ACE 2025 | Professor DING Ding: Diagnostic and Therapeutic Strategies for Endometriosis – A Novel Clinical Approach Balancing Standardization and Effectiveness

Prevention and control of endometriosis malignancy and whole-course management are key priorities and challenges in clinical obstetrics and gynecology practice. To further promote the scientific implementation and standardized application of precise diagnostic and therapeutic strategies in this field, Obstetrics and Gynecology Network invited Professor DING Ding from Obstetrics and Gynecology Hospital of Fudan University to share insights on "Key Clinical Practices and Whole-Course Management Strategies for Endometriosis from the Perspective of ACE 2025". The sharing addresses practical questions faced by clinicians in formulating treatment plans for patients with fertility needs, implementing multidisciplinary team (MDT) collaboration, and conducting long-term follow-up monitoring. It also clarifies misconceptions about endometriosis and enhances awareness of early standardized diagnosis and treatment, providing professional and guiding perspectives for medical colleagues. This aims to help diagnostic and therapeutic strategies better serve disease prevention and public health, and jointly advance the achievement of precise prevention, control, and high-quality management of endometriosis in China.

Obstetrics and Gynecology Network:

At ACE 2025, Professor Ding shared the radical treatment process of a case of endometriosis malignant transformation into adenosarcoma. Adenosarcoma with high-risk factors has a high recurrence rate, and the background of endometriosis may increase the complexity of subsequent management. For endometriosis patients with malignant transformation and fertility needs, how will the MDT adjust treatment and follow-up strategies?

Professor DING Ding:

At ACE 2025, I shared a case of a 26-year-old patient with deep infiltrating endometriosis of the rectovaginal septum that had undergone malignant transformation into adenosarcoma. The patient was unmarried and childless, with a 7-8 year history of dysmenorrhea, but had not received standardized gynecological examinations or treatment. Malignant transformation was already present at the first visit.

In addition, among the endometriosis patients with malignant transformation I have treated, there are types such as ovarian endometrioid cyst malignant transformation and ovarian clear cell carcinoma, with the youngest patient being only 29 years old. Usually, the age of onset of endometriosis malignant transformation is over 40 years old, but young cases are not uncommon. Especially when combined with unmarried status, childlessness, and fertility needs, the MDT team must accurately balance treatment and fertility requirements. Specific strategy adjustments are as follows:

1. Adjustments to Treatment Strategies

Comprehensive Evaluation First: The MDT team will refer to diagnostic and therapeutic guidelines for ovarian cancer or uterine tumors, and conduct a comprehensive evaluation based on the patient's tumor stage, pathological grade, and high-risk factors. For endometriosis-related ovarian cancer, reference is made to ovarian cancer diagnosis and treatment standards; for uterine adenosarcoma, the staging and treatment standards for uterine corpus tumors are followed.
Individualized Selection of Surgical Plans: For early-stage patients without pathological high-risk factors, fertility-preserving surgery can be performed to retain the uterus or contralateral ovary to maintain fertility. Depending on the tumor's grade and stage, if fertility-preserving surgery is not suitable, radical surgery is required to improve the patient's subsequent survival rate. It should be noted that case studies have shown that the recurrence rate of fertility-preserving surgery for uterine adenosarcoma is higher than that of radical surgery. It is usually recommended that patients consider further hysterectomy and oophorectomy after completing childbirth.
Optimization of Fertility-Assisted Plans: Postoperatively, patients with fertility needs undergo a comprehensive fertility assessment, including ovarian function, fallopian tube patency, and intraoperative Endometriosis Fertility Index (EFI) score. For patients with a low EFI score, poor fertility reserve, or inadequate ovarian function, IVF-assisted reproduction may be considered. However, the use of hormonal drugs during IVF requires caution. Since endometriosis is an estrogen-dependent disease, a local high estrogen environment is a high-risk factor for malignant transformation. It is necessary to be alert to the potential risk of increased tumor recurrence or progression caused by hormone use.

2. Adjustments to Follow-Up Strategies

Enhanced Follow-Up Frequency: Compared with patients without fertility needs, endometriosis patients with malignant transformation and fertility needs require more frequent follow-up to closely monitor for signs of tumor recurrence, detect abnormalities in a timely manner, and implement interventions.
Focus on Hormone-Related Monitoring: During follow-up, close attention is paid to changes in hormone levels, especially for patients undergoing IVF-assisted reproduction. Dynamic assessment of the impact of hormone use on the condition is necessary to avoid inducing tumor recurrence.
Clear Core Follow-Up Content: Targeted follow-up plans are formulated based on tumor type, including imaging examinations, tumor marker detection, and specialized gynecological examinations. At the same time, fertility-related indicators are recorded to achieve dual management of disease monitoring and fertility planning.

Currently, issues such as the safe duration and specific protocols of hormone use during assisted reproduction still require further exploration through multicenter prospective studies to form more precise diagnostic and therapeutic standards, and better ensure the treatment effect and fertility safety of such patients.

Obstetrics and Gynecology Network:

Regarding the exchange session of this conference, what is the most important insight or keyword you want to share?

Professor DING Ding:

The keyword I want to share most is "integration of scientific research and clinical practice", which is also the essence and core significance of this conference.

This conference brought together top experts in the field of endometriosis from around the world, including not only Asian experts but also senior scholars from regions such as the United States and Europe, many of whom are long-term colleagues and friends in this field. The core purpose of experts from various countries gathering together is to exchange the latest research results in clinical practice and scientific research, and the on-site discussion atmosphere was very enthusiastic.

From the perspective of scientific research, many expert teams are focusing on the research of endometriosis pathogenesis, exploring the role of immune cells and inflammatory cells (such as mast cells) in the occurrence and development of endometriosis, and identifying potential therapeutic targets. For example, targeting inflammatory factors and leukocytes, studies are being conducted to determine whether blocking these factors can inhibit immune-inflammatory responses, angiogenesis, and fibrosis processes, thereby relieving patient pain, delaying disease progression, and reducing lesions. Various teams are making intensive efforts in this direction.

The ultimate goal of scientific research is to solve practical clinical problems, which is also an important core of the exchange session. Experts actively exchanged experiences around clinical pain points related to endometriosis, with a particular focus on practical issues related to endometriosis and reproduction. For example, for patients who failed IVF, discussions were held on the circumstances under which clinical surgical intervention is needed, and how many IVF failures warrant adjustments to treatment plans. The value of such practical exchanges is the important significance of the conference's exchange session.

In short, scientific research provides new directions and targets for clinical treatment, while clinical practice provides real problems and research scenarios for scientific research. The two are complementary, which is the most profound insight I gained from the exchange session of this conference.

Obstetrics and Gynecology Network:

Endometriosis requires whole-course management covering adolescence, childbearing age, and perimenopause. Could you share specific diagnostic and therapeutic strategies for different age groups?

Professor DING Ding:

Whole-course management of endometriosis requires formulating individualized strategies based on the characteristics of the patient's age group, which is also a core principle of the international ESHER guidelines and the 3rd Edition of China's Guidelines for the Diagnosis and Treatment of Endometriosis. The focus and treatment goals of patients of different age groups vary significantly, and the specific diagnostic and therapeutic strategies are as follows:

1. Adolescent Patients: Focus on Pain Relief and Development Protection

Core Goal: The core is to relieve dysmenorrhea and ensure normal development, especially for patients whose bone mass has not yet peaked.
Choice of Drug Treatment: Priority is given to drugs that have little or only mild inhibitory effect on the hypothalamic-pituitary-ovarian (HPO) axis, such as dydrogesterone. This drug has essentially no inhibitory effect on the HPO axis, can effectively relieve dysmenorrhea in adolescents, and is suitable for girls with incomplete development and unpeaked bone mass, with high safety.
Key Consideration: The selection of drugs must strictly evaluate side effects to avoid affecting the patient's subsequent normal development.

2. Reproductive-Age Patients: Balance Disease Control and Fertility Needs

Core Goal: To balance pain relief, disease progression control, and fertility desires, management is relatively complex.
Formulation of Treatment Plans: Individualized plans are selected based on the severity of the disease and fertility needs. For patients eligible for drug treatment, medications such as dienogest or dydrogesterone are used. Among them, dydrogesterone has little effect on the HPO axis and is suitable for women planning pregnancy, needing to enhance luteal function, or adjust the menstrual cycle.
Key Consideration: Fertility needs are an important dividing line in the selection of treatment plans. Further clinical research is needed to explore the impact of such drugs on the clinical pregnancy rate of reproductive-age women planning pregnancy, and optimize the details of drug selection.

3. Perimenopausal Patients: Focus on Malignancy Prevention and Control

Core Goal: To be alert to the possibility of malignant transformation, while improving quality of life and implementing interventions related to hormone replacement therapy.
Malignancy Prevention and Control Measures: Perimenopausal or postmenopausal patients with newly diagnosed endometriosis or a long disease course require close monitoring. If there is a sudden increase in lesions, elevated CA125 levels, changes in pain rhythm, or imaging/magnetic resonance examinations indicating rich blood flow and solid structures in the lesions, malignant transformation should be suspected, and surgical treatment should be performed in a timely manner if surgical indications are met.
Hormone Replacement Therapy (MHT) Management: The average age of menopause in endometriosis patients is 2 years earlier than that in healthy women. Attention should be paid to the quality of life during perimenopause and the application of MHT. A combined estrogen-progesterone regimen is recommended, and single estrogen therapy is prohibited. During treatment, close monitoring of lesion changes and related indicators is required.
Key Consideration: Currently, the impact of hormone replacement therapy on the recurrence or malignant transformation of perimenopausal endometriosis patients lacks high-quality clinical research evidence, and enhanced monitoring and long-term follow-up are needed.

Summary

In this interview, combining the sharing at ACE 2025, Professor DING Ding provided an in-depth interpretation of key issues in the diagnosis and treatment of endometriosis. For endometriosis patients with malignant transformation and fertility needs, the MDT team achieves a balance between treatment and fertility through comprehensive evaluation, individualized surgery, optimized fertility-assisted plans, and enhanced follow-up. The conference highlights the core of "integration of scientific research and clinical practice", and the two complement each other to promote the development of the field. At the same time, Professor Ding clarified the phased diagnostic and therapeutic strategies for endometriosis patients in adolescence, childbearing age, and perimenopause, emphasizing the importance of individualization and whole-course management. The content is both professional and practical, providing practical guidance for clinical diagnosis and treatment, and helping to improve the level of endometriosis prevention, control, and management.

Expert Profile

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Professor DING DingChief Physician, Doctor of MedicineDepartment of Gynecology, Obstetrics and Gynecology Hospital of Fudan University

Visiting Scholar at the University of Michigan, USA (2012) and Tottori University, Japan (2019)
Core Member of the Excellent Endometriosis Team of the Hospital
Member and Secretary of the Endometriosis Group, Obstetrics and Gynecology Branch of Shanghai Medical Association
Young Member of the Minimally Invasive and Non-Invasive Medicine Professional Committee, Chinese Medical Doctor Association
Standing Committee Member and Secretary-General of the Gynecological Urology and Pelvic Floor Reconstruction Professional Committee, Chinese Maternal and Child Health Association
Standing Committee Member of the Laparoscopy International Training Center, Medical Continuing Education Professional Committee, Chinese Adult Education Association
Member of the World Endometriosis Society (WES)
Physician with Grade IV Laparoscopic Surgery Qualification in Shanghai

Professor Ding specializes in the diagnosis and treatment of endometriosis, adenomyosis, benign and malignant gynecological tumors (such as uterine fibroids, ovarian tumors, cervical cancer, and endometrial cancer), as well as laparoscopic minimally invasive surgical treatment. She has long been engaged in clinical and basic research on endometriosis, adenomyosis, and gynecological tumors. As the first author, co-first author, or corresponding author, she has published 16 SCI-indexed papers. She has presided over 2 National Natural Science Foundation of China projects, 1 Natural Science Foundation project of the Shanghai Science and Technology Commission, and 1 Natural Science Foundation project of the Baoshan District Science and Technology Commission. She has also participated in multiple general and key projects of national and Shanghai-level fund programs. She has participated in the compilation and translation of many obstetrics and gynecology monographs, and has attended many international conferences such as the World and Asian Congresses on Endometriosis, delivering numerous invited speeches and oral presentations. She won the Best Oral Presentation Award at the 5th Asian Congress on Endometriosis.

Editor-in-Charge: Lily