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1、 EndometriosisEndometriosis Womens Hospital, School of Medicine Zhejiang UniversityWomens Hospital, School of Medicine Zhejiang University Prof. Lin JunProf. Lin Jun Definition Endometriosis Endometriosis is usually defined as the is usually defined as the presence of endometrial-like tissue, that i
2、s, presence of endometrial-like tissue, that is, glands and stroma, outside the endometrium glands and stroma, outside the endometrium in uterine cavity and myometrium. in uterine cavity and myometrium. Common sites of endometriosis The most common sites： uterosacral ligament rectouterine pouch ovar
3、y Others： uterine serosa fallopian tube sigmoid colon (乙状结肠) outside of the pelvis : Umbilicus(脐) , bladder, kidney Prevalence present in 10%-15% of women in reproductive age group, especially from age 25 to 45 normally not seen before age 15 or after menopause early and more childbearing latest stu
4、dy: more frequent menses (cycle length 27 days ) and prolonged menstrual flow ( 1 week) 2 times risk PathogenesisPathogenesis Theories of sources of ectopic endometrium Endometrial implanting theory (种植学说) Sampson 1921 endometrium transfer implant grow retrograde menstruation (经血逆流) theory transport
5、 by lymph and vein iatrogenic (医源性的) implantation PathogenesisPathogenesis Theories of source of ectopic endometrium metaplasia theory(化生学说) inducement theory（诱导学说） PathogenesisPathogenesis Factors related with endometriosis Genetic Abnormalities ：high risk in first-degree relatives Immunologic Fact
6、ors : increased concentrations of white blood cells, cytokines, and growth factors IL-6、IL-8、TNF-、MCP-1 inflammation: EMs lesions chronic pelvic inflammation Pathology ectopic endometrium hemorrhage proliferation of fibrous tissue adhesions dark blue or dark brown spots scarring nodules or cysts Gro
7、ss appearance : ovarian endometriosis red, blue, or brown spots endometriomas chocolate cysts Gross appearance : peritoneal endometriosis common sites： uterosacral ligament、rectouterine pouch upurple spots udark brown spots ured lesions uwhite lesions uperitoneum lack peritoneal endometriosis perito
8、neal endometriosis cervix umbilicus(脐) The microscopic findingsThe microscopic findings ： endometrial glands endometrial stroma fibrin red blood cells and hemosiderin（含铁血黄素） 2 findings to be diagnosed Clinical FindingsClinical Findings symptoms： dysmenorrhoea（痛经） and chronic pelvic pain the most typ
9、ical symptom：secondary dysmenorrhea that worsens over time dyspareunia（性交痛） abnormal uterine bleeding heavy menses, prolonged menstruation or premenstrual spotting infertility：40% of patients acute abdomen: inter-cyst hemorrhage(囊内出血), or rupture Clinical FindingsClinical Findings symptoms： others：
10、diarrhoea（腹泻） constipation（便秘） bloody stool painful urination bloody urine backache Causes of infertility 1) Mechanical reason 2) Environmental change in the peritoneal cavity 3) Abnormal immune function 4) Abnormal ovarian function (anovulation,LPD, Lufs) 5) Increase in spontaneous abortion Clinica
11、l FindingsClinical Findings Pelvic Examination： fixed retroverted uterine tender nodules on uterosacral ligament or rectouterine pouch tender and fixed adnexal masses Diagnosis history pelvic examination laparoscopy golden diagnosis standard diagnosis, classification treatment ultrasound, (CT and MR
12、I, expensive) serum CA125 but usually 100IU/ml anti-endometrium antibody Diagnosis Clinical classification Revised American Fertility Society (r-AFS), 1985 Useful for: Assessment of severity Selection of therapeutic regimen Comparison Prognosis r-AFS Differential Diagnosis Ovarian tumor ascites（腹水）,
13、 solid or mixed, B ultrasound image, CA-125100 IU/ml Abdominal inflammatory mass history of infection, fever, not cyclic, treatment with antibiotics effectively Adenomyosis (子宫腺肌病) medial, severe pain, uterus slightly enlarged Treatment Principles of treatment： Treatment should be individualized acc
14、ording to the age, severity of the condition and desire for childbearing. With mild symptom: expectant therapy With childbearing desire: mild-condition: medication severe-condition: fertility preservation surgery No childbearing desire : Surgical treatment: ovary preservation or radical surgery Trea
15、tment Expectant Therapy Follow-up symptoms management：NSAIDs（非甾体类抗炎药） Treatment Medication Objective: cause atrophic changes in the ectopic endometrium （使异位内膜萎缩） Medication Pseudopregnancy therapy oral contraceptives：a pill once daily for 6-12 m progestins： medroxyprogesterone （醋酸甲孕酮）30mg daily mege
16、strol （甲地孕酮） 40mg daily norethindrone （炔诺酮） 5mg daily Side effects: Intermittent breakthrough bleeding, nausea, breast tenderness, fluid retention, weight gain Medication Pseudomenopause therapy GnRH-a Mechanism: Medical hypophysectomy (药物性垂体切除) / Medical oophorectomy (药物性卵巢切除) leuprorelin （亮丙瑞林，抑那通
17、）3.75mg goserelin （戈舍瑞林，诺雷德）3.6mg tryptorelin （曲普瑞林，达菲林） 3.75mg m / H, 1 inj/q28d, start d1 Medication GnRH-a Side effects: (1) Menopausal symptoms : hot flashes, dryness in vagina, loss of libido(性欲) (2) Osteoporosis Medication Pseudomenopause therapy Danazol A derivative of 17-ethinyltestosterone
18、（17-乙炔睾酮衍生物） Mechanism: Directly suppressing ovarian steroidogenesis （甾体激素生成） Direct inhibiting the growth of endometrium 400-600 mg/d for 6 months Medication Danazol Side effects: acne, deepening of the voice, oily skin, headache, hot flashes, loss of libido, weight gain Medication others： gestrino
19、ne （孕三烯酮） mifepristone（米非司酮） Surgical treatment Purposes： diagnosis and classification excise or destroy all endometriotic tissue remove all adhesions, restore pelvic anatomy enhance fecundity relieve pain Surgical treatment laparoscopy + medicine golden standard of treatment Surgical treatment Mode
20、s of surgical operation: (1) Fertility preservation (2) Ovarian function preservation (3) Radical surgery (4) Surgery for pain relief Treatment Combination of medication and surgery surgery + surgery + medicationmedication medication + medication + surgery + surgery + medicationmedication Treatment
21、for patients with infertility Prevention Prevent retrograde flow of menses Contraception with medicine Avoid iatrogenic (医源性) implantation of the ectopic endometrium Adenomyosis DefinitionDefinition Adenomyosis is defined by the presence of endometrial glands and stroma within the myometrium. It is
22、associated with myometrial hypertrophy and proliferation. Endometriosis Endometriosis Adenomyosis Adenomyosis Pathogenesis histological confirmation Sites of lesions Clinical findings Adenomyosis is thought to be unrelated to endometriosisAdenomyosis is thought to be unrelated to endometriosis . . C
23、linical findings Multiparas（40 y） were most commonly affected. Symptoms： prolonged and heavy menses Dysmenorrhea that worsens over time Pelvic exam： enlargement of uterus tenderness DiagnosisDiagnosis Typical symptoms and signsTypical symptoms and signs Histopathologic examination Histopathologic examination standard of the diagnosis standard of the diagnosis B ultrasound would suggest the disease.B ultrasound would suggest the disease. T Treatmentreatment 1. Medication ：GnRH-a 2. Surgical treatment : total hysterectomy Thank you !