Endometriosis

Introduction to endometriosis Endometriosis is a persistent disease that begins at the cellular level and ends with pelvic pain and infertility, often causing great problems for young women. Endometriosis refers to the ectopic endometrial tissue with growth function outside the uterine cavity. The main pathological change is the ectopic implantation of the endometrium with periodic ovarian steroid hormone changes. Blood, secretions and tissue fragments accumulate in the interstitial space, plasma and hemoglobin are slowly absorbed, and there is an inflammatory reaction similar to the infection around the lesion. The fibrous tissue proliferates, adheres, wrinkles and forms scars, forming purple-brown spots on the lesions or The vesicles finally form purple-blue nodules or masses of different sizes, which can be divided into peritoneal endometriosis, ovarian endometriosis and adenomyosis according to the location of the vesicles. basic knowledge Probability ratio: Susceptible people: women Mode of infection: non-infectious Complications: dysmenorrhea, infertility, irregular menstruation

Endometriosis

Countercurrent planting factors (20%):

In 1921, Sampson proposed the theory that the endometrium was implanted with the menstrual blood through the fallopian tube. Up to now, the theory of menstrual blood reflux is still accepted by most people. According to the countercurrent menstrual blood in the pelvic cavity, the viable endometrial cells can be found. Endometriosis is a strong evidence of the intimal implant theory, but Sampson's theory cannot explain endometriosis outside the pelvic cavity. In addition, iatrogenic dissemination also supports planting theory, as a typical example is a cross-section. Abdominal wall scar endometriosis after taking the fetus, accounting for about 90% of abdominal wall scar endometriosis.

Blood-lymphatic dissemination (25%):

Endometrial tissue can be metastasized through blood and lymph, but systemic endometriosis should not be so rare. Whether this is related to the immune function of the body is still difficult to determine.

Body cavity metaplasia (5%):

So far, this theory has not seen sufficient clinical reports and experimental evidence.

Immunity factor (18%):

The immune mechanism plays an important role in the occurrence and development of endometriosis. In recent years, studies have shown that the pathogenesis of endometriosis may be caused by the imbalance of immunosuppression and immune promotion leading to immune loss. In the early stage of disease development, The body exhibits a positive immune response. At this time, the number of NK cells, macrophages increases, lymphocyte activity increases, cytotoxicity increases, and various pathways are initiated to remove ectopic endometrial debris, but harmful factors released by endometrial tissue (such as During the process of growth and decline of the immune system, the immune system is induced to release a series of feedback factors, which synergistically further inhibit the clearance of ectopic endometrium by immunocompetent cells and reverse the immune system to immune promotion. A series of active factors are released from immune cells to promote the implantation, adhesion and proliferation of ectopic endometrium. The clinical features of the disease and autoantibodies may be a monoclonal activation pattern, indicating that it has the characteristics of autoimmune diseases.

Endometriosis prevention

According to the cause of endometriosis, in order to prevent the occurrence of endometriosis, the following preventive measures can be taken:

1. Unnecessary gynecological examination should be avoided during menstruation. It is necessary to prevent excessive force from squeezing the uterus during the examination to prevent the endometrium from being squeezed into the fallopian tube and causing intraperitoneal implantation.

2. Avoid intrauterine surgery during menstruation, such as tubal patency test, must be carried out 3 to 7 days after menstruation is clean, if the menstrual blood is not clean, the endometrial debris can enter the abdominal cavity through the fallopian tube, causing ectopic Planting.

3. Try to avoid gynecological surgery near the menstrual period. It must be gentle when moving, and avoid squeezing hard.

4. Adhere to contraception, do not or less artificial abortion, due to the use of negative pressure suction, if the pressure and use method used during the operation is not appropriate, it can also cause blood to flow into the abdominal cavity, causing endometriosis .

5. The uterus is extremely deformed or cervix, vaginal stenosis, congenital vaginal (with uterus) and other genital malformations. Cervical adhesions can cause poor discharge of menstrual blood or can not be discharged. Endometriosis is caused by menstrual blood flow. The above diseases should be actively treated to prevent the occurrence of endometriosis.

6. Avoid iatrogenic implantation: in the removal of uterine fibroids, especially those who penetrate the uterine cavity during surgery, or cesarean section, cesarean section surgery, should protect the surgical incision, so as not to end the endometrium Debris is planted in the incision to cause abdominal wall incision endometriosis, or brought into the pelvic implant to cause pelvic endometriosis.

7. Pay attention to menstrual hygiene and prohibit sexual life during menstruation.

Endometriosis complications Complications, dysmenorrhea, infertility, irregular menstruation

Due to the biological characteristics of endometriosis and multi-system lesions, the complications are also manifested as diversity. Such as infertility, dysmenorrhea, irregular menstruation and so on.

Endometriosis Symptoms Common symptoms Sexual pain, lower abdominal pain, dysmenorrhea, female infertility, cervical atresia

Symptom

According to the different parts of the lesion, different symptoms appear. The most common symptoms are dysmenorrhea, menstrual disorders, sexual pain, infertility, etc., as follows:

(1) Dysmenorrhea and chronic lower abdominal pain: The patient is characterized by secondary and progressive dysmenorrhea. The following abdominal and anal pains are mainly painful. It can start from 1 to 2 days before menstruation, disappear after menstruation, and pain from the waist. The ankle, the abdomen begins, radiates to the vagina, perineum, anus or thigh. The degree of pain is related to the location of the ectopic foci, but not proportional to the size of the lesion. For example, a small ectopic nodule in the sacral ligament of the uterus can cause the patient. Unbearable pain, while larger ovarian endometriotic cysts are mild or asymptomatic, 25% of patients may have no dysmenorrhea, and 20% to 30% of patients with endometriosis have chronic lower abdominal pain.

(2) Menstrual disorders: 15% of patients with endometriosis may have increased menstrual flow, prolonged menstruation or spotted bleeding, due to ovarian destruction by ectopic cysts, or ovarian adhesion caused by ovarian dysfunction caused by menstrual disorders At the same time, patients often have uterine fibroids or uterine adenomyosis can also cause menorrhagia or menstrual extension, etc., 9.9% of cases of endometriotic cysts with adenomyoma, 8.4% with uterine fibroids.

(3) Infertility: Patients with endometriosis often have infertility and have become one of the important causes of infertility.

(4) Sexual pain: About 30% of patients with endometriosis often complain of sexual pain, mostly due to mechanical stimulation, which occurs in the uterus rectal recession, vaginal rectal septum of endometriosis, so that around Tissue swelling, fibrosis, uterine contraction rises during sexual intercourse and pain occurs. The degree of sexual pain is related to the location of endometriosis, such as ectopic nodules in the patellofemoral ligament, low fixation after uterine adhesion, Tao The degree of sexual pain in the cavity is increased.

(5) Intestinal symptoms: If the endometriotic lesion is located in the uterus rectum and near the rectum, the menstrual period due to lesions congestion, edema, stimulation of the rectum leading to anal bulge and frequent or painful bowel movements, constipation may also occur Diarrhea, if the lesion invades the rectal wall and protrudes into the intestinal lumen or the lesion is large, it may cause intestinal stenosis or intestinal obstruction. If a small number of patients invade the intestinal wall and reach the muscular layer, edema may occur due to local intestinal mucosal congestion. Periodic stools carry blood, not caused by lesions invading the intestinal mucosa.

(6) urinary tract symptoms: If the endometriotic lesion is located in the bladder and ureter, the patient may have periodic urinary frequency, dysuria and hematuria, endometriosis lesions are rare in the ureter, slow ureteral obstruction is mostly due to pelvic cavity Endometriosis causes tissue adhesion around the pelvis or larger endometriotic cysts, causing distortion of the ureteral scar, stenosis or obstruction, and formation of hydronephrosis and secondary compression renal atrophy due to obstruction of the ureter .

(7) Other parts of endometriosis Symptoms: If endometriosis occurs and grows in other parts of the body, periodic pain occurs in the affected area, bleeding and massive enlargement, such as lesions occurring in the umbilicus In the abdominal wall wound and genital area, if the lesion involves the lung, pleura or sacral pleura, menstrual pneumothorax occurs repeatedly during menstruation, and premenstrual hemoptysis, dyspnea and/or chest pain may occur in the uterus of the brain. Membrane ectopic disease is very rare, and if it occurs, typical recurrent headaches and neurological deficits can occur.

(8) acute abdomen symptoms: a small number of ovarian endometriotic cysts, before menstruation or menstrual period due to increased intracapsular pressure, the capsule wall is broken, if the breach is small, there is not much spillage, abdominal pain can be gradually relieved If the mouth is large and the contents of the capsule overflow into the abdominal cavity, it will cause acute abdomen symptoms, which is a new problem worthy of attention in the field of obstetrics and gynecology.

2. Signs

With the location, extent and extent of the lesion, the typical pelvic endometriosis is characterized by uterine adhesions caused by posterior tilt fixation, the uterus can be enlarged, generally no more than 3 months pregnant uterus size, uterus The attachment area on one side or both sides can touch the inactive cystic mass connected to the uterus. The rectal uterus is concave or the uterine ligament, and the lower part of the posterior wall of the uterus can touch the irregular rice size to the broad bean size, single or Multiple, obvious tenderness, sometimes in the vagina, cervical or surgical scars, umbilical and other visible purple-blue nodules, menstrual period is more obvious.

Endometriosis examination

Common inspection

Rectal, periodic bleeding of the bladder, pain during menstrual defecation, first consider the rectum, endometriosis of the bladder, cystoscopy or proctoscopy if necessary, and tissue should be taken for pathological examination when there is ulcer.

Abdominal wall scars have periodic induration, pain, and a history of abdominal uterine abdominal wall suspension, caesarean section or cesarean section, the diagnosis can be established.

Suspicious cases can also be diagnosed if they are effective.

Where a local lumps are formed close to the body surface, the tissue should be taken as far as possible (cut or taken with a liver puncture needle) for pathological examination, which can be diagnosed.

B super

The acoustic image of the endometrioid cyst is a small granular echo. If the cystic fluid is viscous and there are inner membrane fragments floating inside, it is easy to resemble the echo characteristic of the hair contained in the teratoma fat, that is, the small light in the liquid. The belts are distributed in parallel dotted lines, sometimes separated inside, and are divided into several pockets of different sizes. The echoes between the capsules are inconsistent, often adhere to the uterus, and the boundary between the two is unclear. The teratoma is generally The cystic boundary is clear, and the ovarian endometrioid cyst is also easily confused with the attachment inflammatory mass and the oviduct pregnancy sonogram. Therefore, it should be identified in combination with the clinical characteristics. In addition, the vaginal probe is applied to make the mass in the near field of high frequency sound. Located in the identification of the nature of the pelvic mass, it has its superiority, can determine the nature and source of the tumor, can also puncture the cyst fluid or biopsy under ultrasound guidance to confirm the diagnosis.

X-ray inspection:

Can be used for pelvic gastroscope alone, pelvic gas angiography and uterine fallopian tube iodine angiography and uterine fallopian tube angiography, most endometriosis patients have internal genital adhesions and adhesions to the intestines, ectopic endometrium is most easily implanted in the uterus rectum Concave, so the adhesion of the internal genitalia is prone to uterine rectum depression, making it shallower, especially in the pelvic inflatable contrast lateral radiograph shows more obvious, the fallopian tube ovary can form adhesions, in the film or in the inflatable angiography shows more clearly Iodine oil hysterosalpingography can be kept unobstructed or unobstructed. Often, the 24-hour reexamination showed that the lipiodol was poorly spread due to adhesion, and it was like a small mass or a small snow-like appearance. Other causes of infertility and a history of dysmenorrhea can help diagnose endometriosis.

Laparoscopy:

In order to diagnose the endometriosis, the freshest planting spot seen by microscopic examination is yellow small blisters; the most biologically active is a large flame-shaped hemorrhage; most of the scattered lesions are merged into brown plaques and implanted deep; The patellofemoral ligament is thickened, hardened and shortened; the pelvic floor peritoneal scar is formed, which makes the uterus rectal fossa shallow; the ovarian implanted lesions are mostly in the free edge of the ovary and its dorsal side, initially 1 to 3 mm granuloma, gradually developing into the ovarian cortex. , the formation of chocolate sac, the surface is gray-blue, mostly bilateral, sticky to each other, inverted to the uterus rectal fossa, and the uterus, rectum and surrounding tissue extensive adhesion, I-II stage oviduct no abnormal, III ~ IV stage egg tube Over the capsule, passive extension, edema, limited peristalsis, more normal umbrella, smooth or unobstructed, uterine tubal fluid should be done when doing laparoscopic surgery.

Endometriosis diagnosis and differentiation

diagnosis:

According to the characteristics of this disease, women of childbearing age have progressive dysmenorrhea or history of infertility, gynecological examination can be found in the pelvic cavity with inactive mass or painful nodules, generally can be initially diagnosed as pelvic Endometriosis: For patients with a slightly complicated condition, the above laboratory tests and special examination methods can be used for diagnosis. The general diagnosis is not difficult, but in the process of diagnosis, the medical history must be detailed and the gynecological examination should be carried out carefully. ,: Especially the gynecological triad examination, comprehensive analysis of the condition to get a correct diagnosis.

Differential diagnosis:

1. Ovarian malignant tumor: The patient is generally in poor condition and the disease develops rapidly. It is often accompanied by persistent abdominal pain, abdominal distension, pelvic mass during gynecological examination. If the tumor is compressed by pelvic nerve or tumor tissue necrosis, the lower abdomen may occur. Abdominal pain in the lumbosacral region, accompanied by ascites, B-ultrasound showed that the tumor was solid or mixed, irregular shape.

2. Pelvic inflammatory mass: attachment inflammatory mass is caused by inflammation or tuberculosis. Careful medical history, patients with acute pelvic infection and recurrent history or history of tuberculosis, patients not only menstrual pain, but also usually accompanied by abdominal pain With fever, anti-inflammatory or anti-tuberculosis treatment, gynecological examination can be in one or both sides of the attachment area and inactive, the boundary line is not clear, generally stick to the uterus, such as the pelvic uterus When the differential diagnosis of membrane ectopic disease is difficult, B-ultrasound or uterine fallopian tube iodine angiography can be performed to further confirm the diagnosis.

3. Adenomyosis: Patients may also have dysmenorrhea, but the uterus generally has increased uniformity, hard quality, menstrual examination of uterine tenderness, and menstrual uterus enlargement, uterine contraction after menstruation, B-ultrasound can be seen uterine muscle Irregular echoes in the layer are enhanced. Factor adenomyosis often coexists with pelvic endometriosis, so the attachment area can sometimes be covered with mass.

4. Rectal cancer: Patients with rectal cancer often have blood or blood in the stool, and the symptoms are not affected by menstruation. The blood is stained on the finger sleeve during anal examination, but when the pelvic endometriosis is serious, it can invade the rectum wall and lead to the rectum. Narrow, with stool bulging, and even blood in the stool, need to be differentiated from rectal cancer, feasible barium enema or proctoscopy to determine the diagnosis.

5. Identification with women, surgical acute abdomen: due to the increasing incidence of ovarian endometriosis, the incidence of rupture of endometriotic cysts is also increasing, when the cyst is ruptured, due to a large number The contents of the capsule overflow into the abdominal cavity to produce sudden and intolerable severe abdominal pain. At this time, it is often misdiagnosed as ectopic pregnancy, ovarian cyst torsion, appendicitis, peritonitis and other gynecological diseases. Therefore, in the diagnosis of the disease, the medical history should be carefully asked. To understand whether there has been a history of endometriosis, history of menopause, and history of fever, all of which are helpful for differential diagnosis.

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