endometriosis
Introduction
Introduction to endometriosis The lesions and symptoms caused by the growth of the endometrium outside the uterine cavity are called endometriosis. Under normal circumstances, the endometrium covers the surface of the uterine cavity. If the endometrium grows in other parts of the body due to certain factors, it can become endometriosis. This ectopic endometrium is histologically. Not only the glands of the endometrium, but also the endometrial interstitial; there is a significant change in function with the level of estrogen, that is, with the menstrual cycle, but only a part of the progesterone, can produce a small amount of "menstruation" Caused a variety of clinical phenomena. If the patient is pregnant, the ectopic endometrium may have a decidual change. Although this ectopic endometrium grows in other tissues or organs, it is different from the invasion of malignant tumors. The peak of this disease is 30 to 40 years old. The actual incidence of endometriosis is much higher than that seen in clinical practice. basic knowledge The proportion of sickness: 0.01% Susceptible people: women Mode of infection: non-infectious Complications: menorrhagia, infertility, dysmenorrhea
Cause
Causes of endometriosis
Planting theory (30%):
The earliest (1921) people believe that the occurrence of pelvic endometriosis, endometrial debris with the menstrual blood flow, through the fallopian tube into the pelvic cavity and implanted in other parts of the ovary or pelvic cavity, clinically during the menstrual period laparotomy The menstrual blood can be found in the pelvic cavity, and the endometrium can be found in the blood. The abdominal wall scar endometriosis formed after cesarean section is a good example of the implant theory.
Serosal theory (25%):
Also known as the theory of metaplasia, it is believed that ovarian and pelvic endometriosis is caused by the mesenchymal cell layer of the peritoneum. The accessory kidney tube is developed from the primitive peritoneal invagination, with the ovarian hair growth epithelium, pelvic cavity. Peritoneal, atresia of the peritoneal depression, such as the peritoneal sheath (nucleus) of the inguinal region, rectal vaginal septum, umbilicus, etc., are all differentiated from the body cavity epithelium, where the tissue from the body cavity epithelium has potential capacity Produces tissue that is almost indistinguishable from the endometrium. Therefore, peritoneal mesothelial cells may be prone to metastasis under mechanical (including fallopian tube ventilation, posterior uterus, cervical obstruction), inflammatory, ectopic pregnancy and other factors. The endometrium of ectopic disease, the hair growth epithelium on the surface of the ovary belongs to the original body cavity epithelium, and has the potential of differentiation. Under the influence of hormones and inflammation, various tissues can be formed into embryos, including the endometrium. The ovary is the most easily involved part of extrinsic endometriosis. It is easy to explain with the theory of metaplasia. The implant theory cannot explain the occurrence of endometriosis beyond the pelvic cavity. .
Immunology (25%):
In 1980, Weed et al reported that lymphocytes and plasma cells infiltrated around the ectopic endometrium. The macrophages contained hemosiderin and various degrees of fibrosis. They believed that the ectopic endometrial lesions acted as foreign bodies and activated. Since the body's immune system, many scholars have explored the etiology and pathogenesis of endometriosis from cellular immunity and humoral immunity.
First, the cellular immune function defect
1. T lymphocyte function defects;
2, natural killer cell (NK) functional defects: NK cells are a group of heterogeneous multi-functional immune cells, its functional features are no need for antibodies, without antigen sensitization, can kill some tumors Cells or virus-infected cells play an important role in immune surveillance in vivo.
Second, body fluid immune function defects
Theories about the occurrence of endometriosis are as follows: 1 Lymphatic dissemination theory, that the endometrium can be spread by lymphatics, and it has been found that the parametrial lymph nodes and the intraorbital lymph nodes contain endometrial tissue, but this The weakness of the theory is that the endometrial tissue is rarely seen in the central lymph node, and the normal site does not conform to normal lymphatic drainage. 2 The blood flow dissemination theory, according to the literature, in the vein, pleura, liver parenchyma, kidney, upper arm, The ectopic endometrium has been found in the lower extremities. Some scholars believe that the most likely endometria is caused by the blood flow to the above tissues and organs, and it has caused experimental endometriosis in the rabbit lung. However, some people think that these conditions may be caused by blood circulation, but the local metaplasia can not be ruled out. Because the pleura is also differentiated from the body cavity epithelium, it is possible to produce germ and middle kidney tube during embryonic period. The body cavity epithelium is located in it, and the tissue can be metaplasticized in the future to form endometriosis in each part.
Regardless of the source of ectopic endometrium, its growth is related to ovarian endocrine. Clinical data may indicate that most of the symptoms occur in women of reproductive age (more than 80% of 30-50 years old), and often have ovarian dysfunction, resection After the ovary, the ectopic endometrium is atrophied. The growth of the ectopic endometrium mainly depends on estrogen. During pregnancy, progesterone is secreted more, and the ectopic endometrium is inhibited. Long-term oral synthesis of progestogens such as acetylidene ketone causes False pregnancy can also cause atrophy of the ectopic endometrium.
Pathological changes:
1. Intrinsic endometriosis
The endometrium grows from the base to the muscular layer and is confined to the uterus. Therefore, it is also known as adenomyosis. The ectopic endometrium is often dispersed throughout the uterine muscle wall. Due to the intimal invasion, the fibrous tissue and muscle fibers are reactively proliferated. The uterus is inflated, but rarely exceeds the full-term fetus. Uneven or focal distribution is common in the posterior wall. Because it is confined to the uterus, it often makes the uterus irregularly enlarged, resembling the uterus. In fibroids, the hyperplastic muscle tissue on the cut surface is also like a vortex-like structure of the fibroids, but no fibroids have a capsule-like tissue separate from the surrounding normal muscle fibers. There is a softening zone in the middle of the lesion, and even a small amount of stale product is scattered. The small cavity of blood, the endometrial gland seen by microscopic examination is the same as the endometrial gland, surrounded by the endometrial stroma, and the ectopic endometrium changes with the menstrual cycle, but the secretory phase changes are not obvious. , indicating that the ectopic endometrial gland is less affected by progesterone. When conceived, the stromal cells of the ectopic endometrium may show obvious decidual changes, as described above.
2. Interstitial endometriosis
It is a special type of endometriosis, which is rare, that is, the ectopic endometrium has only endometrial stroma tissue, or the extent and extent of endometrial invasion of the endometrium. Far more than glandular components, the general uterus consistency increases, ectopic cells are scattered in the muscle layer or concentrated in a certain area, the color is yellow, often has elastic rubber hardness, softer than fibroids, often can be seen in the cut surface Small insect-like protrusions can be used to establish a diagnosis. The ectopic tissue can also develop into a polypoid mass in the uterine cavity. It is multiple, smooth, and the pedicle width is directly related to the uterine muscle wall. The wall protrudes into the uterine cavity or along the uterine blood vessels into the broad ligament, causing menstruation to the uterine cavity to cause menorrhagia or even postmenopausal bleeding; to the broad ligament prominent can be diagnosed by gynecological double-combination, interstitial endometrial The disease can be spread by the lungs, even after several years of uterine resection. Because of this feature, some people think that interstitial endometriosis is a low-grade malignant sarcoma.
3. External endometriosis
The intima invades tissues other than the uterus (including the ectopic endometrium that invades the uterine serosa by the pelvis) or organs, often involving multiple organs or tissues.
The ovary is the most common site of extrinsic endometriosis, accounting for 80%, followed by the peritoneum of the uterus rectal fossa, including the uterine iliac ligament. The anterior wall of the uterus rectal fossa is equivalent to the posterior vaginal fornix and the posterior wall of the cervix. Corresponding to the inner cervix, sometimes the ectopic endometrium invades the anterior wall of the rectum, making the intestinal wall densely adhere to the posterior wall of the uterus and the ovary. It is difficult to separate during surgery. External endometriosis can also invade the rectum. The vaginal septum forms scattered dark purple dots on the mucous membrane of the vagina and can even form cauliflower-like protrusions, which resemble cancerous tumors. It can be confirmed as endometriosis by biopsy. In addition, the fallopian tubes, cervix and vulva are mentioned above. , appendix, umbilical, abdominal wall incision, hernia sac, bladder, lymph nodes, and even pleural and pericardium, upper extremities, thighs, skin may have ectopic endometrial growth.
The ectopic endometrium at the rectal fossa can also form a purple-black hemorrhage or a small blood sac on the peritoneum, which is embedded in the fibrous tissue with severe adhesion. The typical endometrium can be seen by microscopy. The endometrial tissue can still form a tender and solid nodule to the rectal vaginal septum and uterine ligament, or penetrate the posterior vaginal mucosa to form a blue-violet papillary mass. Many small bleeding spots may occur during menstruation, such as the rectal front wall involvement. Menstrual pain can occur in the menstrual period. Sometimes the endometrial lesions form a narrow ring around the rectum. It is very similar to the cancer. The intestinal invasion accounts for about 10% of the endometriosis. The lesion is often located in the serosa and muscle layer. Less mucosal invasion and ulceration, occasionally due to the formation of a mass in the intestinal wall or fibrous stenosis or adhesion caused by excessive flexion of the intestine, intestinal obstruction, and can cause irritation, such as intermittent diarrhea, menstrual period is more serious.
Prevention
Endometriosis prevention
According to the currently recognized etiology, the following points may be noted to prevent the occurrence of endometriosis:
1. Avoid unnecessary, repetitive or excessive gynecological double-consistency in the menstrual period, so as not to squeeze the endometrium into the fallopian tube and cause abdominal cavity planting.
2, gynecological surgery to avoid approaching menstrual period, must be carried out, intraoperative operation should be gentle, avoid forced to squeeze the palace, otherwise it may be possible to squeeze the endometrium into the fallopian tube, abdominal cavity.
3, timely correction of excessive stenosis of the uterus and cervical stenosis, so that the menstrual blood flow smoothly, avoid stasis, causing backflow.
4, strict control of the tubal patency test (ventilation, fluid) and angiographic procedures, can not be done in the menstrual just clean or directly in the curettage cycle, so as not to inject the endometrial debris into the abdominal cavity through the fallopian tube.
5, cesarean section and cesarean section of the fetus should pay attention to prevent the uterine cavity overflow into the abdominal cavity, when suturing the uterus incision, do not let the suture through the endometrial layer, suture the abdominal wall incision before the application of saline wash, to prevent Endometrial planting.
Since the reasons are manifold, the above-mentioned prevention opinions are only applicable to a few cases, and whether or not the menstrual blood flow itself causes endometriosis is still controversial.
Complication
Endometriosis complications Complications, menstruation, infertility, dysmenorrhea
At the same time, there are many menstrual periods, infertility, dysmenorrhea, and painful intercourse.
Symptom
Symptoms of endometriosis common symptoms dysmenorrhea menstruation volume menstrual sudden arrest secondary infertility
Symptoms and signs of endometriosis vary with the location of the ectopic endometrium and are closely related to the menstrual cycle.
1, symptoms
(1) Dysmenorrhea: a common and prominent symptom, mostly secondary, that is, from the occurrence of endometriosis, the patient complained that there was no pain in the past menstrual cramps, and dysmenorrhea began from a certain period, which may occur in Before menstruation, menstruation and menstruation, some dysmenorrhea is more difficult, need to rest in bed or use drugs to relieve pain, pain often aggravates with the menstrual cycle, due to the rising levels of estrogen, ectopic endometrial hyperplasia, Swelling, such as re-fertilization of progesterone, bleeding, stimulating local tissue, resulting in pain, such as endometriosis, can also cause uterine muscle contracture, dysmenorrhea is bound to be more significant, ectopic tissue without bleeding, its Dysmenorrhea may be caused by vascular congestion. After menstruation, the ectopic endometrium gradually shrinks and the dysmenorrhea disappears. In addition, in the pelvic endometriosis, many inflammatory processes can be detected, and it is likely that the local inflammatory process is accompanied by an active peritoneum. Lesions, which produce prostaglandins, kinins and other peptides that cause pain or tenderness, but the degree of pain often does not reflect the disease detected by laparoscopy Degree, clinical endometriosis is significant, but no dysmenorrhea, accounting for about 25%, women's psychological status can also affect pain.
(2) Menorrhagia: Intrinsic endometriosis, menstrual flow tends to increase, menstrual period prolonged, may be due to increased endometrium, but more accompanied by ovarian dysfunction.
(3) infertility: endometriosis patients often accompanied by infertility, according to Tianjin, Shanghai reported that primary infertility accounted for 41.5 to 43.3%, secondary infertility accounted for 46.6 to 47.3%, infertility The causal relationship with endometriosis is still controversial. Pelvic endometriosis can often cause adhesions around the fallopian tubes to affect the oocyte pickup or blockage of the lumen, or the infertility caused by ovarian lesions affecting the normal progression of ovulation. However, some people think that long-term infertility, menstruation without a closed period, can cause endometriosis opportunities; and once pregnant, the ectopic endometrium is inhibited and shrunk.
(4) pain of sexual intercourse: endometriosis occurs in the rectal fossa of the uterus, vaginal rectum, so that the surrounding tissue is swollen and affects sexual life, and the premenstrual period is not quick and sexy.
(5) Swelling of the stool: generally occurs in the premenstrual period or after menstruation, the patient feels the pain when the feces pass through the rectum, but does not have this feeling at other times. It is a typical symptom of endometriosis near the rectal fossa and the rectum. Occasionally, the ectopic endometrium is deep into the rectal mucosa, and there is menstrual rectal bleeding. The endometriosis lesions around the rectum form a stenosis with urgency and obstruction, so it is similar to cancer.
(6) bladder symptoms: more common in the endometriosis to the bladder, periodic urinary frequency, urinary pain symptoms; invading the bladder mucosa, periodic hematuria can occur.
Endometriosis of the abdominal wall and uterine endometriosis have periodic localized masses and pain.
2, signs
Patients with intrinsic endometriosis often have uterine bloating, but rarely more than 3 months of pregnancy, mostly consistent swelling, may also feel that a certain part is more prominent like uterine fibroids, such as the posterior uterus, often adhesion Fixed, in the uterus rectal fossa, uterine ligament or posterior wall of the cervix often touch one or two hard small nodules, such as mung bean or soybean size, more obvious tenderness, more obvious anal diagnosis, this is very important Occasionally, in the vagina, there are black and purple bleeding spots or nodules. If there are more lesions in the rectum, you can touch a hard block or even be misdiagnosed as rectal cancer.
Ovarian hematoma often adheres to the surrounding, fixed, gynecological double-combination can touch the mass of the larger mass and tenderness, combined with infertility history is easily misdiagnosed as an annex inflammation block, internal bleeding occurs after rupture, manifested as acute abdominal pain.
Examine
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.
Diagnosis
Diagnosis and differentiation of endometriosis
diagnosis
The disease mostly occurs in women aged 30 to 40 years, the main complaint is secondary progressive severe dysmenorrhea, should be highly suspected as endometriosis, patients often accompanied by infertility, menorrhagia and sexy unpleasant, uterus during gynecological examination Slightly swelled, uterine ligament or posterior wall of the cervix with nodules, can be diagnosed as endometriosis, in the presence of ovarian endometrial cysts, double-diagnosis can touch one or both cystic or sac Solid mass, usually within 10cm diameter, has a sticky feeling with the surrounding.
Differential diagnosis
1, uterine fibroids
Uterine fibroids often show similar symptoms, general endometriosis dysmenorrhea is heavier, secondary, progressive, uterine consistency swell, but not very large, such as accompanying other parts of the ectopic endometrium, it helps Identification, indeed difficult patients can try drug treatment, such as rapid symptoms (1 to 2 months of medication) improvement, diagnosis tends to endometriosis, it should be noted that adenomyosis can coexist with uterine fibroids (about 10 %), generally difficult to identify before surgery, subject to surgical removal of the pathological examination of the uterus.
2, annex inflammation
Ovarian endometriosis, often misdiagnosed as accessory inflammation, both can form a tender mass in the pelvic cavity, but patients with endometriosis have no history of acute infection, patients with various anti-inflammatory treatments There is no effect, and should be asked in detail about the beginning of dysmenorrhea and the degree of pain. This case often has ectopic endometrial nodules at the rectal fossa. If you check it carefully, it can be diagnosed, it can help diagnose, and if necessary, drug testing can be used. Observe whether there is curative effect to identify, generally in the ovarian endometriosis, the fallopian tube is often unobstructed, so you can try the tubal water test, such as unobstructed, you can rule out tubal inflammation.
3, ovarian malignant tumor
Ovarian cancer misdiagnosed as ovarian endometriosis, delay treatment, it must be careful, ovarian cancer does not necessarily have abdominal pain symptoms, if it is often persistent, unlike periodic abdominal pain of endometriosis, Ovarian cancer is a parenchyma at the time of examination, the surface is uneven, and the volume is also large. The endometriosis of the ovary may also be accompanied by endometriosis in other parts, and the signs of each part of the lesion are Patients who cannot be identified should have a laparotomy for their older age and a short-term treatment for endometriosis to observe the effect.
4, rectal cancer
When endometriosis invades the rectum and the sigmoid colon is wide, it often forms a hard block there, causing partial obstruction. In some cases, ectopic endometrial invasion and intestinal mucosa cause bleeding, which is more like rectal cancer, but rectum. The incidence of cancer is much higher than that of intestinal endometriosis. Generally, patients with rectal cancer have significant weight loss, frequent intestinal bleeding, no relationship with menstruation, no dysmenorrhea, and the tumor is fixed on the intestinal wall during anal examination. All are narrow, the intestinal mucosa is uneven in the barium enema, the sputum filling is small, the sigmoid colonoscopy sees ulcers, bleeding, biopsy can be diagnosed, intestinal endometriosis does not lose weight, intestinal bleeding is rare, individual bleeding is also in menstruation During the period, the dysmenorrhea is heavier. The mucosa of the anus is not adhered to the bottom mass. Only the anterior wall is hard. The barium enema shows smooth intestinal mucosa and a wide range of sputum filling.
