1、子宫内膜异位症Endometriosis张喜1Definition 子宫内膜异位症Endometriosis张喜2Common sites of endometriosisThe most common sites：uterosacral ligament rectouterine pouch ovaryOthers：uterine serosa fallopian tube sigmoid colon(乙状结肠)outside of the pelvis:Umbilicus(脐),bladder,kidney子宫内膜异位症Endometriosis张喜3Prevalence present
2、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 study:more frequent menses(cycle length 27 days)and prolonged menstrual flow(1 week)2 times risk子宫内膜异位症Endometriosis张喜4 Theories of sources
3、of ectopic endometrium Endometrial implanting theory(种植学说种植学说)Sampson 1921 endometrium transfer implant grow retrograde menstruation(经血逆流)theory transport by lymph and vein iatrogenic(医源性的医源性的)implantation子宫内膜异位症Endometriosis张喜5Theories of source of ectopic endometrium metaplasia theory(化生学说)inducem
4、ent theory（诱导学说）子宫内膜异位症Endometriosis张喜6 Factors related with endometriosis Genetic Abnormalities：high risk in first-degree relatives Immunologic Factors:increased concentrations of white blood cells,cytokines,and growth factors IL-6、IL-8、TNF-、MCP-1 inflammation:EMs lesions chronic pelvic inflammatio
5、n 子宫内膜异位症Endometriosis张喜7Pathology ectopic endometrium hemorrhage proliferation of fibrous tissue adhesions dark blue or dark brown spots scarring nodules or cysts 子宫内膜异位症Endometriosis张喜8Gross appearance:ovarian endometriosis red,blue,or brown spots endometriomas chocolate cysts子宫内膜异位症Endometriosis张
6、喜9Gross appearance:peritoneal endometriosiscommon sites：uterosacral ligament、rectouterine pouch upurple spotsudark brown spotsured lesionsuwhite lesionsuperitoneum lack 子宫内膜异位症Endometriosis张喜10peritoneal endometriosis子宫内膜异位症Endometriosis张喜11peritoneal endometriosis子宫内膜异位症Endometriosis张喜12cervix umbi
7、licus(脐)子宫内膜异位症Endometriosis张喜13：endometrial glands endometrial stroma fibrin red blood cells and hemosiderin（含铁血黄素）2 findings to be diagnosed子宫内膜异位症Endometriosis张喜14 symptoms：dysmenorrhoea（痛经）（痛经）and chronic pelvic pain the most typical symptom：secondary dysmenorrhea that worsens over time dyspareu
8、nia（性交痛）（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子宫内膜异位症Endometriosis张喜15symptoms：others：diarrhoea（腹泻）constipation（便秘）bloody stool painful urination bloody urine backache
9、子宫内膜异位症Endometriosis张喜16Causes of infertility1)Mechanical reason2)Environmental change in the peritoneal cavity3)Abnormal immune function4)Abnormal ovarian function(anovulation,LPD,Lufs)5)Increase in spontaneous abortion子宫内膜异位症Endometriosis张喜17Pelvic Examination：fixed retroverted uterine tender nodu
10、les on uterosacral ligament or rectouterine pouch tender and fixed adnexal masses 子宫内膜异位症Endometriosis张喜18Diagnosis history pelvic examination laparoscopy golden diagnosis standard diagnosis,classification treatment ultrasound,(CT and MRI,expensive)serum CA125 but usually 100IU/ml anti-endometrium a
11、ntibody 子宫内膜异位症Endometriosis张喜19DiagnosisClinical classificationRevised American Fertility Society(r-AFS),1985Useful for:Assessment of severity Selection of therapeutic regimen Comparison Prognosis子宫内膜异位症Endometriosis张喜20r-AFS子宫内膜异位症Endometriosis张喜21Differential Diagnosis Ovarian tumor ascites（腹水）（腹
12、水）,solid or mixed,B ultrasound image,CA-125100 IU/ml Abdominal inflammatory mass history of infection,fever,not cyclic,treatment with antibiotics effectively Adenomyosis(子宫腺肌病子宫腺肌病)medial,severe pain,uterus slightly enlarged子宫内膜异位症Endometriosis张喜22Treatment Principles of treatment：Treatment should b
13、e individualized according to the age,severity of the condition and desire for childbearing.With mild symptom:expectant therapyWith childbearing desire:mild-condition:medication severe-condition:fertility preservation surgeryNo childbearing desire:Surgical treatment:ovary preservation or radical sur
14、gery子宫内膜异位症Endometriosis张喜23TreatmentExpectant Therapy Follow-up symptoms management：NSAIDs（非甾体类抗炎药）（非甾体类抗炎药）子宫内膜异位症Endometriosis张喜24TreatmentMedicationObjective:cause atrophic changes in the ectopic endometrium（使异位内膜萎缩）（使异位内膜萎缩）子宫内膜异位症Endometriosis张喜25MedicationPseudopregnancy therapy oral contrace
15、ptives：a pill once daily for 6-12 m progestins：medroxyprogesterone（醋酸甲孕酮）（醋酸甲孕酮）30mg daily megestrol（甲地孕酮）（甲地孕酮）40mg daily norethindrone（炔诺酮）（炔诺酮）5mg daily Side effects:Intermittent breakthrough bleeding,nausea,breast tenderness,fluid retention,weight gain子宫内膜异位症Endometriosis张喜26MedicationPseudomeno
16、pause therapyGnRH-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）（亮丙瑞林，抑那通）3.75mggoserelin（戈舍瑞林，诺雷德）（戈舍瑞林，诺雷德）3.6mgtryptorelin（曲普瑞林，达菲林）（曲普瑞林，达菲林）3.75mg m/H,1 inj/q28d,start d1 子宫内膜异位症Endometriosis张喜27MedicationGnRH-a Side effects:(1)Menopausal symptoms
17、:hot flashes,dryness in vagina,loss of libido(性欲性欲)(2)Osteoporosis子宫内膜异位症Endometriosis张喜28MedicationPseudomenopause therapy Danazol A derivative of 17-ethinyltestosterone（17-乙炔睾酮衍生物）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-
18、600 mg/d for 6 months子宫内膜异位症Endometriosis张喜29Medication Danazol Side effects:acne,deepening of the voice,oily skin,headache,hot flashes,loss of libido,weight gain子宫内膜异位症Endometriosis张喜30Medicationothers：gestrinone（孕三烯酮）mifepristone（米非司酮）子宫内膜异位症Endometriosis张喜31Surgical treatmentPurposes：diagnosis an
19、d classification excise or destroy all endometriotic tissue remove all adhesions,restore pelvic anatomy enhance fecundity relieve pain子宫内膜异位症Endometriosis张喜32Surgical treatmentlaparoscopy+medicine golden standard of treatment子宫内膜异位症Endometriosis张喜33Surgical treatmentModes of surgical operation:(1)Fe
20、rtility preservation(2)Ovarian function preservation(3)Radical surgery(4)Surgery for pain relief子宫内膜异位症Endometriosis张喜34Treatment Combination of medication and surgery Treatment for patients with infertility子宫内膜异位症Endometriosis张喜35Prevention Prevent retrograde flow of menses Contraception with medic
21、ine Avoid iatrogenic(医源性医源性)implantation of the ectopic endometrium子宫内膜异位症Endometriosis张喜36 Adenomyosis 子宫内膜异位症Endometriosis张喜37 Adenomyosis is defined by the presence of endometrial glands and stroma within the myometrium.It is associated with myometrial hypertrophy and proliferation.子宫内膜异位症Endomet
22、riosis张喜38 Pathogenesis histological confirmation Sites of lesions Clinical findings子宫内膜异位症Endometriosis张喜39Clinical findingsMultiparas（40 y）were most commonly affected.Symptoms：prolonged and heavy menses Dysmenorrhea that worsens over timePelvic exam：enlargement of uterus tenderness子宫内膜异位症Endometriosis张喜40子宫内膜异位症Endometriosis张喜411.Medication：GnRH-a2.Surgical treatment:total hysterectomy 子宫内膜异位症Endometriosis张喜42Thank you!子宫内膜异位症Endometriosis张喜43
