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1、子宫内膜异位症子宫内膜异位症(Endometriosis)-(Endometriosis)-张喜张喜Definition Endometriosis is usually defined as the is usually defined as the 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 endomet
2、rium in uterine cavity and myometrium. in uterine cavity and myometrium. Gross appearance :ovarian endometriosis red, blue, or brown spots endometriomas chocolate cystsGross appearance :peritoneal endometriosiscommon sites： uterosacral ligament、rectouterine pouch uupurple purple spotsspotsuudark bro
3、wn spotsdark brown spotsuured lesionsred lesionsuuwhite lesionswhite lesionsuuperitoneum lack peritoneum lack peritoneal endometriosisperitoneal endometriosisperitoneal endometriosiscervix umbilicusumbilicus( (脐脐) ) The microscopic findings ：endometrial glands endometrial stroma fibrinred blood cell
4、s and hemosiderin（含铁血黄素） 2 findings to be diagnosedClinical Findings symptoms：dysmenorrhoea（痛经）（痛经） and chronic pelvic pain the most typical symptom：secondary dysmenorrhea that worsens over time dyspareunia（性交痛）（性交痛）abnormal uterine bleeding heavy menses, prolonged menstruation or premenstrual spott
5、inginfertility：40% of patients acute abdomen: inter-cyst hemorrhage(囊内出血), or ruptureClinical Findingssymptoms： others：diarrhoeadiarrhoea（腹泻）（腹泻）constipationconstipation（便秘）（便秘）bloody stool bloody stool painful urination painful urination bloody urine bloody urine backachebackacheCauses of infertili
6、ty1) Mechanical reason2) Environmental change in the peritoneal cavity3) Abnormal immune function4) Abnormal ovarian function (anovulation,LPD, Lufs)5) Increase in spontaneous abortionClinical FindingsPelvic Examination：fixed retroverted uterinetender nodules on uterosacral ligament or rectouterine
7、pouch tender and fixed adnexal masses Diagnosis historypelvic examinationlaparoscopy golden diagnosis standard diagnosis, classification treatmentultrasound, (CT and MRI, expensive)serum CA125 but usually 100IU/ml anti-endometrium antibody DiagnosisClinical classificationRevised American Fertility S
8、ociety (r-AFS), 1985Useful for: Assessment of severity Selection of therapeutic regimen Comparison Prognosisr-AFSDifferential Diagnosis Ovarian tumor ascites（腹水）（腹水）, solid or mixed, B ultrasound image, CA-125100 IU/ml Abdominal inflammatory mass history of infection, fever, not cyclic, treatment wi
9、th antibiotics effectively Adenomyosis (子宫腺肌病子宫腺肌病) medial, severe pain, uterus slightly enlargedTreatment Principles of treatment：Treatment should be individualized according to the age, severity of the condition and desire for childbearing.With mild symptom: expectant therapyWith childbearing desi
10、re: mild-condition: medication severe-condition: fertility preservation surgeryNo childbearing desire : Surgical treatment: ovary preservation or radical surgeryTreatmentExpectant Therapy Follow-upsymptoms management：NSAIDs（非甾体类抗炎药）（非甾体类抗炎药） TreatmentMedicationObjective: cause atrophic changes in th
11、e ectopic endometrium（使异位内膜萎缩）（使异位内膜萎缩）MedicationPseudopregnancy therapy oral contraceptives：a pill once daily for 6-12 m progestins：medroxyprogesterone （醋酸甲孕酮）（醋酸甲孕酮）30mg dailymegestrol （甲地孕酮）（甲地孕酮） 40mg dailynorethindrone （炔诺酮）（炔诺酮） 5mg daily Side effects: Intermittent breakthrough bleeding, nause
12、a, breast tenderness, fluid retention, weight gainMedicationPseudomenopause 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, st
13、art d1 MedicationGnRH-a Side effects: (1) Menopausal symptoms : hot flashes, dryness in vagina, loss of libido(性欲性欲) (2) OsteoporosisMedicationPseudomenopause 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）Di
14、rect inhibiting the growth of endometrium 400-600 mg/d for 6 monthsMedication Danazol Side effects:acne, deepening of the voice, oily skin, headache, hot flashes, loss of libido, weight gainMedicationothers：gestrinone （孕三烯酮） mifepristone（米非司酮）Surgical treatmentPurposes： diagnosis and classification
15、excise or destroy all endometriotic tissue remove all adhesions, restore pelvic anatomy enhance fecundity relieve painSurgical treatmentlaparoscopy + medicinelaparoscopy + medicine golden standard of treatmentgolden standard of treatmentSurgical treatmentModes of surgical operation:(1) Fertility pre
16、servation (2) Ovarian function preservation (3) Radical surgery (4) Surgery for pain reliefTreatment Combination of medication and surgery surgery + medication surgery + medication medication + surgery + medicationmedication + surgery + medicationTreatment for patients with infertilityPreventionPrev
17、ent retrograde flow of mensesContraception with medicine Avoid iatrogenic (医源性医源性) implantation of the ectopic endometrium Adenomyosis Definition Adenomyosis is defined by the presence of endometrial glands and stroma within the myometrium. It is associated with myometrial hypertrophy and proliferat
18、ion.Endometriosis AdenomyosisPathogenesis histological confirmation Sites of lesionsClinical findingsAdenomyosis is thought to be unrelated to endometriosisAdenomyosis is thought to be unrelated to endometriosisAdenomyosis is thought to be unrelated to endometriosis. . .Clinical findingsMultiparas（4
19、0 y） were most commonly affected.Symptoms：prolonged and heavy menses Dysmenorrhea that worsens over timePelvic exam：enlargement of uterustendernessDiagnosisTypical symptoms and signsTypical symptoms and signsHistopathologic examination Histopathologic examination standard of the diagnosis standard of the diagnosisB ultrasound would suggest the disease.B ultrasound would suggest the disease.Treatment1. Medication ：GnRH-a2. Surgical treatment : total hysterectomy Thank you !Thank you !
