Patient's question:
What are the reactions of endometriosis? What is endometriosis?Doctor's answer:
Endometriosis is a disease caused by the presence of endometrial tissue with growth function in locations outside the uterine body, leading to blood stasis and stagnation in the uterine cavity and the (Chong Ren) channels. It is most commonly found in the pelvic reproductive organs and adjacent visceral peritoneal surfaces, hence it is referred to as pelvic endometriosis. If the endometrium grows within the myometrium but does not spread to the serosal layer, it is termed adenomyosis or uterine adenomyosis. Both endometriosis and adenomyosis are diseases caused by ectopic endometrium, and they can coexist clinically, though their pathogenesis and histogenesis differ, as do their clinical manifestations. The incidence of this disease has significantly increased in recent years, making it one of the most common gynecological disorders, particularly among women of reproductive age (30–40 years).Clinical Manifestations
The typical symptoms include lower abdominal pain, dysmenorrhea, dyspareunia, and infertility.
1. Lower abdominal pain and dysmenorrhea: The pain is secondary and progressively worsens over time. Initially, there is no dysmenorrhea in the first few years after menarche, but it may develop after several years or more, gradually intensifying. The pain is often located in the deep lower abdomen and lumbosacral region, most commonly in the central pelvic area, and may radiate to the vagina, perineum, anus, or thighs. It typically appears at the onset of menstruation and persists throughout the menstrual period. The severity of pain does not necessarily correlate with the size of the lesion. Approximately 20%–35% of patients experience no dysmenorrhea. Some patients may experience pain that is not synchronized with menstruation, while a few may have chronic lower abdominal pain that intensifies during menstruation.
2. Dyspareunia: Deep dyspareunia may occur when the ectopic endometrium involves the rectouterine pouch or the uterosacral ligaments, especially during the premenstrual period.
3. Menstrual irregularities: Menorrhagia, prolonged menstrual periods, or spotting before menstruation are common.
4. Infertility: About 40% of patients with endometriosis are infertile, primarily due to pelvic adhesions, tubal obstruction, or weakened peristalsis, which impair the transport of ova. Other factors include luteinized unruptured follicle syndrome, insufficient corpus luteum function, or autoimmune reactions that interfere with fertilization and implantation.
5. Other symptoms: Intestinal lesions may cause diarrhea or constipation, or cyclic bleeding. Urinary system involvement may lead to dysuria, urinary retention, or cyclic hematuria. Remote ectopic endometrial lesions may cause menstrual hemoptysis or epistaxis. In cases of ruptured ovarian endometrioma, sudden severe lower abdominal pain may occur, accompanied by nausea, vomiting, and rectal fullness, often during or around menstruation.
Pattern Differentiation
The disease is primarily located in the uterine cavity, uterine vessels, uterine ligaments, and pelvis. However, due to the different sites of ectopic endometrial metastasis and growth, it may involve the intestinal wall, vagina, vulva, or bladder. Clinical diagnosis should be based on symptoms, signs, and other findings to determine the location of the ectopic lesion.
1. Qi stagnation and blood stasis: Mild lower abdominal distension and pain before or during menstruation, irregular menstruation with dark red blood and clots (pain after passing clots). Breast tenderness, rectal fullness, irritability, dark tongue with petechiae or ecchymoses, white coating, and wiry, stasis-indicating pulse.
2. Cold congealing blood stasis: Mild lower abdominal cold pain that improves with warmth, irregular menstruation with dark blood and clots (pain after passing clots). Chills, limb coldness, nausea, vomiting, rectal heaviness, and loose stools. Pale complexion, pale dark tongue with white coating, and deep, tense or wiry-tense pulse.
3. Heat stagnation and blood stasis: Mild lower abdominal burning pain that worsens with pressure, fever before or during menstruation, early menstruation with excessive, viscous blood and clots. Bitter taste, thirst, irritability, dark yellow urine, constipation, and palpable, painful pelvic nodules. Red or dark red tongue with petechiae or ecchymoses, yellow coating, and wiry, rapid pulse.
4. Qi deficiency and blood stasis: Mild lower abdominal pain that improves with pressure and warmth, dark red or clotted menstruation. Fatigue, poor appetite, rectal fullness, and loose stools. Pale complexion, pale dark tongue with teeth marks, white coating, and fine, slow or weakly wiry pulse.
5. Kidney deficiency and blood stasis: Mild lower abdominal pain that improves with pressure and warmth, lower back and knee weakness, dizziness, tinnitus, irregular menstruation with dark red or clotted blood (low volume with spotting). Fatigue, poor libido, difficulty conceiving, rectal fullness, and loose stools. Dull complexion, dark spots on the forehead, pale dark tongue with ecchymoses, white coating, and deep, fine, or stasis-indicating pulse.
Health Education
1. Reduce anxiety: Educate patients about the nature and characteristics of the disease, emphasizing that it is a benign condition that can be relieved with treatment. Pregnancy can delay the onset of the disease, and patients who have already married or experienced dysmenorrhea may conceive after treatment. For those with children, long-term contraceptive medication can shrink the endometrium and reduce menstrual flow, decreasing the risk of retrograde menstruation and endometriosis. Encourage patients to participate in treatment decisions, explaining that the course of treatment is long and adherence to standardized care is essential for effective outcomes.
2. Explain the causes of dysmenorrhea: Advise patients to maintain a calm mood during menstruation, avoid strenuous exercise, and rest in bed if pain is severe. Keep the abdomen warm, especially below the waist, using warm compresses.
3. Maintain menstrual hygiene: Avoid sexual activity during menstruation or immediately after. Accurately track menstrual cycles to avoid gynecological examinations, hysteroscopy, or hysterosalpingography during the menstrual period. Prevent iatrogenic endometrial implantation.
4. Keep the vulva clean: Avoid tub baths or swimming during menstruation. Change pads and underwear frequently, and clean the vulva with 1:5000 potassium permanganate or warm water 1–2 times daily to prevent infection.
5. Maintain regular menstruation: Early treatment is necessary for patients with uterine retroversion, reproductive tract obstruction, or cervical stenosis to prevent retrograde menstruation.
6. Hormone therapy: The course of treatment is long, so patients should cooperate actively, especially those who are childless. Explain potential side effects such as low-grade fever, nausea, fatigue, loss of appetite, or amenorrhea before starting treatment to alleviate concerns. Adherence to medication is crucial; discontinuing it may cause uterine bleeding. Amenorrhea is normal and will return to normal after several months of stopping treatment.
7. Surgical options: For patients with intractable pain unresponsive to medication, surgical treatment may be considered based on age and fertility goals, including conservative surgery to preserve fertility, semi-conservative surgery to preserve ovarian function, or radical surgery.
8. Dietary care: A light, nutritious, and easily digestible diet is recommended, with plenty of fresh vegetables and fruits. Avoid cold, spicy, fried, greasy, or irritating foods.
- Qi stagnation and blood stasis: Benefit from Yimucao decoction or brown sugar decoction before or during menstruation to facilitate blood flow and reduce pain. Tianqi stewed black chicken may also be used.
- Cold congealing blood stasis: Ginger-brown sugar decoction, mugwort decoction, or moderate consumption of warm yellow wine can warm the uterus, dispel cold, and relieve pain.
- Qi deficiency and blood stasis: Donggui blood-nourishing decoction or Donggui lamb soup before or after menstruation. Regular consumption of yam, jujubes, or longan may be beneficial.
- Heat stagnation and blood stasis: Fresh juice or watermelon juice during fever, along with vegetables, fruits, and honey. Ma-ren pills (9g, once nightly) may be used if constipation persists.
- Kidney deficiency and blood stasis: Enhance dietary nutrition, including turtle, pig kidneys, lamb, yam, goji berries, or mulberry.
9. Medication administration: Blood-activating and stasis-resolving decoctions for endometriosis should be taken warm after meals. For heat-stagnation and blood-stasis patterns, cooling and blood-activating decoctions should be prepared for a shorter duration and served cool or slightly warm.
Discharge Instructions
1. Adhere to standardized treatment: Hormone therapy patients should follow medical advice, taking medication for 3–6 months, and report any unusual discomfort.
2. Post-surgery care: Abstain from sexual activity for one month after surgery, and attend a follow-up appointment one month post-discharge.
3. Menstrual and postpartum hygiene: Avoid sexual activity during menstruation, and postpartum women should start postpartum exercises early to prevent uterine retroversion.
4. Dietary care: Avoid excessively cold, greasy, or raw foods, as well as medications and cold items, to reduce pain.
5. Exercise: Strengthen physical fitness.