Endometriosis Treatment

1. Drug therapy
(1) the purpose of medical treatment: The main symptoms and solutions for the control of fertility requirements of non-endometriosis-induced pain at the time of diagnosis should not, in order to exclude the effects of ectopic lesions may be experimenting with drugs suppress ovarian function in the program. Described before, 30% ~ 50% of endometriosis associated with infertility in this part of the treatment of sick The main purpose is to promote fertility. Generally desirable from a minimum of destructive and effective method if the continuous treatment beginning 3 ~ 6 cycles invalid, and further may wish to consider the more complex treatment program, IVF-ET treatment technology such as their final choice.

(2) drug treatment: symptomatic treatment including drug therapy and hormone suppression therapy The former applies to lesions confined to the stage Ⅰ ~ Ⅱ have chronic pelvic pain without fertility requirements, and symptomatic treatment may cause the progression of the disease or cause of infertility so that the uterus membrane of hormone therapy to shrink than to make decidualization better therapeutic effect, and in pseudopregnant period, pituitary and ovarian function suppression is stronger than sham-menopausal therapy. Medication during the period mid-LH, FSH, P, E2 water average lower exogenous estrogen / progesterone and the endometrium and ectopic endometrium on the corresponding receptor binding, leading to endometrial atrophy, edema and decidua and so on, and then enable the absorption of necrotic lesions happen.
① estrogen / progestin hormone-induced pseudopregnancy therapy:
A. oral contraceptives. By Kistner in 1958 with the first, the law continued to take high doses of estrogen / progesterone hormone producing a high of amenorrhea produced similar changes and pregnancy, pseudopregnancy named. A variety of oral contraceptives can be used to induce pseudopregnancy, one of progesterone containing preparations efficient best, such as acetylene Connaught progesterone (18 L-norgestrel) 0.5mg + ethinylestradiol (ethinylestradiol) 0.05mg, etc.
Usage: 1 every day, continuing for 6 to 9 months, every time a breakthrough after a hemorrhage, to amenorrhea effect until the effective dose varies from person to person: relief of symptoms depends on the induced amenorrhea. Some patients at the beginning of treatment, lesions could expand symptoms worsened after gradually reduce the effect of this method than danazol (danazol) GnRHa effect of the bad. Its adverse reactions and contraindications with the same contraceptive.
B. Progesterone: alone synthetic progesterone by inhibiting pituitary gonadotropin secretion, resulting in non-cyclical low estrogen status, but also with cell progesterone and androgen receptor binding, directly to the ectopic foci the role of anti-estrogen effect. Synthetic progesterone and estrogen endogenous common role, resulting in a high progesterone and the decidua of amenorrhea, and the formation of pseudopregnancy but because of the level of endogenous estrogen fluctuation prone to breakthrough bleeding, may add a small amount of estrogen use hormone to form a typical pseudopregnancy. This method can be used for danazol (danazol), GnRHa taboos are. Commonly used synthetic progesterone preparations can be divided into two categories: one for the C-2l type of progesterone, such as medroxyprogesterone acetate (MPA), etc.; one for the C-19 type of progesterone, such as Gestrinone (within the U.S. Qualcomm), the latter the role of a strong androgen.
Usage: medroxyprogesterone acetate (MPA) 40mg / d or norethisterone (nore-thindrone) 30mg / d or norethindrone acetate (norethindrone acetate) 15mg / d. Late and non-reproductive requirements of the patients with surgical contraindications, available long-acting medroxyprogesterone acetate (depot-MPA) 100 ~ 200mg, monthly one time. Gestrinone (with PR) 1.25 ~ 2.5mg, week 2 times, and 6 months.
Adverse reactions: the more estrogen / progesterone combination therapy less medroxyprogesterone acetate (depo-MPA) with a slow absorption and excretion characteristics of it applies to prevent the recurrence of residual disease because of drug absorption can cause irregular bleeding instability . Does not apply to the treatment shortly after birth has required. Gestrinone (PR inside) of the adverse reactions of weight gain (an average increase of 2.1kg), headache, hyperhidrosis, hirsutism and irregular bleeding after drug withdrawal natural recovery.
② danazol (danazol): 20 century and the mid-70s for the treatment of endometriosis, is still the drug of choice in many countries. It is a steroid derivative structure on a similar androgen, 17α-acetylene testosterone rapidly absorbed by the gastrointestinal tract and rapidly metabolized by the excretion of urine and faeces. 2h after oral 400mg to achieve maximum blood concentration (200μg/ml), the average half-life of 28h, after a single 400mg oral, 60h plasma concentration fell to 27.5ng/ml
A. the role of mechanisms:
a. with a variety of receptor-binding and thus has many functions, can be in the peripheral circulation and sex hormone-binding globulin (SHBG) with lower free testosterone level of SHBG increased. At the target cells with androgen receptor binding, danazol - hormone receptor complex into the nucleus, synthesis of new proteins
b. to replace the progesterone hormone and cortisone and corticosteroid-binding globulin binding.
c. estrogen and cell combination does not happen.
d. steroidal substances by competitive enzyme activity, inhibition of adrenal and ovarian steroid generation enzyme role.
e. the hypothalamus - pituitary levels, inhibiting the mid-FSH, LH peak to lower the level of both basic and direct role in ovarian steroidal ovarian suppression generation capacity and reduce the peripheral circulation in steroid levels, resulting in power and ectopic endometrium atrophy.
f. can be directly related to endometrial androgen and progesterone receptor binding, inhibition of proliferation of endometrial cells.
g. Danazol Immunomodulatory effects of in vitro studies have shown Danazol by testosterone, progesterone and glucocorticoid receptors affect intracellular calcium and cAMP / cGMP and play a role. After danazol treatment, in vivo autoantibody levels were significantly decreased, while in vivo immunoglobulin IgGIgM, IgA levels also declined in recent years, studies show that endometriosis Patient peripheral blood macrophages can promote their own endometrial cells of hyperplasia, add at after danazol, the role of cell proliferation were inhibited.
B. Usage: menstrual day 1, danazol 200mg, 3 ~ 4 times / d, or 12mg / (kg d), continued for 6 to 9 months. Amenorrhea at the start, can be reduced to 600mg / d during the administration of serum E2 levels are maintained at 20 ~ 50pg/ml. The length of treatment depends on the individual's response and disease stages, the only plant without endometriosis peritoneal tumors are generally 3 to 4 months of amenorrhea have been enough to make lesions were completely degraded. <3cm of the endometrial tumor, treatment may be extended to 6 months,> 3cm often takes 6 to 9 months of treatment, but usually lesions should not completely disappear, surgery can be used to remove the.
C. effect: treatment decisions in the drug dose and serum E2 response to the degree of ovarian suppression. With the beginning of amenorrhea after treatment appears to improve symptoms, course of treatment after the end of about 90% of the symptoms completely disappear laparoscopic cure rate of 70% ~ 90%. Pregnancy rate at 800mg / d for 50% ~ 83%. Discontinuation of one year recurrence rate was 23% indicates that there is residual lesions exist, after the annual recurrence rate was 5% ~ 9%
D. Adverse Reactions
③ tamoxifen (TAM TAM): is a non-steroidal estrogen antagonist with normal ovarian function, when the women taking tamoxifen (TAM), they can compete with the estrogen-estrogen receptor, reducing the effects of estrogen and progesterone stimulate the synthesis, and has played the role of anti-estrogen. When Low, when ovarian function, tamoxifen (TAM) for the weak performance of the role of estrogen.
Usage: Every time 10mg2 ~ 3 times / d, taking 3 to 6 consecutive months.
Side effects: for hot flashes nausea, vomiting, edema, vaginitis, and depression, such as androgen response, but the reaction than danazol light. Possible long-term effect on endometrial estrogen stimulation caused endometrial hyperplasia and even endometrial malignant transformation, such as. Strict selection should be the object of high-risk cases should have chosen other methods.
④ Gestrinone (PR inside): also known as leukotriene Metorchis Connaught ketone (R-2323). For 19 - to a testosterone derivative, the 20th century, beginning the 80's for the treatment of endometriosis it has a complex hormone and anti-estrogen properties, which is also a suitable treatment of endometriosis drug . Study shows that Gestrinone (with PR) regulate gene expression through specific receptor-binding role of target tissue, it can inhibit the pituitary secretion of FSH and LH, and progesterone receptor binding capacity has a strong and androgen receptor with androgen combined with its role and norethisterone similar. Of estrogen receptor-binding role of weak.
Usage: menstruation start day 1, each 2.5mg, orally 2 times a week, sustained for 6 months.
The effect of: A. the pain disappeared: in the treatment of the first 1 month, 60% of women to alleviate pain or disappeared, the treatment of 4 months 90% improvement in symptoms; B. AFS score: Mettler reported Gestrinone (in PR ) in the treatment of 6 months after the AFS score from pre-treatment average of 15.5 hours to 2.0 hours, indicating that significantly reduced the disease; C. pregnancy: treatment of 24 months after the pregnancy rate for 60%, slightly higher than danazol; D. relapse rate: 12% ~ 17%.
⑤ GnRHa: synthetic analogues GnRHa has two characteristics, namely the pituitary GnRH receptor has a high degree of affinity and resistance to endopeptidase degradation and extend the half-life, long-acting formulations may be the maintenance of effective concentrations of 4-week early in the application that this compound has to promote the role of pregnancy, so named as GnRH agonists, then clear at 2 weeks after medication, may be short-lived FSH, LH rise, followed by sharp decline in the regulating role. Commonly used preparations and usage.
Drugs due to individual and different, there is increase or decrease in dose may be, in general, because of congestive nasal spray nasal absorption unstable. To 6 month course of treatment is appropriate, when a serious situation of low estrogen, the treatment corresponding to shorten the treatment effect with danazol symptoms similar complete remission rates of> 50%, partial remission rate of> 90% of lesions and laparoscopic narrowing score reduced by about 50 %.
Side effects: mainly pituitary - ovarian axis dysfunction, lower levels of estrogen caused by menopause syndrome similar to the performance of critical hot hyperhidrosis, vasomotor instability in breast narrow vaginal dryness for the common response, accounting for 90% about the general does not affect the continued use. Serious reduction in estrogen (E2 <20pg/ml), can increase the absorption of calcium in bone and osteoporosis happened, the severity of the inconsistency, rather than restore the original after stopping migraine and depression are not applications, so as not to add to the original have symptoms. Period of appropriate medication regularly to guide the level of detection of E2 dose, as needed and to what level of E2 in order to show that the best dose of medication, and clinical efficacy with hormone Lower line, such as the severity of the problem, it is not very clear. Barbieri reported different organizations estrogen threshold varies, according to the endometrium of the reaction of danazol in the treatment of E2 concentration during the 20 ~ 60pg/ml appropriate.
⑥ Mifepristone: also known as RU-486. For the synthetic 19 - to methyl testosterone derivatives mifepristone (RU-486) treatment of endometriosis are the main mechanism of its anti-progesterone effect, causing amenorrhea after treatment, so that lesions to shrink. Light adverse reactions, efficacy, and is a promising method of treatment.
Usage: 50mg / d for 6 months, medication at the first month that a medication during amenorrhea symptoms disappear, about 50% of patients with androgen at physiological levels to maintain. Domestic trials of low-dose, 10mg / d for 90 days, was also satisfied with the effect. Its efficacy and danazol and GnRHa similar.
Adverse Reactions: The main anti-glucocorticoid response, and other side effects have nausea, vomiting, dizziness and fatigue and so on.

(3) comparison of the various drugs:
① effects: The drug treatment, the vast majority of patients with endometriosis can eliminate pain, to achieve a high remission rate of symptoms, signs of improvement while Buserelin (buserelin) the best, its so ovarian chocolate cyst reduce the efficacy was significantly superior to danazol or Gestrinone (with PR) (P <0.01) (Table 89). AFS score decreased efficacy, only found in by Buserelin (buserelin) subcutaneous injection for treatment of severe endometriosis group, from pre-treatment (18.5 ± 1.6) hours after treatment decreased (14.O ± 2.8) hours, the difference has a very significant (P <0.005).
② Comparison of adverse reactions: the mechanism of various drugs and their adverse reactions related. Progesterone hormones is now less commonly used by foreign androgen derivatives or GnRH synergist. Androgen derivatives main adverse reactions to liver dysfunction and androgen-like response to one of Gestrinone (PR inside) caused by weight gain, excess sebum, acne hair many significant than danazol for the light.
GnRH synergist showed only peri-menopausal symptoms. No matter what kind of reaction, may disappear after stopping.
③ drug efficacy and histology study on the relationship between more than 20 years, new drugs for the treatment of endometriosis have come out in succession, indicating its good prospects. But no matter what the drugs, the total has 10% ~ 20% of patients should not receive effect. The reason there is summed up as follows several hypotheses:
A. because of fibrosis around the lesion, so that drugs are not accessible locally.
B. Light microscopy and electron microscopy proved ectopic endometrial morphology and normal endometrium was often not the same lesions seen mesenchymal without glandular epithelium.
C. ectopic endometrial cells may have its own genetic program, and endocrine effects of only secondary, and individual cell differentiation due to different degrees, so that effects of different.
D. ectopic endometrium in the number of steroid hormone receptor Low. Ectopic endometrium, unlike normal endometrium by endocrine regulation and thus could lead to a lack of endocrine dependence.
Although drug treatment at a good clinical efficacy, but any kind of drugs are still a problem, that is, relapse after drug withdrawal. To this end, Donnez of 201 cases of endometriosis were divided into 5 groups: Danazol, linezolid progesterone (female propargyl enol) Gestrinone (PR inside), Buserelin (buserelin) nasal inhalation and Bouchereau Baorui Lin (buserelin) treatment with subcutaneous injection and has 32 cases of control. 6 months after treatment of ovarian endometriotic lesions for the residual histology examination. The results of 97% ~ 100% of cases of biopsy can still see the endometrial glandular epithelium, of which 46% ~ 84% for the Events Officer temper endometriosis, this with a lot of different literature reports. Group 5 to Buserelin (buserelin) after subcutaneous injection of the treatment of lesions of the lowest rates of activity, but were significantly higher than those reported in clinical relapse rate after drug treatment (30% ~ 40%).

2. Surgical treatment
(1) abdominal surgery: Surgery is the only means to cure this disease because of the popularity of laparoscopic use, making possible the early diagnosis of this disease, coupled with its close relationship with infertility, so young and have reproductive requirements of patients, conservative surgical treatment of more and more important
Conservative surgery for the purpose of generally have the following points: ① to remove lesions and adhesions; ② restore normal anatomical relations; ③ hemostasis; ④ non-traumatic and plastic surgery.

Surgical indications:
① pain: chronic pelvic pain refers to pain, intercourse pain and dysmenorrhea. The degree of pain and lesions RAFS classification has nothing to do with the depth and extent of lesions related to it is removed ovarian or ovarian function suppression can be the treatment of pain, removal of lesions can also be effective treatment for pain.
② mass: a result of ovarian cysts or ectopic mass within the broad ligament, uterine rectum of ectopic nodules and uterine adhesions and laparoscopic examination found one of about 0.04% for the malignant tumor, it should be According to patient's age, size and nature of mass, sick time and B ultrasonic diagnosis, such as careful patient selection. Size and nature of mass, it was reported that <5cm, and about 1% for the malignant; 5 ~ 10cm, and there is 11% for malignant;> 10cm, and 72% malignant.
③ infertility: endometriosis patients with infertility, surgery is the preferred treatment of disagreement such as pigmentation of the only very early lesions or small ectopic foci, surgery can improve pregnancy rate and reduce the pain, divergent views, the opposing views that the superficial parts of the surgery not only ineffective, but it will also result in adverse consequences, such as adhesion, and micro-lesions can not be completely clear. And advocate the views of the purposes of surgical treatment that patients with endometriosis the incidence of infertility is indeed higher than that in normal women seized the timely implementation of laparoscopic diagnosis of the disease at the same time, also found that other causes of infertility and the necessary treatment, such as pain associated with surgery is even more early.

Laparotomy operation with conventional surgery
(2) laparoscopic surgery: the advantages of laparoscopic restore order to facilitate quick, small and economic injury.
① superficial treatment of ectopic foci: a small and superficial lesions can be used for unipolar or bipolar coagulation, thermal coagulation or vaporization, as far as possible to bring focus to avoid damage to surrounding tissue such as lesions after removal of the effect of solidification add the most好. Large lesions blunt feasible separation, then use scissors or laser in the surrounding normal peritoneal operate on.
② uterine deal closed rectum: rectum uterine closure has prompted deep recto-vaginal lesions. Rectum part of the uterus is closed, the swelling from the rectum and sacral ligament and uterine adhesions connected. Partially closed, said there is deep under the plant peritoneal lesions, so that the location of change in the rectum. When the rectum uterus of a complete closure, often associated with adhesions around the organs. The purposes of pre-operative patients should first clearly therapeutic purposes, such as for relief of pain, they should be en bloc resection of lesions as a result of infertility, it would take to restore the uterus, fallopian tubes and ovarian anatomy and physiological functions of the main. Surgery should be carefully dissected to identify the neighboring organs whatever types of surgical treatment of ectopic lesions, should be from the superficial to deep, and try to bring order to avoid injury lesions adjacent organs. Finally, as far as possible to carry out peritoneal wound, and prevention of postoperative adhesions.
③ ovarian endometrioma (chocolate cyst) surgery: ovarian endometrioma endometriosis accounted for 50% ~ 70% of its performance and other parts of the lesions is different from a cyst in the same period can be expressed in different organizational components such as epithelial cysts, tubal ciliated epithelium, endometrial and stromal organization, and has engulfed hemosiderin macrophages.
A. laparoscopic ovarian endometriotic cyst puncture: the most simple operation, applicable to small or close adhesion of the cyst should not divest. Steps are as follows: a. The most distinguishing feature in the cyst to puncture; b. Intracapsular aspiration of liquid; c. within the intracapsular and pelvic rinse; d. electrocoagulation or laser damage to wall.
B. endometriotic ovarian tumor fenestration: a. The most distinguishing feature of firms in the cyst 1 with electric condensate, b. condensate along with electricity for all the mouth; c. suction in addition to intracystic structures, running water; d. electrocoagulation marginal incision to stop bleeding, to retain an open incision; e. Rinse
C. wall dissection: a. The most distinguishing feature of firms in the cyst one electric condensate zone, along with electric condensate for all I; b. clear the capsule contents, side edges flush operation and attract; c. separation wall and the ovarian cortex; d. use of grasping forceps to seize the wall, Shun a reverse direction; e. In addition to wall all the twisting to stop bleeding after electrocoagulation; f. reservations open incision or suturing; g. such as the separation wall and the ovary is not easy to find the line with grasping forceps living wall raised, to see the sub-interface, with pointed tip electrocoagulation or laser separation carefully.
D. Ovarian partial laryngectomy: the larger cysts, adhesions, more restrictive, when a clean spin-off should not be considered part of ovary excision. A. in the following steps at the bottom and ovarian cysts at the junction, electrocoagulation or laser cutting cyst; b. retained normal ovarian tissue as possible; c. If it is retained ovarian tissue is too small, could be leaving part of wall; d. electrocoagulation residual wall to prevent recurrence; e. ovarian suture.
E. ovarian surgery: ovarian tissue has been used only for ectopic endometrial tissue was completely destroyed, and can not line ovarian adhesions serious case of partial resection. Operation with other ovarian cyst removal of the same; a. grasping forceps against ovarian exposed cyst pedicle; b. pedicle ligation in 3 times; c. between node 2,3 in the first cut under the electric condensate cyst; d. electrocoagulation pedicle haemostasis and prevent adhesion; e. wall for large puncture device can be removed if necessary, can be broken up and then removed.

3. United drugs and surgical treatment of endometriosis of the conservative treatment has three kinds of methods: surgery, drug suppression and the combined application of both forms of treatment depends on the selection of general pain, infertility and the severity of the lesions. At present, laparoscopy has been minimal change at all, the vast majority of lesions and the majority of mild to severe lesions in the preferred method of treatment, but most scholars believe that a considerable number of patients still required the combined drug treatment.
Surgical treatment restore normal anatomic relationship between the removal of lesions and at the same time separation of adhesions, but there are also deficiencies, such as postoperative adhesions may cause infertility, severe adhesions so that the complete removal of lesions, and deep under the microscope of the lesions to be seen, postoperative complications and sometimes it is difficult to avoid, such as drug therapy despite good effect, but probably after stopping short-term lesion recurrence, dense adhesions impede the arrival of drugs affecting the efficacy of intralesional Over the years, has been using drugs before and after surgical treatment, the ideal measures are in use after 3 to 6 months is invalid, the Bank seized the second laparoscopy to identify the reasons for timely treatment. Postoperative adhesions are the main reason for the effect of the impact of surgery, preoperative application of danazol or GnRHa, at the role of low estrogen, the reduction of intra-abdominal hyperemia, capillary hyperemia and expansion are not clear that there is conducive to the extraction operation. At the same time, reduce the capacity of peritoneal fluid and clear, in which fibrin was reduced, so that peeling adhesions, ovarian cysts within the abdominal cavity peeling these changes can also be the prevention of postoperative adhesion formation.
After application of 1 ~ 2 months of drugs, can inhibit the operation of the lesions missed, prevention of recurrence after surgery mild endometriosis lesions removed, different inhibitory drugs can be used in intra-abdominal post-operative environment has changed is conducive to the restoration of fertility, most of the pregnancy after the operation took place in post-operative within one year, during ovulation induction therapy can be considered to promote fertility after surgery for 6 to 12 months after pregnancy, infertility in identifying causes, may give inhibit endometriosis drug treatment.

4. Choose treatment endometriosis treatment primarily on the basis of a lot of patient's age, infertility duration, symptom severity, lesion area, as well as to make a choice RAFS phases. At present the view that the morphological characteristics of lesions and determination of steroid hormone receptors on the choice of treatment methods will be more important.
(1) treatment of pre-decision-making to consider:
① natural course of disease: the traditional concepts are as time goes by, the number of species of plants ectopic endometrium and the size increased. Buttram and Betts could not confirm the patient's age and severity of disease has a significant contact, such circumstantial evidence is that not all the endometriosis patient had aggravated sexual characteristics. Thomas and Cooke (1987) reported that forward-looking use of placebo-controlled study with placebo before and after the application of laparoscopy to determine the scope of lesions found with placebo after 6 months, his condition did have sexual heavier; but in 17 cases of minor light severe endometriosis, the four cases with placebo, the lesions completely eliminated. Prompted mild cases there is probably a natural recovery, but requires further evaluation, it was identified. Able to predict what kind of cases such as dead will increase, which probably died cases improved, treatment choices will have great value.
② severity of illness: the first thing to consider is whether the damage to pelvic organs and adhesions, because any kind of hormone therapy can not salpingostomy adhesion release, that is, changes in drugs on the anatomical structure not improve. In contrast, surgical removal of endometriosis is not only able to remove endometriosis lesions and infertility caused by mechanical factors, there are a reasonable selection Virtue infertility.
Lesions in patients with extensive endometriosis should be taken to surgery, surgical methods may be based on clinical staging. Whether the surgery took only one or with drugs but in most cases, although the argument advocated perioperative medication, particularly Buserelin (buserelin) the best.
③ age and reproductive status: Patient chief complaint of infertility to consider the age factor is particularly important. On very young patients with endometriosis, a series of drug therapy is appropriate; but older (30 years of age) women's drug treatment are probably a waste of time to surgical treatment at this time to take more practical; older women ( over 40 years of age), such as childbearing has been completed, but to avoid premature ovarian failure, according to Buserelin (buserelin) recommended Resectability uterus and ectopic foci, retain all or part of ovarian tissue in order to maintain endocrine function. Patient near menopause (45 years of age), drug therapy can be feasible through the menopause, ovarian function after recession endometriosis can often be self-healing. However, in patients with severe or accompanied by other genital lesions, it is desirable that line hysterectomy and bilateral attachment to retain the side of surgery such as ovarian possible activation of residual symptoms of ectopic endometrium hair again, it should be given medical treatment after 3 ~ 6 months.
④ morphological criteria: ectopic endometrium because the basic organizational structure and similar to normal endometrium, causing it easy to assume that endometriosis is the ectopic endometrium. In fact, ectopic endometrium in endometriosis and their own morphology, histochemistry and biochemistry often see different:
A. ectopic endometrium with varying degrees of differentiation, differentiation of immature on the sex hormones is not sensitive, especially for non-response to progesterone. Thus ectopic endometrium and endometrial endogenous ovarian hormone effects may not be synchronized by the two organizations is not fully consistent.
B. ectopic endometrium poorer metabolic function, whether in its glandular epithelium, surface epithelium or vascular endothelial small spiral, the alkaline phosphatase activity than those of the endometrium for the weak. Ectopic endometrial surface epithelial cells and phagocytic activity of acid phosphatase increased significantly, acid phosphatase as lysosomal enzyme, results suggest that intracellular catabolism and the role of enhanced autolysis
C. cytoplasm and nucleus within the ER, PR levels and cyclical changes it is obvious there is another, ectopic endometrium in the level of ER and PR in endometrial lower than their own, and usually there is a sex hormone receptor
Differences in the use of such prediction possible endometriosis patients with response to treatment is estimated that no effect of hormone therapy, and surgical treatment should be taken
(2) treatment options:
① look forward to the treatment: of minor or mild endometriosis patients, some scholars have suggested that firms look forward to treatment. Malinak schenken and reported 75% (12/16) with mild endometriosis without treatment, at 1 year to conceive, and by conservative surgery the pregnancy was 72.4% (21/25). Seibel such forward-looking study 19 cases of mild endometriosis in 13 cases observed at one year to conceive, pregnancy rate was 68%; compared with 13 cases of treatment with danazol for 6 months and then observed for six months only five cases of conception, pregnancy rate was 38%. At present, such as patients think young, minor lesions, diagnosed by laparoscopy can be observed Wait for 6 to 9 months due to 30% ~ 60% of such patients did not meet the treatment can also be conceived.
② drug therapy: there is a wide range of drugs now available, based on age, breeding history and severity to make a choice. The future can be used such as morphological criteria for deciding the treatment modalities, will now take the other standards play a leading role, is expected to reach the appropriate treatment, improve efficacy purposes.
③ surgical treatment: Since the popularization and application of new technologies, including microsurgical techniques, laparoscopic and laser surgery, so that the status of surgical treatment and more important.
Infertility are the main symptoms of endometriosis, one of the restore fertility are an important indicator to assess efficacy. Olive and Martin literature review of endometriosis patients with the use of various methods of fertility after treatment to compare the results: A. The treatment of mild endometriosis can not prove that the most advantageous ways. B. severe endometriosis by noninvasive laser microsurgery and laparoscopic surgery the highest success rate. C. look forward to therapy and drug therapy the cumulative pregnancy rate (life table method) is obviously due to different stages stages stages late pregnancy are low; and microsurgery or laparoscopic laser period after pregnancy with no apparent relationship.
④ Individual treatment: endometriosis treatment of individual patients are the most reasonable method
A. endometriosis associated with infertility:
a. infertility associated with minimal or mild endometriosis, such as young patients, asymptomatic lesions may be the pilot light look forward to therapy, but should be fully valued and to correct the other factors of infertility. Yet such as pregnancy, that is, using the experience of the treatment of drug therapy or surgery to retain functionality. Older who look forward to therapy or long-term hormone therapy is inappropriate, conservative surgery is preferred. Such as the failure of the above methods can add auxiliary measures to promote fertility, depending on the circumstances the use of uterine rectal insemination, gamete intrafallopian transfer (GIFT) or in vitro fertilization (IVF).
b. associated with infertility or severe endometriosis, pelvic adhesions due to the existence of treatment methods and different treatment on the most widely, but older patients need surgery as soon as possible, can only consider short-term perioperative medication. After pregnancy fails, assisted reproduction is further possible selection, according to the specific terms of lesions and decide methods, most of the need for IVF.
B. endometriosis associated pelvic pain:
a. require fertility patients: mild or mild lesions reference age factor may choose to use drug therapy or conservative surgery. More serious lesions of women using combination therapy is the best, when necessary, for presacral neurectomy to relieve pelvic pain.
b. patients with non-reproductive requirements: can be used in patients with mild non-hormonal drugs, the sole purpose of pain relief, hormone therapy can be applied. More serious lesions often need combined treatment of women, because hormonal symptoms alone difficult to complete remission. Radical surgery is usually as second-line treatment of disease such as endometriosis has been drug control, are more likely to retain ovarian function (Table 11).
⑤ the treatment of relapse cases: one year after treatment the recurrence rate varies for each reported 16% ~ 52% of relapse cases in treatment and untreated cases remains the same is based on the patient's symptoms to determine treatment. Drug therapy can control disease development, reconstruction surgery can be used simultaneously to remove the residual lesion and correct abnormal anatomy.