Endometriosis is defined as: the appearance of endometrial tissue (glandular and mesenchymal) with a growth function in the uterine cavity other than the overlying endometrium and the myometrium. Although benign in histology, it has malignant behavior such as proliferation, infiltration, metastasis and recurrence, with a malignancy rate of about 1%. It is one of the most common diseases among women in their reproductive years. It is called the “modern disease” and is common among women aged 25-45 with an incidence of 10%-15%. In recent years, its incidence has increased significantly.
Endometriosis is a hormone-dependent disease, with a significantly higher incidence in women who have fewer or later children than in those who have more children, and a significantly higher risk in women with menstrual cycles ≤ 27 days and menstrual periods ≥ 7 days. Ectopic endometrium can invade any part of the body, but most of them are located in the pelvis, with the uterosacral ligament, the rectal sulcus and the ovaries being the most commonly invaded sites.
It is now widely accepted in domestic and international medicine that endometriosis is caused by a combination of etiological factors, such as physical factors, immune defense defects, plasma membrane epithelium, septic endothelium, and endocrine dysfunction. However, not all women with menstrual reflux suffer from endometriosis, suggesting that the refluxed endometrium is induced by genetic factors, immune factors, and inflammation to grow and form ectopic endometrium, which is mainly related to the adhesion, invasion, and angiogenic capacity of in situ endometrial cells.
Seventy-five percent of women with endometriosis have symptoms, commonly secondary to progressively increasing dysmenorrhea, chronic pelvic pain (70%), painful intercourse, irregular menstruation and infertility (50%). If an endometriotic cyst causes acute abdominal pain due to a sharp increase in pressure or rupture. In extra-pelvic ectopic endometrium implantation and growth, nodular masses mostly appear at the lesion site with periodic pain, bleeding and enlargement of the masses during menstruation and shrinkage of the masses after menstruation.
In larger ovarian endometriosis cysts, a mass with uterine adhesions can be found during gynecological examination. Typical gynecological examination of pelvic endometriosis reveals a posteriorly inclined fixed uterus, a painful nodule can be palpated in the rectal recess of the uterus, the uterosacral ligament and the lower part of the thick wall of the uterus. If the lesion involves the rectovaginal septum, a nodular painful nodule may be found in the posterior vaginal fornix. Nodular masses may be found at the incision in endometriosis lesions of the abdominal wall and perineum.
What is the diagnosis of endometriosis based on? The diagnosis of endometriosis should be made by laparoscopy, or by histopathological diagnosis by dissection. For the diagnosis of endometriosis, the following aspects can be used as the basis for the diagnosis of this type of disease.
1, to understand the female medical history focusing on menstrual history, maternity history, family history and surgical history. Pay special attention to the development of pain or dysmenorrhea in relation to menstruation and surgery such as cesarean section, abortion and tubal lavage.
2, pelvic endometriosis, the uterus is mostly posterior, poor mobility or fixed; the uterosacral ligament and the posterior vault have painful nodules as characteristic signs; in ovarian endometriosis, cystic masses can be palpated in the adnexal area with the uterus or broad ligament and pelvic wall adhesions, often with mild tenderness, poor mobility, and cysts generally less than 10 cm. nodular masses can be found in the abdominal wall and perineal incision.
3. Imaging examination, elevated CA125 and positive endometrial antibodies help in diagnosis.
Laparoscopy is now internationally recognized as the best method for the diagnosis of endometriosis. The diagnosis can be basically established when the typical lesions described by gross pathology are seen under laparoscopy, and what is seen during the operation is also an important basis for clinical staging. In particular, laparoscopy should be the preferred method of diagnosis in patients with mild to moderate endo, infertility caused by suspected endo, chronic pelvic pain, and pelvic tenderness nodules on gynecologic examination without positive findings on B-mode ultrasonography, if available. However, the lesions are hidden and easily missed outside the abdominal cavity, and the laparoscopic diagnosis is affected by the level and recognition ability of the operator.
4, confirming the diagnosis finally relies on pathological diagnosis.
The current study found that about 1% of endometriosis can become cancerous, 80% of which occur in the malignant transformation of ovarian chocolate cysts, mostly adenocarcinoma and clear cell carcinoma, with younger onset, earlier stage and better prognosis. The incidence is low, mainly adenocarcinoma and a few sarcomas, especially in older patients or those who found endometriosis nodules or nodules increasing in size after hysterectomy + double adnexal resection.
Patients with endometriosis suffer a lot of pain, poor quality of life and heavy economic burden. Their treatment is aimed at reducing and removing lesions, relieving and eliminating pain, improving and promoting fertility, and reducing and avoiding recurrence. Treatment methods are mainly divided into surgical treatment, drug treatment, interventional treatment and assisted reproduction treatment, which are considered according to the patient’s age, the severity of the disease and whether there are fertility requirements. Treatment methods should vary from person to person.
Surgical treatment: It was first used for the treatment of endometriosis and is still one of the main means. It is mainly suitable for those who have severe disease or severe pain and drug treatment is not effective;
(i) Conservative surgery: Only the endometriosis lesion is removed and the ovaries and uterus are preserved. It is suitable for those who are young and want to preserve their fertility, and about 50-60% can get pregnant after surgery. However, the recurrence rate of pain is high;
(b) Semi-radical surgery: removal of the ectopic lesion with removal of the uterus and preservation of at least part of the ovaries. It is suitable for those who have given birth, are over 35 years old, have persistent pain or have concomitant uterine lesions. Semi-radical surgery can cure dysmenorrhea and there is little chance of recurrence of ectopic disease after surgery.
(c) Radical surgery: Removal of bilateral adnexa and uterus can cure endometriosis, which is suitable for menopausal women;
(ii) Drug therapy: It is suitable for those with mild disease and small ovarian chocolate cysts. The duration of treatment is usually 6-9 months. If used as adjuvant treatment before and after surgery, the course of treatment can be shortened to 3-6 months.
(a) Danazol, although side effects are more common, most of them are not serious and do not require discontinuation of the drug. Occasionally, if the liver function is too high, it is advisable to stop the drug and give hepatoprotective treatment in time;
(ii) Endometrium, which has mild side effects and is easy to administer;
(iii) progestin drugs, such as gynecomastia tablets, gynenol tablets, Angioprogesterone, etc., are suitable for those who have a heavy economic burden and cannot take danazol or endometrium, but the effect of promoting fertility is small, and liver function should also be checked regularly during the use of drugs;
(iv) contraceptive pills: It should be noted that the estrogen in contraceptive pills can stimulate the growth of uterine fibroids, so be careful with those who have fibroids;
(v) gonadotropin-releasing hormone agonists, long-term use of drugs may cause osteoporosis. It is suitable for menopausal women, especially those with combined uterine fibroids; however, the economic burden of patients is heavy.
(vi) Triamcinolone acetonide, which does not inhibit ovulation, has good effect on relieving dysmenorrhea, has small side effects, has poor efficacy on the signs of ectopic disease, and is suitable for those with heavy symptoms and light signs;
Interventional treatment: Interventional treatment is the best conservative treatment method at present. Interventional treatment has advantages that are incomparable to traditional surgical treatment and can partially replace traditional surgery. Interventional treatment has the following advantages: (1) no wound, no incision (2) the efficacy of the exact, can retain the normal function of the uterus (3) fewer side effects, fast recovery (4) postoperative does not affect sexual life.
However, it is limited by the fact that many hospitals do not have the conditions for interventional treatment.
Endometriosis is a relatively complex disease, so it is very important to emphasize standardized treatment. For the traditional surgery introduced above, patients will have big surgical trauma, long recovery time and relatively heavy post-operative adhesions, drug treatment, firstly, will increase the economic burden of patients, secondly, may cause liver and kidney damage to patients, in recent years, laparoscopic surgery is widely carried out for the treatment of endometriosis, and laparoscopic surgery can be done for all surgeries that can be done by open surgery. And laparoscopy has a magnifying effect, can find the patient’s abdominal cavity, pelvic cavity in the tiny lesions, resection lesions removed more thoroughly, in addition, laparoscopic surgery also has the advantages of small trauma, fast recovery and less postoperative pelvic adhesions. The postoperative symptom relief rate and pregnancy rate can be better than those of open surgery. It is getting more and more attention;
There was a case of deep infiltrative endometriosis in our hospital. The patient, Sun Jie, female, 33 years old, was admitted to our hospital because of “lower abdominal pain during menstruation for 2 months, aggravated for 1 month”. (solid occupancy of posterior cervical wall) and CA125:25.98U/ml, the patient was considered to have endometriosis of the uterosacral ligament, and the patient’s sacral ligament nodes were adherent to the ureter, so the operation would be more difficult, and the patient was a fertile woman, so the operation should be operated carefully to remove the lesion completely as far as possible, reduce the possible damage to the ureteral intestine and bleeding, and achieve the best treatment effect.
Prevention
I. Reduce the chance of medical endometrial implantation, pelvic examinations should not be done during menstruation, abortion is best not done or done less often, and intrauterine device contraception should not be used for those with excessive menstruation;
Second, active treatment of high-risk factors: attention should be paid to the detection and active treatment of cervical stenosis, reproductive tract obstruction. Do not do strenuous exercise during menstruation, and should avoid high mental tension. Active treatment of severe primary dysmenorrhea and excessive menstruation may also have a preventive effect on ectopic disorders. Those with a family history of ectopic disorders should have regular gynecological examinations to detect ectopic disorders in time for early treatment. It is advisable to have children at the right time;
Other: regular physical activity may reduce the occurrence of ectopic disease, and long-term use of contraceptive pills may also have a certain preventive effect.
Minimally invasive surgery for endometriosis is one of the most basic treatment methods. As the most advanced modern surgical method today, laparoscopic technology has great advantages in the diagnosis and treatment of pelvic endometriosis and has become the golden technology for the treatment of endometriosis.