子宫内膜异位症(Endometriosis)张喜.ppt

EndometriosisEndometriosisWomen’s Hospital, School of Medicine Zhejiang UniversityWomen’s Hospital, School of Medicine Zhejiang UniversityWomen’s Hospital, School of Medicine Zhejiang University Prof. Lin JunProf. Lin JunProf. Lin JunDefinitionDefinition Endometriosis Endometriosis is usually defined as the is usually defined as the is usually defined as the presence of endometrial-like tissue, that is, presence of endometrial-like tissue, that is, presence of endometrial-like tissue, that is, glands and stroma, outside the endometrium glands and stroma, outside the endometrium glands and stroma, outside the endometrium in uterine cavity and myometrium. in uterine cavity and myometrium. in uterine cavity and myometrium. Common sites of endometriosisCommon sites of endometriosisThe most common sitesThe most common sites：：• •uterosacral ligamentuterosacral ligament• •rectouterine pouch rectouterine pouch • •ovaryovaryOthersOthers：：• •uterine uterine serosaserosa• •fallopian tubefallopian tube• •sigmoid colon (sigmoid colon (乙状结肠乙状结肠) )outside of the pelvisoutside of the pelvis : :• •Umbilicus(Umbilicus(脐脐) , bladder, kidney) , bladder, kidneyPrevalencePrevalence• •present in 10%-15% of women in reproductive present in 10%-15% of women in reproductive age group, age group, especially from age 25 to 45especially from age 25 to 45• •normally not seen before age 15 or after normally not seen before age 15 or after menopausemenopause• •early early and more and more childbearingchildbearing• •latest study: more frequent menses (cycle latest study: more frequent menses (cycle length ≤ 27 days ) length ≤ 27 days ) and and prolonged menstrual prolonged menstrual flow (≥ flow (≥ 1 week1 week) 2 times risk) 2 times risk PathogenesisPathogenesis Theories of sTheories of sources ources of ectopic endometriumof ectopic endometrium • • Endometrial implanting theory Endometrial implanting theory ( ( ( (种植学说种植学说种植学说种植学说) ) ) ) ——Sampson 1921——Sampson 1921 endometrium endometrium transfer → implant →growtransfer → implant →grow ⒈⒈retrograde menstruation (retrograde menstruation (经血逆流经血逆流) theory) theory ⒉⒉transport by lymph and vein transport by lymph and vein ⒊⒊iatrogenic iatrogenic ( ( ( (医源性的医源性的医源性的医源性的) ) ) ) implantation implantationPathogenesisPathogenesisTheories of sTheories of source ource of ectopic endometriumof ectopic endometrium • •metaplasia theory(metaplasia theory(化生学说化生学说) )• •inducement theoryinducement theory（诱导学说）（诱导学说） PathogenesisPathogenesis Factors related with endometriosisFactors related with endometriosis• •Genetic Abnormalities Genetic Abnormalities ：：high risk in high risk in first-degree relativesfirst-degree relatives • •Immunologic Factors : Immunologic Factors : increased concentrations of white increased concentrations of white blood cells, cytokines, and blood cells, cytokines, and growth factors growth factors —— IL-6 —— IL-6、、IL-8IL-8、、TNF-TNF-α α、、MCP-1MCP-1 • •inflammation: inflammation: EMsEMs lesions → chronic pelvic inflammation lesions → chronic pelvic inflammation Pathology Pathology ectopic endometrium ectopic endometrium ↓ ↓hemorrhagehemorrhage ↓ ↓proliferation of fibrous tissue proliferation of fibrous tissue ＆＆ adhesions adhesions ↓ ↓dark blue or dark brown spots dark blue or dark brown spots ↓ ↓scarring nodules or cysts scarring nodules or cysts Gross appearance :Gross appearance :ovarian endometriosisovarian endometriosis • • red, blue, or brown spots red, blue, or brown spots • • endometriomasendometriomas —— chocolate cysts —— chocolate cystsGross appearance :Gross appearance :peritoneal endometriosisperitoneal endometriosiscommon sitescommon sites：： uterosacral ligamentuterosacral ligament、、rectouterine pouchrectouterine pouch uupurple purple spotsspotsuudark brown spotsdark brown spotsuured lesionsred lesionsuuwhite lesionswhite lesionsuuperitoneum lack peritoneum lack peritoneal endometriosisperitoneal endometriosisperitoneal endometriosisperitoneal endometriosiscervix cervix umbilicusumbilicus( (脐脐) ) The microscopic findingsThe microscopic findings ：：• •endometrial glands endometrial glands • •endometrial stroma endometrial stroma • •fibrinfibrin• •red blood cells and hemosiderinred blood cells and hemosiderin（含铁血黄素）（含铁血黄素） ≥ ≥2 findings to be diagnosed2 findings to be diagnosedClinical FindingsClinical Findings symptomsymptoms s：：• •dysmenorrhoeadysmenorrhoea（痛经）（痛经）（痛经）（痛经） and and chronic pelvic pain chronic pelvic pain the most typical symptomthe most typical symptom：：s secondary dysmenorrhea that worsens econdary dysmenorrhea that worsens over timeover time • •dyspareuniadyspareunia（性交痛）（性交痛）（性交痛）（性交痛）• •abnormal uterine bleedingabnormal uterine bleeding h heavy menses, prolonged menstruation or premenstrual spottingeavy menses, prolonged menstruation or premenstrual spotting• •i infertilitynfertility：：40% of patients40% of patients • •acute abdomen: acute abdomen: inter-cyst hemorrhage(inter-cyst hemorrhage(囊内出血囊内出血), or rupture), or ruptureClinical FindingsClinical Findingssymptomsymptoms s：： othersothers：：diarrhoeadiarrhoea（腹泻）（腹泻）constipationconstipation（便秘）（便秘）bloody stool bloody stool painful urination painful urination bloody urine bloody urine backachebackacheCauses Causes of iof infertilitynfertility1) Mechanical reason1) Mechanical reason2) Environmental change in the peritoneal cavity2) Environmental change in the peritoneal cavity3) Abnormal 3) Abnormal immuneimmune function function4)4) Abnormal Abnormal ovarianovarian function function ( (anovulation,LPDanovulation,LPD, , LufsLufs) )5 5) ) Increase in spontaneous abortionIncrease in spontaneous abortionClinical FindingsClinical FindingsP Pelvic elvic E Examinationxamination：：• •fixed retroverted uterinefixed retroverted uterine• •tender nodules on uterosacral ligament or tender nodules on uterosacral ligament or rectouterine pouch rectouterine pouch • •tender and fixed adnexal masses tender and fixed adnexal masses D Diagnosis iagnosis • •h historyistory• •p pelvic elvic e examinationxamination• •l laparoscopy aparoscopy ———— golden diagnosis standard golden diagnosis standard diagnosis, classification diagnosis, classification ＆＆treatmenttreatment• •ultrasound, (ultrasound, (CT and MRI, expensive)CT and MRI, expensive)• •serum CA125 serum CA125 ↑ ↑but usually but usually ＜＜100IU/ml100IU/ml • •anti-anti-endometriumendometrium antibody antibody D DiagnosisiagnosisClinical classificationClinical classificationRevised American Fertility Society (r-AFS), 1985Revised American Fertility Society (r-AFS), 1985Useful for:Useful for:• • Assessment of severityAssessment of severity• • Selection of therapeutic regimen Selection of therapeutic regimen• • Comparison Comparison• • Prognosis Prognosisr-AFSr-AFSDifferential DiagnosisDifferential Diagnosis• • Ovarian tumorOvarian tumor a ascitesscites（腹水）（腹水）（腹水）（腹水）, solid or mixed, B ultrasound image, , solid or mixed, B ultrasound image, CA-125>CA-125>1 100 00 I IU/mlU/ml• • Abdominal inflammatory massAbdominal inflammatory mass h history of infection, fever, not cyclic, treatment with istory of infection, fever, not cyclic, treatment with antibiotics effectivelyantibiotics effectively• • Adenomyosis Adenomyosis ( (子宫腺肌病子宫腺肌病子宫腺肌病子宫腺肌病) ) mmedial, severe pain, uterus slightly enlargededial, severe pain, uterus slightly enlargedT Treatment reatment Principles of treatmentPrinciples of treatment：：Treatment should be individualized according to the age, Treatment should be individualized according to the age, severity of the severity of the conditioncondition and desire for childbearing. and desire for childbearing.• •With mild symptom:With mild symptom: expectant therapyexpectant therapy• •With childbearing desire:With childbearing desire: mild-condition: mild-condition: medicationmedication severe-condition: severe-condition: fertility preservation surgeryfertility preservation surgery• •No childbearing desire :No childbearing desire : Surgical treatment: ovary preservation or radical surgerySurgical treatment: ovary preservation or radical surgeryT TreatmentreatmentExpectant TherapyExpectant Therapy • •Follow-upFollow-up• •symptoms managementsymptoms management：：NSAIDsNSAIDs（非甾体类抗炎药）（非甾体类抗炎药）（非甾体类抗炎药）（非甾体类抗炎药） T TreatmentreatmentMMedicationedicationObjective: Objective: cause atrophic changes in the ectopic endometriumcause atrophic changes in the ectopic endometrium（使异位内膜萎缩）（使异位内膜萎缩）（使异位内膜萎缩）（使异位内膜萎缩）MMedicationedicationPseudopregnancy therapyPseudopregnancy therapy⒈⒈ oral contraceptives oral contraceptives：：a pill once daily for 6-12 ma pill once daily for 6-12 m⒉⒉ progestinsprogestins：：• •medroxyprogesterone medroxyprogesterone （醋酸甲孕酮）（醋酸甲孕酮）（醋酸甲孕酮）（醋酸甲孕酮）30mg daily30mg daily• •megestrol megestrol （甲地孕酮）（甲地孕酮）（甲地孕酮）（甲地孕酮） 40mg daily 40mg daily• •norethindrone norethindrone （炔诺酮）（炔诺酮）（炔诺酮）（炔诺酮） 5mg daily 5mg daily Side effects: Side effects: Intermittent breakthrough bleeding, nausea, breast Intermittent breakthrough bleeding, nausea, breast tenderness, fluid retention, weight gaintenderness, fluid retention, weight gainMMedicationedicationP Pseudoseudomenopausemenopause therapytherapy⒈⒈GnRH-a GnRH-a Mechanism:Mechanism: Medical hypophysectomy ( Medical hypophysectomy (药物性垂体切除药物性垂体切除) ) / Medical oophorectomy ( / Medical oophorectomy (药物性卵巢切除药物性卵巢切除) )• •lleuprorelin euprorelin （（（（亮丙瑞林亮丙瑞林亮丙瑞林亮丙瑞林，，，，抑那通）抑那通）抑那通）抑那通）3.75mg3.75mg• •ggoserelin oserelin （戈舍瑞林（戈舍瑞林（戈舍瑞林（戈舍瑞林，，，，诺雷德）诺雷德）诺雷德）诺雷德）3.6mg3.6mg• •ttrryyptorelin ptorelin （（（（曲曲曲曲普普普普瑞林瑞林瑞林瑞林，，，，达菲林达菲林达菲林达菲林）））） 3.75mg 3.75mg m / H, 1 inj/q28d, start d1 m / H, 1 inj/q28d, start d1 MMedicationedication⒈⒈GnRH-a GnRH-a Side effects:Side effects: (1) Menopausal symptoms : (1) Menopausal symptoms : hot flashes, dryness in vagina, loss of libido( hot flashes, dryness in vagina, loss of libido(性欲性欲性欲性欲) ) (2) Osteoporosis (2) OsteoporosisMMedicationedicationPseudomenopause therapyPseudomenopause therapy⒉⒉ Danazol Danazol A derivative of 17-α-ethinyltestosterone A derivative of 17-α-ethinyltestosterone （（（（17-α17-α乙炔睾酮衍生物）乙炔睾酮衍生物）乙炔睾酮衍生物）乙炔睾酮衍生物） Mechanism:Mechanism:• •Directly suppressing ovarian steroidogenesis Directly suppressing ovarian steroidogenesis （甾体激素生成）（甾体激素生成）• •Direct inhibiting the growth of endometriumDirect inhibiting the growth of endometrium 400-600 mg/d for 6 months400-600 mg/d for 6 monthsMMedicationedication⒉⒉ Danazol Danazol Side effects:Side effects:acne, deepening of the voice, oily skin, headache, acne, deepening of the voice, oily skin, headache, hot flashes, loss of libido, weight gainhot flashes, loss of libido, weight gainMMedicationedicationothersothers：：• •gestrinone gestrinone （孕三烯酮）（孕三烯酮） • •mifepristonemifepristone（米非司酮）（米非司酮）Surgical treatmentSurgical treatmentPurposesPurposes：：⑴⑴ diagnosis and classification diagnosis and classification⑵⑵ excise or destroy all endometriotic tissue excise or destroy all endometriotic tissue⑶⑶ remove all adhesions, restore pelvic anatomy remove all adhesions, restore pelvic anatomy ⑷⑷ enhance fecundityenhance fecundity⑸⑸ relieve painrelieve painSurgical treatmentSurgical treatmentlaparoscopy + laparoscopy + medicinemedicine golden standard golden standard of treatmentof treatmentSurgical treatmentSurgical treatmentModes of surgical operation:Modes of surgical operation:(1) Fertility preservation (1) Fertility preservation (2) Ovarian function preservation (2) Ovarian function preservation (3) Radical surgery (3) Radical surgery (4) Surgery for pain relief(4) Surgery for pain reliefT Treatmentreatment Combination of medication and surgery Combination of medication and surgery • •surgery + surgery + surgery + medicationmedicationmedication • •medication + medication + medication + surgery + surgery + surgery + medicationmedicationmedicationTreatment for patients with infertilityTreatment for patients with infertilityPreventionPrevention• •Prevent retrograde flow of mensesPrevent retrograde flow of menses• •Contraception with medicineContraception with medicine • •Avoid iatrogenic (Avoid iatrogenic (医源性医源性医源性医源性) implantation of the ) implantation of the ectopic endometriumectopic endometrium Adenomyosis Adenomyosis DefinitionDefinition• • Adenomyosis is defined by the presence of Adenomyosis is defined by the presence of endometrial glands and stroma within the endometrial glands and stroma within the myometriummyometrium. . It is associated with myometrial It is associated with myometrial hypertrophy and proliferation.hypertrophy and proliferation.Endometriosis Endometriosis ＆＆ Adenomyosis Adenomyosis• •Pathogenesis Pathogenesis ＆＆ histological histological confirmation confirmation • •Sites of lesionsSites of lesions• •Clinical findingsClinical findingsAdenomyosis is thought to be unrelated to endometriosisAdenomyosis is thought to be unrelated to endometriosisAdenomyosis is thought to be unrelated to endometriosis. . .Clinical findingsClinical findingsMultiparasMultiparas（＞（＞（＞（＞4040 y y）））） were most commonly affected.were most commonly affected.SymptomsSymptoms：：：：• •prolonged and heavy menses prolonged and heavy menses • •DysmenorrheaDysmenorrhea that worsens over timethat worsens over timePelvic examPelvic exam：：：：• •enlargement of uterusenlargement of uterus• •tendernesstendernessDiagnosisDiagnosis• •Typical symptoms and signsTypical symptoms and signsTypical symptoms and signs• •Histopathologic examination Histopathologic examination Histopathologic examination —— standard of the diagnosis—— standard of the diagnosis—— standard of the diagnosis• •B ultrasound would suggest the disease.B ultrasound would suggest the disease.B ultrasound would suggest the disease.T Treatmentreatment1. Medication 1. Medication ：：GnRH-aGnRH-a2. Surgical treatment : 2. Surgical treatment : total hysterectomytotal hysterectomy Thank you !Thank you !Thank you !Thank you !。