Endometriosis

　　The etiology of endometriosis has not been elucidated yet, and there are several theories: Koninckx's theory of retrograde menstruation, the theory of endometrial implantation, the theory of metaplasia of serosal epithelium, the theory of derivation of fetal epithelium, the theory of stimulation of local cell metaplasia by chemical substances, the theory of dissemination, the theory of genetic transmission, the theory of benign metastasis, and the theory of immunity. These theories are not suitable for all patients, so the pathogenesis is still unclear. However, by exploring the high-risk factors of endometriosis from these etiologies, we can provide a basis for the prevention of this disease.

　　1. Hormonal dependency

　　Clinical and laboratory observations have proven that endometriosis is an estrogen-dependent disease, and estrogen is crucial for the growth and maintenance of EM. EM does not occur in girls before menarche, and the incidence is also low in women with anovulatory menstruation. The tissue of EM presents many molecular biological abnormalities related to abnormal estrogen secretion and metabolism.

　　In ectopic lesions, aromatase is the final synthetic enzyme, converting C19 steroids into estrogens. Whether it is the rapid regulatory protein of the steroid gene or aromatase, these enzyme-linked reactions ensure that the ectopic endometrium is in an estrogenic action environment. The locally produced estrogen exerts its biological effects in its own tissue, that is, an autocrine effect.

　　2. Coelomic epithelial metaplasia

　　This theory holds that some peritoneum is a tissue with differentiation ability and can differentiate into tissue similar to normal endometrium. Since the ovaries and müllerian ducts both originate from the coelomic epithelium, the theory of coelomic metaplasia can explain endometriosis of the ovaries. The peritoneal mesothelium also has the ability to proliferate and differentiate, so this theory can even be extended to the peritoneum to explain peritoneal endometriosis. However, no endometriosis has been found in other tissues differentiated from the coelomic epithelium, such as the ovaries, müllerian ducts, and peritoneum, which has led to skepticism about the theory of coelomic epithelial metaplasia.

　　3. Menstrual blood reflux

　　The theory of endometrial implantation is widely accepted by scholars and was first proposed in the 1920s, making it the earliest proposed and widely accepted theory. During the menstrual period, women's menstrual blood can reflux through the fallopian tubes into the peritoneum, causing the spread of endometrial tissue within the peritoneum. The endometrial fragments in the refluxing menstrual blood adhere and infiltrate the peritoneal mesothelium, obtain blood supply, and continue to survive and grow. In recent years, Lang Jinghe and others have found that the in situ endometrium of patients with endometriosis plays a significant role in their pathogenesis.

　　However, 90% of women have menstrual blood reflux during their menstrual period, but only 10% develop EM clinically. The current view is that other multifactorial factors may be involved in the pathogenesis of EM, such as the spread of endometrial cells through blood vessels or lymphatic vessels, and mechanical implantation mechanisms.

　　4. Immune mechanism

　　Although most women have the condition of menstrual blood reflux, only a few ultimately develop endometriosis. The menstrual blood and endometrium refluxing into the peritoneum are usually cleared by the body's immune cells, such as macrophages, NK cells, and lymphocytes. Therefore, when menstrual blood refluxes, the failure of the immune system to function may also be one of the mechanisms of endometriosis. Damaged cells, humoral immunity, growth factors, and cytokines are all found in the ectopic endometrial tissue. The immune mechanism plays an important role in the implantation, localization, adhesion, and growth of EM.

　　The reduction in apoptosis of endometrial cells refluxing into the peritoneum promotes their survival ability and is conducive to their evading macrophage-mediated immune surveillance and clearance. Meanwhile, matrix metalloproteinases are continuously and stably expressed in the refluxed endometrial cells, enhancing their invasiveness into the peritoneum and further triggering proliferative responses.

　　5. Gene mutation and polymorphism

　　The familial aggregation of endometriosis suggests a polygenic inheritance pattern, and researchers have studied some genes. The study used sib pair linkage analysis and high-throughput analysis of gene expression patterns. A large-scale study investigated more than 1000 patient sister groups, determining that the chromosomes are located at 10q26, indicating a dominant genetic disease. The study also showed a smaller correlation at 20p13. Two candidate genes and their nearby sites have also been identified. One of the genes is EMX2, which is a necessary transcription factor for the development of the reproductive tract and is abnormally expressed in the endometrium of patients with endometriosis. Chip technology was applied to study the differences in gene expression between the normal endometrium of endometriosis patients and normal women.

　　6. Familial Aggregation

　　The onset of EM has a familial tendency. The increased incidence of endometriosis in first-degree relatives suggests that this may be a monogenic or polygenic genetic disease. In a genetic study of endometriosis, Simpson et al. found that sisters (5.9%) and mothers (8.1%) of endometriosis patients also currently have endometriosis, while the incidence rate in the female first-degree relatives of the patients' husbands is only 1%. Therefore, some scholars believe that EM is a genetic disease with a disorder of immune surveillance function.

　　7. Anatomical Defects

　　The exacerbation of retrograde menstrual blood due to obstruction of the reproductive tract outlet is likely to lead to the progression of endometriosis. Therefore, endometriosis is more likely to occur in patients with unicornuate uterus, hymen phimosis, and vaginal septum. Therefore, during laparoscopic diagnosis and treatment, we recommend correcting these anatomical abnormalities at the same time. By repairing anatomical abnormalities, the risk of endometriosis can be reduced.

　　8. The Theory of Lymphatic or Vascular Spread

　　The theory of lymphatic or vascular spread: There is evidence to support the theory that endometriosis originates from the abnormal spread of endometrial tissue through lymph or blood vessels. The occurrence of endometriosis in some rare sites such as perineum or inguinal area further supports this theory. Isolated lesions found only in the peritoneal cavity support the theory of lymphatic spread.

　　9. Environmental Toxins

　　A large number of studies have shown that exposure to environmental toxins may play a certain role in the development of endometriosis. 2, 3, 7, 8-tetrachlorodibenzo-p-dioxin (TCDD) is the most common environmental toxin. TCCD can activate aryl hydrocarbon receptors, which act as basic transcription factors, mediating the transcription of various genes, and have similar functions to the protein family of the same steroid hormone receptors. TCCD stimulates the formation of endometriosis by binding to estrogen and seems to block the regression changes of endometriosis mediated by progesterone. In the environment, TCCD and other dioxin-like compounds are by-products of industrial production, and the most common exposure methods are consuming contaminated food or accidental contact.

Endometriosis, as an estrogen-dependent disease that is prone to recurrence, has the ability to metastasize and grow in distant places, so although it is a benign lesion, it has malignant behavior. Common complications include irregular menstruation, dysmenorrhea, dyspareunia, and infertility.

 　　1, Irregular menstruation:Patients with endometriosis often have symptoms such as shortened menstrual cycle, increased menstrual flow, or prolonged menstrual periods, indicating that the patients have ovarian dysfunction. Irregular menstruation can be used as a reference for diagnosis, but it has no value in differential diagnosis.

　　2, Dysmenorrhea:The clinical characteristics of endometriosis are progressive dysmenorrhea, which is a common and prominent feature, mostly secondary, that is, from the onset of endometriosis, patients report that they did not experience pain during their menstrual periods before, but dysmenorrhea began to appear from a certain period. It can occur before, during, and after the menstrual period. Some dysmenorrhea is severe and hard to bear, requiring bed rest or medication for pain relief, and even to the extent of rolling on the bed or hitting the head. Pain often worsens with the menstrual cycle and disappears after menstruation, but 21% of cases without dysmenorrhea are reported in China.

　　3. Dyspareunia:When ectopic endometrial nodules in the vaginal fornix, rectal凹nodules or adhesions, or ovarian adhesions at the pelvic floor are present, sexual intercourse pain can occur. When the fibrosis and hyperplasia of the posterior leaf of the broad ligament are obvious, they can externally compress the ureter, causing it to become narrow and blocked, and urinary system symptoms may also occur, which may lead to hydronephrosis or pyelonephrosis in severe cases.

　　4. Infertility:About 50% of endometriosis patients have infertility, and about 30-40% of patients with unexplained infertility have endometriosis. Infertility in endometriosis patients is often caused by factors such as pelvic mass, adhesions, tubal obstruction, poor follicle development, or ovulatory disorders due to lesions; once pregnant, the ectopic endometrium is suppressed and atrophies, which is a good treatment for endometriosis. In cases of habitual abortion, some are caused by endometriosis.

　　The symptoms and signs of endometriosis vary with the location of ectopic endometrium and are closely related to the menstrual cycle.

　　One. Symptoms

　　1. Dysmenorrhea: Patients report that they did not experience pain during their menstrual periods before, but dysmenorrhea began to appear from a certain period. It can occur before, during, and after the menstrual period. Some dysmenorrhea is severe and hard to bear, requiring bed rest or medication for pain relief. Pain often worsens with the menstrual cycle. Due to the continuous increase in estrogen levels, ectopic endometrium proliferates and swells, and if affected by progesterone, bleeding occurs, stimulating local tissues, leading to pain. If it is an intrauterine endometriosis, it can further promote uterine muscle contraction, making dysmenorrhea more pronounced. In cases without bleeding from ectopic tissues, dysmenorrhea may be caused by vascular congestion. After menstruation, the ectopic endometrium gradually atrophies and dysmenorrhea disappears. Clinically, endometriosis is significant, but there are about 25% of patients without dysmenorrhea. The psychological condition of women can also affect pain perception.

　　2. Menorrhagia: Intrauterine endometriosis often leads to increased menstrual volume and prolonged menstrual periods. It may be due to increased endometrium, but it is often accompanied by ovarian dysfunction.

　　3. Infertility: Patients with endometriosis often suffer from infertility. The etiological relationship between infertility and endometriosis is still controversial. Pelvic endometriosis can often cause surrounding adhesions of fallopian tubes, affecting oocyte retrieval or leading to tubal obstruction. Or, due to ovarian lesions affecting the normal process of ovulation, infertility may occur. However, some people believe that long-term infertility, without a menstrual period, can create an opportunity for endometriosis; and once pregnant, the ectopic endometrium is suppressed and atrophies.

　　4. Dyspareunia: Occurring in the uterine rectal pouch, endometriosis in the vaginal rectal septum causes surrounding tissue swelling and affects sexual life, with increased sexual discomfort before the menstrual period.

　　5. Analgesia: It usually occurs before or after menstruation, where the patient feels excruciating pain when passing stool through the rectum, while there is no such feeling at other times. This is a typical symptom of endometriosis in the rectouterine pouch and around the rectum. Occasionally, deep endometrial tissue can reach the rectal mucosa, causing rectal bleeding during the menstrual period. Endometriotic lesions surrounding the rectum can cause tenesmus and obstruction symptoms, so they are similar to cancer. They often occur during the menstrual period and may be accompanied by nausea, vomiting, and a feeling of rectal prolapse.

　　6. Bladder symptoms: It is more common in patients with endometriosis in the bladder, with symptoms of periodic urinary frequency and dysuria; when the bladder mucosa is invaded, cyclic hematuria may occur. Endometriosis in abdominal scar and umbilicus can cause periodic local masses and pain.

　　Second, signs

　　Patients with intrinsic endometriosis often have an enlarged uterus, but rarely exceed 3 months of pregnancy, mostly uniform expansion, and may feel that some parts are more prominent like a uterine fibroid. If the uterus is posterior, it is often adherent and fixed. One or more hard nodules, as small as mung beans or soybeans in size, can often be felt in the rectouterine pouch, uterosacral ligament, or posterior uterine wall, with significant tenderness, which is more obvious in rectal examination. Occasionally, blackish purple large hemorrhagic points or nodules can be seen in the posterior fornix of the vagina. If there are more lesions in the rectum, a hard mass can be felt, and it may even be misdiagnosed as rectal cancer.

　　Ovarian hematoma is often adherent and fixed around the ovary, and can be felt as a tense mass with tenderness during gynecological bimanual examination. Combined with a history of infertility, it is easy to be misdiagnosed as adnexal inflammation. After rupture, it can cause internal hemorrhage, manifested as acute abdominal pain.

　　Endometriosis is a disease caused by the presence of endometrial tissue with growth function in the extra-uterine wall of the uterine cavity. According to currently recognized etiology, attention should be paid to the following points to prevent the occurrence of endometriosis.

　　1. For girls with a family history of heredity, if they have primary dysmenorrhea or menorrhagia after menarche, they can consider taking oral contraceptives cyclically and intermittently, and stop taking them when they want to become pregnant.

　　2. Women with endocrine dysfunction should not use contraception after marriage and should have children early.

　　3. Women with obstructive reproductive tract should be detected and treated early to prevent the backflow of retained menstrual blood into the abdominal cavity.

　　4. For women with dysmenorrhea or menstrual irregularities, heavy menstrual bleeding, and who do not want to become pregnant temporarily, after excluding other organic diseases, they should be guided to use contraceptives.

　　5. For those who have not conceived after one year of marriage without contraception, they should actively and comprehensively undergo infertility examinations. If infertility is found to be caused by endometrial displacement, laser therapy or hormone therapy can be used. Hormone therapy must be used under the guidance of a doctor.

　　6. It is generally not recommended to perform pelvic examinations during menstruation. When necessary, the uterus should not be squeezed forcefully to prevent the endometrium from being pushed into the fallopian tubes, causing peritoneal implantation. Artificial abortion should be avoided as much as possible, and the vacuum should be used correctly during abortion. There should be no vacuum when the catheter enters or exits the uterine cavity. The vacuum in the uterine cavity should not be too high and then suddenly withdrawn to prevent the fragments of the decidua from flowing back into the abdominal cavity with the uterine blood, causing endometriosis. The uterus should not be squeezed forcefully after artificial abortion. When treating cervical erosion, it is necessary to avoid causing cervical stenosis.

　　7. Strictly master the operation procedures for fallopian tube patency tests (aerating, irrigating) and contrast. When performing fallopian tube aeration, irrigation, tubal ligation, and local treatment for cervical erosion, the operation time should be scheduled 3 to 7 days after the menstrual period to avoid the entry of endometrial fragments into the abdominal cavity.

　　8. During cesarean section and cesarean section for extraction of the fetus, attention should be paid to prevent the overflow of uterine contents into the abdominal cavity. When suturing the uterine incision, do not let the suture thread pass through the endometrial layer. Before suturing the abdominal wall incision, physiological saline should be used to rinse to prevent endometrial implantation.

　　Endometriosis, also known as inere, is a common benign gynecological disease with the characteristics of proliferation and infiltration. The main examinations include laboratory tests and imaging examinations.

　　Firstly, Laboratory tests

　　1. CA125 (ovarian cancer associated antigen) value measurement: As a tumor-associated antigen, it has certain diagnostic value for ovarian epithelial cancer. However, in patients with endometriosis, the CA125 value can increase, and with the increase of the stage of endometriosis, the positive rate also rises, with high sensitivity and specificity. Therefore, it is helpful for the diagnosis of endometriosis and can also monitor the efficacy of endometriosis treatment.

　　2. Antiembryonic endometrial antibody (EMAb): Antiembryonic endometrial antibody is an autoantibody that targets the endometrium and causes a series of immune pathological reactions, serving as a marker antibody for endometriosis. The detection of serum EMAb is an effective examination method for the diagnosis and efficacy observation of endometriosis patients.

　　Secondly, Imaging examinations

　　1. B-ultrasound examination: B-ultrasound examination is one of the commonly used examination methods in gynecology and obstetrics and plays an important role in the diagnosis of gynecological diseases. It can determine the location, size, shape of cysts, and detect lumps that were not felt during gynecological examination.

　　2. Laparoscopic examination: With the help of laparoscopy, direct visualization of the pelvic cavity is possible, allowing for the identification of ectopic lesions or for biopsy of visible lesions to confirm the diagnosis. The clinical stage of pelvic endometriosis and the determination of the treatment plan can be decided based on the findings of the laparoscopic examination. When under laparoscopy, attention should be paid to whether there are endometriotic lesions in the uterus, fallopian tubes, ovaries, uterosacral ligaments, and pelvic peritoneum. Based on the findings of laparoscopic examination or surgery, staging and scoring of endometriosis can be performed.

　　3. X-ray examination: X-ray examination can perform单独 pelvic air contrast and uterine tube iodine oil contrast to assist in the diagnosis of pelvic endometriosis.

　　4. Magnetic Resonance Imaging (MRI): MRI can directly image in multiple planes, allowing for a direct understanding of the extent, origin, and structures invaded by the lesion. It can accurately locate the lesion and enhance the ability to display soft tissues. Therefore, MRI is of great value in diagnosing endometriosis and understanding pelvic lesions and adhesion conditions.

　　In addition to the treatment methods of traditional Chinese and Western medicine for endometriosis, symptoms can also be improved through the following dietary methods.

　　1. Rose Flower Soup:Boil 15 grams of rose flower and an appropriate amount of brown sugar into a decoction and take it all at once. It is suitable for infertility with qi stagnation and blood stasis.

　　2. Hawthorn Soup:Boil 30 grams of hawthorn charcoal, 30 grams of brown sugar, and 15 grams of sunflower seeds into 2 small bowls of decoction, take 2 times a day. It is suitable for dysmenorrhea with blood stasis.

　　3. Yangqishi Cow Kidney Porridge:Wrap 30 grams of Yangqishi (a type of stone) in gauze, add 1.5 liters of water, and boil for 1 hour. Take the clear decoction, add 1 cow kidney, 50 grams of rice, and an appropriate amount of water, and cook as usual into porridge. Add oil, salt, and seasonings after the porridge is cooked. Take it once a day. It is used to treat endometriosis with yang deficiency and blood stasis.

　　4. Black Fungus Soup:Boil 15 grams of black fungus and an appropriate amount of brown sugar with 500 milliliters of water until soft, and eat it. Take it in two doses, 1 dose per day. It is used to treat endometriosis with blood stasis.

　　5. Litchi Seed Drink:Roast 30 grams of litchi seed and 30 grams of She Xiang (a type of incense) black, grind into fine powder. Take 3 grams per dose, taken with warm wine. Start taking it 3 days before the menstrual period, 2 times per day, until the menstrual period is over. It is used to treat endometriosis with qi stagnation and blood stasis.

　　6. Egg and Chuanxiong Wine Drink:Take 2 eggs, 9 grams of Chuanxiong, and 600 milliliters of water to boil together. After the eggs are cooked, remove the shell and boil for a while, add some yellow wine, and eat the eggs and drink the soup. Start taking it 3 days before the menstrual period, 1 dose per day, for 5 days per course. It is used to treat endometriosis with qi stagnation and blood stasis; symptoms include abdominal pain during menstruation and discomfort due to distension.

　　7. Peach Kernel Porridge:Grind 15 grams of peach kernel into powder, soak in water, strain the juice, and mix with 50 grams of glutinous rice. Place them in a pot, add 500 milliliters of water, and cook over low heat into a porridge. Adjust the amount of brown sugar and eat it. Take one dose every other day, 1 time in the morning and 1 time in the evening. It is used to treat endometriosis with blood stasis.

　　8. Motherwort Egg Soup:Take 45 grams of motherwort, 15 grams of Corydalis yanhusuo, 2 eggs, and 800 milliliters of water to boil together. After the eggs are cooked, remove the shell and boil for a while, discard the medicine residue, and eat the eggs and drink the soup. Start taking it 2 days before the menstrual period, 1 time per day, for 5 consecutive days. It is used to treat endometriosis with blood stasis.

　　The treatment plan for endometriosis varies due to the severity of the condition, the patient's age, and their reproductive status. If the condition is severe, or if there are severe dysmenorrhea symptoms, or if there are confirmed endometriotic nodules found during pelvic examination, then either drug or surgical treatment must be adopted.

　　3. Drug Treatment

　　2. Using drugs to counteract or inhibit the cyclic endocrine stimulation of the ovary. Initially, androgens such as testosterone were used, which had significant side effects and were not strong enough in efficacy, and they have gradually been abandoned. Later, it gradually developed into artificial pregnancy therapy and artificial menopause therapy.

　　1. Artificial Pregnancy Therapy: This method uses potent progestin contraceptives to continuously take a larger dose over a long period of time, causing the menstrual cycle to stop and the endometrium and ectopic endometrium to react similarly to pregnancy under the drug's action, hence the name 'artificial pregnancy therapy'. There are many drugs used for this therapy, and they are still being developed. Oral medications include Anogest, Prolvera, and Nimeison, while intramuscular injections include Hydroxyprogesterone caproate. This therapy needs to last at least six months to stop the activity of ectopic endometrium, finally leading to atrophy and thus producing the therapeutic effect.

　　2. Menopausal Therapy: In the 1970s and 1980s, abroad, a drug called danazol was mainly used, which is a derivative of androgens and has a good effect. It is currently also being used in China, but it has significant side effects. Since the 1980s, abroad, a drug called Goserelin has been widely used, which can strongly inhibit the function of the ovaries, making them almost completely ineffective, thus achieving the therapeutic goal. Moreover, as this drug is a long-acting sustained-release preparation, it only needs to be injected subcutaneously once a month, which is very convenient. This type of drug can cause the endometrium to produce atrophy similar to that in menopausal women, hence the name menopausal therapy.

　　Second, Surgical Treatment

　　Generally, chocolate cysts occurring on the ovary are often large in size, or endometriotic nodules located in other parts with a diameter of more than 2 centimeters are not easily controlled by medication and require surgical treatment; or after six months or even a year of medication, if the condition does not improve, surgical resection should also be considered. If the patient is young and has no children, during surgery, the lesions of endometriosis are usually removed, but the uterus and normal ovarian tissue are preserved. This is called conservative surgery. This type of surgery preserves the possibility of fertility, but the risk of recurrence is relatively high. If the patient already has children and is older (35), the uterus can be removed at the same time as the endometriotic lesions, but the normal ovarian tissue is preserved. This method is more effective in the long run than conservative surgery, but it cannot absolutely prevent recurrence. If the patient is nearing menopause or the endometriotic lesions are too extensive and difficult to completely eradicate, the uterus and ovaries should be removed during surgery.

　　In recent years, the wide application of laparoscopy has provided a new option for the treatment of endometriosis, especially in foreign countries, the combination of laparoscopic surgery and 'Goserelin' medication has become an increasingly widespread treatment plan.