子宫内膜异位(Endometriosis)-赵爱课件.ppt

1、1Endometriosis Endometriosis AdenomyosisAdenomyosis Zhao aimin M.D.,Ph.D.,Professor Department Of Obstetrics&Gynecology Renji Hospital Affiliated to SJTU School of Medicine 2EndometriosisEndometriosis3DefinitionDefinition:Abnormal growth of endometrial tissue outside the uterine cavity.4Incidence an

2、d PrevalenceIncidence and Prevalence:Increase significantly Range from 1 50%General population:1 2%Infertile women:30 50%Occurs primarily in women in 25 45s5PathogenesisPathogenesis:Implantation Theory Retrograde Menustration Theory Sampson，1921 Lymphatic and Vascular Dissemination Theory Javert，195

3、2 Coelomic Theory Meyer Genetic Theory Immune System Dysfunction（immunologic theory）6Genetic factorsGenetic factors：Familial clustering of endometriosis is a common clinical observation.In families with endometriosis，the disease is often confined to the maternal line，and is 7 times more common in fi

4、rst-degree relatives than in the general population.In future studies，evaluation of DNA polymorphism may identify specific genes involved in the development of endometriosis.7Immunologic TheoryImmunologic Theory：Lose control of immunologic balanceBoth cellular immunity and humoral immunity change.1)

5、Macrophage release IL1、IL6、TNF、EGF、FGF etc.stimulate T、B lymphocyte proliferation and activation2)Activity of killer cell（NK cell and T cell）3)Produce antiendometrium antibody4)Abnormal expression of CAMs（cell adhesion molecules）8 The pathogenesis is unclear.multifactor9PathologyPathology macroscopi

6、c appearancemacroscopic appearance（1 1）：The commonest sites：1.Ovary（chocolate cyst）2.Peritoneum of the rectovaginal culdesac of the Pouch of Douglas3.Uterosacral ligaments 4.Sigmoid colon5.Broad ligament10 This is a section through an enlarnged 12 cm ovary to demonstrate a cystic cavity filled with

7、old blood typical for endometriosis with formation of an endometriotic,or chocolate,cyst.1112PathologyPathology macroscopic appearance macroscopic appearance（2 2）：Less common sites：1.Cervix2.Round ligament3.Urinary system（bladder、ureter）4.Umbilicus5.Appendix6.Laparotomy scars13Multiple appearances o

8、fMultiple appearances of endometriosisendometriosis implantsimplants：Brownish，discolored peritoneum Superficial peritoneal ecchymosis Raised，reddish，superficial nodules Reddishblue invasive nodules Fibrotic，whitish nodules Raised，glossy，translucent blobs Patchy，white opacified peritoneum Reddish or

9、bluish ovarian cysts14 Grossly,in areas of endometriosis the blood is darker and gives the small foci of endometriosis the gross appearance of powder burns.Small foci are seen here just under the serosa of the posterior uterus in the pouch of Douglas.Such areas of endometriosis can be seen and oblit

10、erated by cauterization via laparoscopy.15 Upon closer view,these five small areas of endometriosis have a reddish-brown to bluish appearance.16PathologyPathology microscopic appearancemicroscopic appearance Histomorphologically similar to eutopic endometrium Four major components：endometrial glands

11、 endometrial stroma fibrosis hemorrhageEctopic endometrium异位子宫内膜Eutopic endometrium在位子宫内膜17Clinical ManifestationClinical Manifestation18SymptomsSymptoms：Pain progressive dysmenorrhea dyspareunia painful defecation Menstrual disturbance infertilitydysmenorrhea痛经dyspareunia性交痛19SignsSigns：Enlargement

12、 of the ovaries，fixed Fixed retroversion of the uterus Tender nodules within the pelvisvCannot be diagnosed by PV alone.vShould always be considered when patients have symptoms referable to the pelvic cavity.20vVery variablevVary with the focus locationvOften bear no relation to the extent of the di

13、seasevQuite often deposits are found incidentally in women who have no symptoms.（25%have no symptoms）21DiagnosisDiagnosis：History PV examination Laparoscopy（golden standard）Ultrasonography（Btype ultrasound）CA125（200U/ml；normal value 35U/ml）Antiendometrium antibody（+）22Staging systemsStaging systems：

14、In the AFS-r（1985）staging system，points are assigned for severity of endometriosis based on the size and depth of the implant and for the severity of adhesions.The points are summed and the patients are assigned to one to four stages：Stage I minimal disease，15 pointsStage II mild disease，615 pointsS

15、tage III moderate disease，1640 pointsStage IV severe disease，40 points23Differential diagnosisDifferential diagnosis：Malignant ovary tumours Pelvic inflammatory masses Adenomyosis24TreatmentTreatment25Expectant therapyExpectant therapy：Indications：with very limited disease （whose symptoms are minima

16、l or nonexistent）If trying to get pregnant，the best way is to accept laparoscopic therapy as early as possible.26Medical therapyMedical therapy：Indications：chronic pelvic pain severe dysmenorrhea no require to get pregnant no ovarian cyst formation Hormoneinhibition therapy27DrugsDrugs：Danazol：pseud

17、omenopause therapy Gestrinone GnRH a：medical oophorectomy add back therapy Mifepristone RU486 Progestogens：pseudopregnancy therapy28Surgical therapySurgical therapy（1 1）：）：Indications（1）adnexal mass （2）pelvic pain （3）infertility Approaches：(1)trans abdominal (2)laparoscopic29Surgical therapySurgical

18、 therapy（2 2）：）：Methods：v Conservative surgery1)preserve the fecundity2)preserve the ovarian functionv Definitive surgery：hysterectomy+salpingooophorectomy30Combination medicalsurgical treatment：Threestep：surgerymedical therapysecond look（laparoscopy）31v It is important to individualize the choice o

19、f therapy.v Therapy must be tailored to the degree of symptomatology the patients age her desire to maintain fertility32PrognosisPrognosis：With proper treatment，the prognosis is good for relief of pain and enhancement of fertility in mild to moderate endometriosis.In most cases，hormonal therapy is t

20、emporarily effective in controlling symptoms and arresting growth but is generally less effective than surgery in increasing fertility.The recurrent rate is very high.33PreventionPrevention：Avoid possible augmentation of menstrual reflux.Taking oral contraceptive is recommended.Isolation and irrigat

21、ion of the operative site.34CriticalCritical pointspoints（1 1）：）：The pathogenesis is poorly understood，but emerging evidence supports the causative role of retrograde menstruation and implantation of endometrial tissue.Endometriosis is a common in women with pelvic pain or infertility.Laparoscopy is

22、 the optimal technique to diagnose pelvic endometriosis.35CriticalCritical pointspoints（2 2）：）：In most cases，surgical therapy at the time of initial diagnosis effectively relieves pain and may enhance fertility.Alternatively，medical therapy with progestins、danazol、gestrinone or GnRH-a will ameliorat

23、e pelvic pain，but they do not enhance fertility.Endometriosis is a recurrent disease，and definitive treatment with removal of pelvic organs may be necessary.36AdenomyosisAdenomyosis37DefinitionDefinition：A benign uterine condition in which endometrial glands and stroma are found deep in the myometri

24、um.38EtiologyEtiology：Basal endometrial hyperplasia invading a hyperplastic myometrial stroma.Four primary theories：HeredityTraumaHyperestrogenemiaViral transmission39PathologyPathology gross appearance gross appearance：Usually hyperemic with thickened walls The foci are frequently scattered diffuse

25、ly throughout the myometrium.Occasionally，may be more circumscribed，with the formation of a distinct nodule，an adenomyoma.Adenomyosis子宫肌腺症Adenomyoma子宫肌腺瘤40 The thickened and spongy appearing myometrial wall of this sectioned uterus is typical of adenomyosis.There is also a small white leiomyoma at t

26、he lower left.41Clinical featuresClinical features（1 1）：）：Symptomatic adenomyosis occurs primarily in parous women over the age of 40.（30 50）Classic symptoms：secondary dysmenorrhea abnormal uterine bleeding 42Clinical featuresClinical features（2 2）：）：Most common physical sign：a diffusely enlarged ut

27、erus，(rarely exceeds 12 weeks gestation in size)particularly tender during menstruation43DiagnosisDiagnosis：History Pelvic examinations Ultrasonography Serum markers：CA-125 44TreatmentTreatment：Hormone therapy Hysterectomy，the only uniformly successful treatment for adenomyosis，is necessary.45 Zhao aimin M.D.,Ph.D.,Professor Department of Obstetrics&Gynecology Renji Hospital Affiliated to SJTU School of Medicine Thanks for Your Attention