Endometriosis refers to the appearance, growth and infiltration of endometrial tissue (glands
and stroma) in the lining of the uterine cavity and other parts of the uterus, and repeated
bleeding, which causes pain, infertility and nodules or masses. Endometriosis is a common
gynecological disease in Chinese female patients, and its incidence has been increasing in
recent years, which seriously affects the fertility and quality of life of patients. The
typical clinical manifestations of endometriosis mainly include dysmenorrhea, pelvic pain and
dyspareunia. Dysmenorrhea is a common symptom of endometriosis, which is secondary and
persistent. The pain is most severe on the first day of menstruation and disappears
completely at the end of menstruation. Pain is mainly caused by endometriosis bleeding, which
irritates the inflammatory response of local tissues. Endometriosis lesions secrete
prostaglandins, which cause contracture of uterine muscles and aggravate dysmenorrhea.
Ovarian endometriotic cysts are the most common and easily detected type of endometriosis.
Its clinical manifestations include: 1) dysmenorrhea, affecting daily activities and life; 2)
chronic pelvic pain; 3) pain during or after sexual intercourse; 4) often complicated with
infertility; 5) ovarian endometriotic cyst formation by imaging examination; 6) elevated
CA125.
According to the guidelines for the diagnosis and treatment of endometriosis (third edition)
published by Chinese Journal of Obstetrics and Gynecology in December 2021, ovarian
endometriosis cysts can be divided into medical treatment and surgical treatment. The
indications for drug therapy were: 1) ovarian endometriosis cyst diameter <4cm; 2) have
pelvic pain. The treatment drugs include oral contraceptives, progesterone analogues,
gestrinone, gonadotropin-releasing hormone agonist (GnRHa) and traditional Chinese medicine.
The indications for surgical treatment were: 1) the diameter of ovarian endometriosis cyst
≥4cm; 2) combined infertility; 3) pain medications are ineffective. In clinical practice,
most patients lose the opportunity of drug treatment, or drug treatment is ineffective, and
most patients need surgical treatment. Laparoscopic surgery is the first choice for surgical
treatment, and cystectomy is recommended. However, surgical treatment can only remove the
superficial lesions, and it is difficult to remove the deep lesions, which is easy to leave
lesions. After surgery, affected by steroid hormones, the small lesions left are easy to
relapse, leading to the characteristics of recurrent disease. Therefore, the recurrence rate
of ovarian endometriosis cyst after conservative surgery is high, and it must be treated with
drugs and long-term management after surgery.
In the postoperative drug management of ovarian endometriosis cyst, the first-line drugs are
mainly progesterone analogues (dienogest), GnRH-a, dydrogesterone and so on. There is
evidence that the continuous use of dienogest for 24 months after surgery can significantly
reduce the recurrence rate of ovarian endometriosis cysts. Dienogest is a fourth-generation
highly selective progesterone receptor agonist, which acts locally on endometriotic lesions,
has no male, estrogen, glucose and mineralocorticoid activity, and does not affect
metabolism. It is used in the first-line treatment of endometriosis. "In a German
retrospective study, dienogest 2 mg daily for 60 months was effective in reducing
endometriosis associated pelvic pain, and dienogest was well tolerated." However, ovulation
was inhibited in most patients during dienogest treatment. For patients with fertility needs,
menstruation returned to normal after stopping dienogest for 2 months. To pregnant element is
the most common adverse drug reactions: frequent or long time of uterine bleeding (3.2%),
insomnia (2.7%), acne (2.1%), nausea (2.1%), weight (2.1%), lower abdominal discomfort
(1.6%), headache (1.6%), breast discomfort (1.1%), and depressed mood (1.1%). Therefore, it
is not suitable to use dienogest for postoperative management in patients with ovarian
endometriosis who are in urgent need of pregnancy after surgery. At present, the cost of
dienogest in our country is relatively high, about 500 yuan for a box (28 tablets), and there
will be a certain economic burden for ordinary patients.
"Dydrogesterone is similar in structure to conventional progesterone and has only progestogen
activity without estrogen, androgen, or mineralocorticoid activity. It atrophies the ectopic
endometrium, prevents the development of new endometriotic lesions, and does not inhibit
normal endometrium or ovulation. The menstrual cycle is regular in the course of regular
treatment with dydrogesterone, so normal pregnancy can be achieved during the treatment." An
open, multi-center, post-marketing, observational clinical study in Japan showed that
dydrogesterone could effectively inhibit the growth of ovarian endometriosis cysts and
improve the total score of dysmenorrhea and the degree of dysmenorrhea pain. Studies have
shown that long-term treatment of endometriosis with dydrogesterone after surgery for 12
months can significantly reduce endometriosis-associated pain, treat infertility, and prevent
recurrence of the disease. A Japanese multi-center study showed that the incidence of adverse
drug reactions of dydrogesterone was 31.8%, and the most common adverse event was uterine
bleeding. Dydrogesterone endometriosis was effective, safe and clinically beneficial for
patients. For patients in urgent need of pregnancy, natural pregnancy can still be achieved
during postoperative medication.