and endometriosis tissue in the same lesion.
（In 1953, Scott added a fourth diagnostic criterion: morphologic evidence of endometriosis to malignant metastasis, or benign endometriosis tissue , or benign endoheterogeneous tissue joined with malignant tumor tissue.
Atypical endografts: are histopathologically diagnosed and may be precancerous. Atypical endoheterosis refers to atypical or nuclear heterogeneous changes in the ectopic endothelial glandular epithelium that do not breach the basement membrane. Diagnostic criteria: darkly stained or pale, pale nuclei of ectopic endothelial glandular epithelial cells with moderate to severe heterogeneity; increased nuclear/mass ratio; dense, compound or clustered cell protrusions.
The following clinical conditions should alert for endohetero-malignant changes.
(1) Postmenopausal patients with endometriosis and altered pain rhythm.
(2) Oversized ovarian cysts >10 cm in diameter.
(3) Imaging findings of solid or papillary structures within the ovarian cyst, with rich blood flow and low resistance to the lesion on ultrasound.
(4) Excessive serum CA125 level >200 kU/L (excluding infection or adenomyosis).
2. Treatment: EAOC treatment should follow the principles of ovarian cancer treatment. Because of the younger age of onset and earlier stage of EAOC, the prognosis is better than non-EAOC.
3. Prevention: Early diagnosis and treatment of EAOC is the best strategy to prevent malignancy.
Juvenile endometriosis
Juvenile endometriosis is also a progressive disease that affects the quality of life of adolescent patients and their fertility in the future. Patients with adolescent endometriosis should be alert for combined obstructive genital malformations such as vaginal atresia or vaginal oblique syndrome.
Clinical features: dysmenorrhea or periodic abdominal pain, may be accompanied by gastrointestinal or bladder symptoms, may present with ovarian endometriosis cysts, but DIE is rare.
2. Treatment: Adolescent endometriosis is mainly pain and ovarian cysts, and the treatment goals are mainly to control pain, preserve its reproductive function and delay recurrence. Pain control is based on pharmacotherapy, and the process of treatment is the same as that for patients with endometriosis of reproductive age; the preferred surgical treatment for ovarian endometriosis cysts is laparoscopy, but attention should be paid to mastering the indications for surgery, and postoperative adjunctive pharmacotherapy is needed to reduce recurrence and protect reproductive function, and psychotherapy and health education are provided according to the characteristics of adolescents.
In patients with obstructive genital tract anomalies, the obstruction should be released in a timely manner.
Oral contraceptives are the first-line treatment medication for adolescent patients with endometriosis, and they are also safe and effective for patients with endometriosis aged <16 years.
Progestin therapy is effective, but irreversible bone loss may occur with long-term use. Therefore, single progestin analogs should be used with caution in adolescents with endostosis.
GnRH-a + reverse addition therapy: GnRH-a is currently recognized as the most effective drug for the treatment of adult endometriosis and is also used in the treatment of adolescent endometriosis. However, because it can cause bone loss, the application of this drug has certain effects on bone deposition in adolescent patients who have not yet reached peak bone density. Therefore, it is recommended that continuous or cyclic oral contraceptives be chosen as the first-line regimen of pharmacological treatment for adolescent patients with endostosis aged ≤16 years, and GnRH-a can be considered for patients >16 years.
X. Hormone supplementation in patients with endometriosis
Postmenopausal or post-hysterectomy hysterectomy and bilateral adnexal resection in patients with endometriosis can be treated with hormone supplementation to improve the quality of life. Hormone supplementation therapy is individualized according to the patient’s symptoms.
Even if the uterus has been removed, if there are residual endometriosis lesions, estrogen supplementation along with progestin is recommended. In the absence of residual lesions, only estrogen supplementation may be used.
When available, the blood estradiol level should be tested so that the estrogen level conforms to the principle of “two highs and one low”, i.e., “high enough not to cause symptoms, high enough not to cause bone loss, and low enough not to cause recurrence of endometriosis”.
XI. External pelvic endografts
(A) scar endoheterosis
Endoheterosis occurring at the scar of abdominal wall incision and perineal incision is called scar endoheterosis, which is a special type of endoheterosis.
1. Main clinical manifestations: painful nodules at the abdominal wall incision or perineal incision scar, enlarged periodic masses and increased pain associated with menstruation. Perineal scar endometriosis is often accompanied by anal cramps, perianal discomfort during defecation or painful intercourse.
2.Diagnosis: Clinical diagnosis is mainly based on.
(1) History of surgery, etc.: history of cesarean section, lateral perineal incision or tear.
(2) scar site nodules, painful symptoms associated with menstrual cycle.
(3) Ancillary diagnostic methods include ultrasound, MRI, CT examination, etc. Histopathological results are required for confirmation of diagnosis.
3.Treatment.
(1) Surgery is the main treatment method. Preoperative medication can be used for a short period of time in severe cases.
(2) Complete excision of the lesion: the lesion should be completely excised including the old scar around the lesion.
(3) Correct tissue repair: align the anatomical level and repair the tissue structure for obvious defects (abdominal wall patch, anal sphincter repair).
(4) Proper postoperative management: infection prevention and wound management. Dietary management and bowel management are also required after perineal scar endoanalization.
(2) Other rare extra-pelvic and abdominal endoheteropathies
Endo-heterotaxy can invade various parts of the body such as the pleura, lung, groin, umbilicus, diaphragm, sciatic nerve, external ear, and scalp.
The clinical manifestations of extra-pelvic and abdominal endografts are often accompanied by periodic changes in the associated site symptoms. For example, pulmonary endografts may present as menstrual hemoptysis; pleural endografts may present as pneumothorax during menstruation; inguinal endografts present as inguinal masses that occur in the extraperitoneal portion of the round ligament that cannot be returned, and are easily misdiagnosed as inguinal hernias or round ligament cysts. Imaging examinations such as ultrasound, CT or MRI examinations of the site of occurrence are of some significance for diagnosis and evaluation.
Treatment: Depending on the clinical presentation, surgical treatment or pharmacological treatment may be used. Pneumothorax and hemoptysis caused by pleural endomorphism and pulmonary endomorphism often occur during menstruation, and pneumothorax and lung shadows may be present on lung X-ray or CT examination, which usually disappear after menstruation; diagnosis should exclude other diseases of the lung, especially tumors and tuberculosis. Treatment is based on pharmacological therapy, and it is generally recommended to apply GnRH-a for 3 to 6 months to observe the efficacy, and if it is effective to continue maintenance treatment with other drugs. Pregnancy is recommended for those with fertility requirements. There is a possibility of relapse after discontinuation of medication. Long-term follow-up is recommended.
XII. Adenomyosis of the uterus
Endometrial glands and mesenchyme are present in the myometrium, and under the influence of hormones, bleeding and proliferation of myofibrous connective tissue occur, forming diffuse lesions or limited lesions, or adenomyoma. If the cyst is >5 mm in diameter, it is called cystic adenomyosis. Although it is rare, it can occur in young women, and patients often have significant dysmenorrhea, which sometimes needs to be differentiated from residual angular uterine hemorrhage.
1. Etiology: The etiology is unclear. When the endometrium is damaged, the basal layer of endometrium can directly invade and grow within the myometrium, which may be related to the damage to the basal layer of the endometrium. It is generally believed that pregnancy, curettage, abortion procedures and childbirth may be the main causes of damage to the basal layer of the endometrium. Disruption of environmental stability within the endometrium-myometrium binding zone and reduced basal lamina defenses may be involved in the pathogenesis. Other factors including vascular lymphatic vascular dissemination, epithelial metaplasia, estrogen, progesterone and prolactin are also involved in the pathogenesis.
2. Clinical manifestations.
(1) Dysmenorrhea: more than half of the patients have secondary dysmenorrhea with progressive worsening.
(2) Menstrual abnormalities: excessive menstruation, prolonged periods or irregular bleeding.
(3) Infertility.
(4) Uterine enlargement: mostly homogeneous and spherical, but may also be raised unevenly and hard. It can be combined with uterine fibroids and endometriosis.
3. Diagnosis: Preliminary diagnosis can be made based on symptoms, pelvic examination and the following ancillary tests.
(1) Ultrasonography shows an enlarged uterus with thickened myometrium and a more pronounced posterior wall and an anterior shift of the endometrial line. The lesion is isoechoic or echogenically enhanced with punctate hypoechogenicity and no obvious boundary between the lesion and the surrounding area.
(2) MRI examination showed the presence of poorly defined lesions with low signal intensity in the uterus, and T2-weighted images could have lesions with high signal intensity and a widened endometrium-myometrium binding zone of >12 mm.
(3) Serum CA125 level may be elevated in most cases.
(4) Pathological examination is the “gold standard” for diagnosis.
4.Treatment: It depends on the severity of the disease, the patient’s age and the requirement of childbirth.
(1) Expectant therapy: for asymptomatic patients without fertility requirements.
(2) Drug therapy: The usage is the same as that for endometriosis. For young people who wish to preserve the uterus, use oral contraceptives or LNG-IUS; for those who have a significantly enlarged uterus or severe pain symptoms, apply GnRH-a treatment for 3-6 months and then use oral contraceptives or LNG-IUS LNG-IUS Some patients may experience dripping bleeding or even dislodgement of LNG-IUS at the beginning of treatment, which requires intensive follow-up. Certain herbs have obvious relief effect on dysmenorrhea and can be tried.
(3) Surgical treatment: Those who are young and require preservation of reproductive function can undergo focal resection or wedge hysterectomy, which can also be combined with uterine artery blocking; those who do not require reproduction with increased menstrual flow can undergo endometrial removal; those with significant dysmenorrhea can consider uterine artery embolization (UAE); those who have completed childbirth and are older with significant symptoms should undergo hysterectomy, which can cure the disease.
(4) Treatment of combined infertility: For patients with adenomyosis who have fertility requirements, they can choose to be treated with medication (GnRH-a) or conservative surgery plus medication followed by active assisted reproductive technology. The risk of uterine rupture in pregnancy after conservative surgery should be noted. For those without fertility requirements, medication for long-term symptom control or conservative surgery with medication or hysterectomy may be chosen.