Endometriosis is the presence of the growing endometrium in a part of the body other than the uterine cavity. Ectopic sites in the myometrium are called “myometriosis” and in the ovaries are called “ovarian chocolate cysts”. The disease is morphologically benign, but it has malignancy-like behavior such as dissemination, implantation, invasion, or metastasis. The size of the lesion can vary widely and clinical symptoms often do not parallel the extent of the lesion.
The majority of endometriosis lesions are located in the ovaries, the uterosacral ligament, the plasma layer of the lower posterior wall of the uterus, and the rectal recess, the peritoneal layer of the sigmoid colon, and the vaginal rectal diaphragm. Invasion of the ovaries is the most common, accounting for approximately 80% of cases. It can also be seen in the cervix, lateral perineal incision, or surgical incision of the abdominal wall. It can develop in the umbilicus, lungs, and extremities, but it is very rare.
There are five “best methods” of treatment for endometriosis: laparoscopic surgery is the best surgical treatment, ovarian suppression is the best pharmacological treatment, surgery → pharmacological treatment → laparoscopic surgery again (three phase therapy) is the best combined treatment, and pregnancy and pregnancy assistance techniques are the best prospective treatment.
Among these treatments, surgical treatment, especially laparoscopic surgery, is the preferred and best treatment. However, endometriosis is difficult to cure by surgery alone and is prone to recurrence after surgery, therefore, pharmacological treatment still occupies an important place. For endometriosis that is not obvious or can be controlled by medications, surgery can be temporarily avoided.
Surgery can remove the lesion, separate the adhesions, and restore the pelvic anatomy to relieve symptoms, promote fertility, and reduce recurrence. Therefore, surgical treatment is the basic treatment for endoheterosis. Surgery should be considered if endoheterosis presents with pelvic masses, infertility or pelvic pain that has not been treated with medication.
There are three types of surgery: surgery to preserve fertility, surgery to preserve ovarian function and radical surgery, which are mainly decided according to the patient’s age, symptoms, site and extent of the lesion and the requirement for fertility. It has been suggested that anticipatory treatment of intestinal, ureteral, and vaginal-rectal septal endometriosis can in many cases avoid the complications associated with pelvic surgery and the resulting costly procedure.
The choice of surgical modality includes laparoscopic surgery and open surgery, both of which have comparable treatment results. In particular, laparoscopic surgery integrates diagnosis and treatment and is suitable for all stages of endometriosis and has become the gold standard and the preferred surgical procedure for endometriosis diagnosis due to its minimally invasive features, minimal tissue damage, clear visualization, low postoperative adhesion formation, low complications and fast recovery. For infertile patients, tubal lavage or tubal plastic surgery can be performed at the same time to facilitate postoperative conception, which has the advantages that open surgery does not have.
Studies have found that surgery is beneficial in the treatment of early endometriosis infertility. Studies by domestic scholars have found that the mode of surgery also has an effect on pregnancy rates, with laparoscopy generally being superior to open surgery. In infertility due to moderate to severe endometriosis, the laparoscopic 3-year pregnancy rate was 82%, which was significantly higher than the pregnancy rate of 33.3% after open surgery.
The surgery can be divided into 3 types: conservative surgery, semi-radical surgery and radical surgery.
1. Conservative surgery
It is mainly used for young people with fertility requirements. The uterus and adnexa are preserved (bilateral as much as possible), only the lesions are removed, adhesions are separated, ovaries are reconstructed, and tissues are repaired. One of the important purposes of conservative surgery is to hope for a full-term pregnancy and delivery, so both partners should be thoroughly examined for infertility before surgery. In case of recurrence after surgery, conservative surgery can still be used again and the results can still be obtained.
(1) Laparoscopic surgery: Laparoscopic examination can clarify the diagnosis, and tubal lavage examination is also feasible under laparoscopy.
(2) B-ultrasound endometrioid cyst puncture: for recurrent cases after surgical debulking or laparoscopic puncture, ultrasound puncture and drug treatment can be considered.
(3) Conservative dissection: for patients with more severe focal adhesions, especially in medical institutions without laparoscopic equipment or those who are not skilled in laparoscopy, dissection can be performed to separate the adhesions and excavate the ovarian endometrioid cysts, preserving as much normal ovarian tissue as possible, or if the lesion is limited to one side and is heavy and the other side is normal, some advocate removing the diseased side of the adnexa. This has a higher pregnancy rate than that with preservation of the diseased ovary. A simple uterine suspension can also be performed. Whether to do anterior sacral nerve resection is debatable.
2.Semi-radical surgery
In those without fertility requirements and with severe lesions but at a younger age (<45 years), total excision of the uterus and lesions is feasible, but preserving as much normal ovarian tissue on one side as possible to avoid premature onset of menopausal symptoms. The recurrence rate after semi-radical surgery is generally considered to be low, with few sequelae. Removal of the uterus removes the source of viable endometrial cells for implantation, which may reduce the chance of recurrence. However, there is still a possibility of recurrence because the ovaries are preserved.
3. Radical surgery
If the patient is close to menopause, especially if the disease is severe and has recurred, total hysterectomy and bilateral adnexal resection should be performed. Avoid rupture of the ovarian endometrial cyst as much as possible during surgery. The cystic fluid should be aspirated and flushed as soon as possible when it flows out. For postoperative menopausal syndrome, sedation and Neil estrol are available. If endometriosis occurs at the abdominal wall or perineal incision, it should be completely removed or it will recur.
Pharmacological treatment of endometriosis should be limited to the purpose of relieving pain and delaying recurrence, while taking into account the patient’s fertility requirements. Therefore, medication for endometriosis is divided into medication alone, preoperative medication, and/or postoperative medication.
It is common for endometriosis to have tightly adherent lesions during surgery, and the lesions are prone to rupture during separation, making it difficult to remove the lesions completely during surgery. Therefore, it is generally believed that surgical treatment of endometriosis is cytoreductive rather than curative, and therefore there is a possibility of recurrence after surgery. Therefore, it is proposed that postoperative medication for endometriosis can have the dual effect of decompensating residual lesions, delaying the recurrence of endometriosis, and preventing the malignant transformation of lesions. Supplementary drug therapy after conservative surgery for endometriosis is completely necessary.
Gonadotropin-releasing hormone agonists (GnRHa) are currently recognized as the most effective drugs for the treatment of endometriosis and are the most commonly used drugs in developed countries, with a common course of 4-6 months, which can be extended to 12 months or more if available. The side effects are mainly menopause-like symptoms and bone loss caused by low estrogen (patients’ serum E levels are often <30pg/ml).
According to the doctrine of “estrogen window” required for the treatment of endometriosis, the serum E2 level of patients should be 30-50 pg/ml after the drug is administered, so the “add-back therapy” (add-back therapy), which starts from the second to third month of the drug, is mostly advocated. back therapy, which not only reduces the side effects of low estrogen, but also does not reduce the efficacy of endometriosis.
In addition, other drugs used for the treatment of endometriosis include long-acting vinpocetine, mifepristone, triamcinolone and oral contraceptives, and some proprietary Chinese medicines, which are mainly used to activate blood circulation and resolve stagnation, have also been effective in clinical use. In addition, the intrauterine device (IUD) with slow-release levonorgestrel (trade name, Manuel), which has been used in clinical practice in recent years, can significantly improve the symptoms of dysmenorrhea and pelvic pain in patients with ectopic nodules and reduce the size of ectopic nodules.
During treatment, blood CA-125 markers should be monitored for changes in the disease and the malignancy of endometriosis.
Radiotherapy has been used for endometriosis for many years, but is rarely used today. The reason is that the application of multiple drugs and surgery to achieve high efficacy generally does not destroy ovarian function, whereas radiation therapy for endometriosis works by destroying ovarian tissue, thus eliminating the influence of ovarian hormones and causing the ectopic endometrium to atrophy for therapeutic purposes.
The effect of radiation on the destruction of ectopic endometrium is not obvious, but for individual patients who can neither tolerate hormone therapy nor have the lesions located in the intestine, urinary tract and extensive pelvic adhesions, especially in combination with serious diseases such as heart, lung or kidney, and who are very afraid of surgery, extracorporeal radiotherapy can also be used to destroy ovarian function and achieve the purpose of treatment. Even if individual patients receive radiotherapy, the diagnosis must be clearly defined first, especially not to misdiagnose malignant ovarian tumors as endometrial cysts, so that the correct treatment is delayed due to wrong treatment.
Patients with endometriosis are often combined with ovulatory dysfunction, so HMG or/and clomiphene can be used to promote follicular maturation and ovulation, regardless of whether hormonal therapy or conservative surgical treatment is used.
For conservative surgical treatment of infertility, it is controversial whether hormonal therapy should be used for 3-6 months after surgery to consolidate the efficacy. It has been suggested that 1 year after surgery is the time when pregnancy is most likely to occur and that supplemental medication and pseudopregnancy treatment, on the contrary, reduce the chances of conception.
Since the etiology of the occurrence of endometriosis is multifaceted, it is controversial whether menstrual reflux itself causes endometriosis, and some preventive opinions are only applicable to a few cases. However, according to the currently recognized etiology
Prevention should pay attention to the following points.
1. Avoid unnecessary, repetitive or overly rough gynecologic double-opening near the menstrual period to avoid squeezing the endometrium into the fallopian tubes and causing abdominal implantation.
2. Avoid performing gynecological surgery as close to menstruation as possible. When it is necessary, the operation should be performed gently and avoid squeezing the uterine body with force, otherwise the endometrium may be squeezed into the fallopian tube and abdominal cavity.
3, timely correction of excessive retroflexion of the uterus and cervical canal stenosis, so that the drainage of menstrual blood is smooth, to avoid stagnation, causing backflow.
4. Strictly grasp the operating procedures of tubal patency test (ventilation and fluid) and imaging, and do not perform them just after menstruation or directly during the cycle of scraping to avoid pressing the endometrial fragments into the abdominal cavity via the fallopian tubes.
5, caution should be taken to prevent the uterine cavity from overflowing into the abdominal cavity during cesarean delivery and cesarean extraction, and when suturing the uterine incision, do not make the suture pass through the endometrial layer, and apply saline flushing before suturing the abdominal wall incision to prevent endometrial implantation.