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1、ENDOMETRIOSIS Key points1.Cases of endometriosis in the postmenopausal patient are rare, but when found are often associated with estrogen replacement therapy (ERT)2. It is not a neoplasm despite the fact that it can grow into the bowel or bladder. On rare occasions, it may be the site for the devel
2、opment of a malignant growth. 3. Surgery remains the standard for the final diagnosis of endometriosis.4. Medical suppression of endometriosis for infertility patients seeking pregnancy has no proven beneficial effect.5. The endometriosis patients who suffer severe pelvic pain and undergo hysterecto
3、my for control of symptoms experience a high recurrence rate of symptoms unless bilateral salpingoophorectomy is performedLearning objectivesvUnderstandthesymptomsandprinciplesofmanagementofendometriosis.DefinitionEndometriosisisadisorderinwhichabnormalgrowthsoftissue,histologicallyresemblingtheendo
4、metrium,arepresentin locations other thantheuterinelining.(exteriorendometriosis)Adenomyosis is thepresence of endometrialglandsandstromawithinthemyometrium(internalendometriosis)定义l子宫内膜异位症具有生长功能的子宫内膜组织(腺体和间质)出现在子宫腔被覆内膜及宫体肌层以外的其他部位。l良性良性，l但有增生、浸润、转移及复发等恶性行为EpidemiologyThe exact incidence or prevalen
5、ce ofendometriosis is really unknown becausesurgeryisrequiredforitsdiagnosis,butitisestimated to be present in 10% of allreproductive-agewomen.It occurs most commonly in womenbetween the ages of25 and 45 who havedelayed marriage and childbearing. Theincidence of infertility is approximately30% to 40
6、% in patients with the disease,andremainingsufferersareusuallyoflowparity.Typicallydiagnosedattheageof25to29,topeakattheageof40to45,andtodegeneratewithmenopause.postmenopausalendometriosiscasesareassociatedwithERT.Laparoscopyhasbeenincreasinglyperformedinfinaldiagnosisofendometriosis,bydirectobserva
7、tionoftheimplants.PATHOGENESISThecauseofendometriosisisunknown.Maintheories:1.Implantation theorya.Retrogrademenstruation:itisthemostcommonlyheldtheorywhichmeansfunctionalendometriumwithretrogrademenstruationcauselocalimplantation.lb.latrogenicplantinglendometriosisinscarc.endometriosisthroughlympha
8、ticorvascularembolization:endometriosiscanbepresentindistantsitessuchasthelungsandlimbs via pelvic lymph and veins circulation2.coelomicepithelium:whichformsthemullerianducts,fromwhichtheendometriosiscanatanytimeinadultlife,berestimulatedbysomeunknownmechanismandbetransformedintoendometrial tissue b
9、y some unknownmechanism.(menstrualfluidorotherirritants,cyclicovarianhormones,etc.)3.Induction theorya.Genetics:somestudyhaveshowna6%-7%incidence in first-degree relatives ,this isconsistent with a multifactorial mode ofinheritance.b.Aberrationsintheimmunesystem:insomepatients show a decreased clear
10、ance ofendometrialcellsandabnormalproductionofcytokinesbywhitecellsintheperitonealfluidofwomenwithendometrioislc.imflamatoryld.determinantofeutopicendometriumPATHOLOGYlGrossappearancevariesfromsmalltolargelesions;“chocolatecysts”;Itcanerodeintounderlyingtissuesanddistorttheremainorganswithextensivea
11、dhesions.lDistributionexhibitsacharacteristicpattern:lOvary;uterinecul-de-sac,uterosacrallig.posteriorsurfaceofuterus,broadlig.lMicroscopicfindings:lComposedoftissueshistologicallyresemblingendometrialglandsandstromaHemosiderin-ladenmacrophageClinical featuresHalfofthepatientswithendometriosisareasy
12、mptomatic,andtheclinicalfindingsvarygreatlydependingonthenumber,sizeandextent of the lesions and on the patientpopulationbeingexamined.SymptomsvCyclicalpelvicpain:patientscomplainofconstantpelvicpainoralowsacralbackachethatoccurspremenstruallyandsubsidesaftermensesbeginsvDysmenorrhea:secondaryandpro
13、gressiveworseningdysmenorrheavDyspareunia: lesions in the cul-de-sac anduterosacralligamentscauseafixedretroversionofuterinandisassociatedwithdeepdyspareunia.vInfertility:inseverecases,physicalfactorssuchasscarringandadhesionsinterferingwithtubalmobility,obstructingtubes,orinterferingwithovulationan
14、dovumtransportmaybethecauses.Luteinizedunrupturedfolliclesyndrome,lutealphasedefects,acytotoxiceffectofperitonealmacrophagesphagocytosinganddegradingspermandmanymore.Howevernoneofthesetheorieshavebeenconclusivelydemonstratedtoexplainendometriosis-associatedinfertility.l不孕：高达40%。l原因（1）盆腔解剖结构异常（2）盆腔内微
15、环境改变（3）卵巢功能异常（4）自然流产率增加vOtheruncommonsymptoms:lesionsinvolvingtheurinarytractorbowelmayresultinbloodyurineorstool,thepresenceoflargemassmaycausepelvicpressure,andpremenstrualspottingislikelyassociatedwithluteal-phaseinadequacy.Clinical signs1.Fixed tender retroverted uterus andpainuponuterinemotiond
16、uetocul-de-sacadhesions2.NodularthickeningandtendernessintheuterosacralligamentsorpouchofDouglas3.AdnexalswellingortendernessDiagnostic methods1.CA-125measurement:mayelevatedandcorrelatedwiththeamountofdiseasepresentbutisnonspecific(25ng/ml)2.Pelvicimaging(ultrasound,CT,MRI)3.Laparoscopy:madeafinala
17、ndcorrectdiagnosisbydirectobservationoftheimplants.Thehistologicallydiagnosisismadebydemonstrationof endometrial glands and stroma or ofhemosiderin-ladenmacrophagesinthecystwall.Treatment治疗原则治疗原则l症状轻：期待疗法l要求生育：轻：药物治疗重：保守性手术+药物治疗l无生育要求：年轻：45岁，重症患者：根治性手术Medicaltreatment1.Pseudopregnancy: the aim is to
18、 createconstanthighlevelsofprogestinasseeninpregnancy to thin the endometrium andcause its regression with pseudodecidualchanges:oralcontraceptivepills,progestogen,20mg/d,for3-6months2.Pseudomenopause:Danazol acts via several mechanisms totreat endometriosis. It is a syntheticderivativeoftestosteron
19、eandmayactviasuppressionofgonadotropinsecretion.Sideeffects:menopausalsymptoms,weightgain,edema,andmildvirilization.800mg/dfor6months.Gestrinone2.5mg,biw,for3-6months,ismoreeffectiveandhaslesssideeffect,ovulationwasnotinhibited.GnRHagonists:Gonadotripinreleasinghormone(GnRH)agonistsiscongenersofthe1
20、0-amino-acidpeptidehormone,throughcompetitivelycombinewiththepituitaryreceptorsandcausehypogonadismandthenachievemenopause.leuprolideacetate3.75mg/m,im.3-6msgoserelin3.75mg/msubcutaneouslySurgery1.Conservativesurgery:treatmentinwomenwithcomplaintsofinfertilitywhohaveseverediseaseoradhesionsorareolde
21、r.thissurgeryattemptstoexciseordestroyallendometriotictissue,removealladhesions,andrestorepelvicanatomytothebestpossiblecondition.2.Radicalsurgery:patientsdoesnotdesirefuturechildbearingandhasseverediseaseorsymptoms.thisentailstotalabdominalhysterectomy,bilateralsalpingoophorectomy,andexcisionofrema
22、iningadhesionsorimplantation.AssistedReproductioninvitrofertilization,gameteintrafallopiantransfer,etc.ThemostefficaciousofallinfertilitytherapiesforendometriosisSeverediseasehavedecreasedsucccess.Prevention:Isnotcurrentlypossible.(Nottopostponechildbearing.)-havenotbeenproved. ADENOMYOSISAdenomyosi
23、sisdefinedbythepresenceofendometrialglandsandstromawithinthemyometrium.ThepathogenesisofadenomyosisisunknownPathology:Themyometriumisthickeningandofuniformconsistency.Thecutsurfacemayhaveawhorl-likeorgranulartrabecularpattern,andtheremaybecoarsestipplingorgranulartrabecutionwithsmallyelloworbrowncys
24、ticspacescontainingfluidorblood.Clinicalfindingsanddiagnosis:1.hypermenorrhea,2.dysmenorrhea3.enlargeduterus(symmetrically)4.imagingDifferentialdiagnosis:Pregnancy;Submucousleiomyoma:Endometriumcancer;Pelviccongestionsyndrom(Taylorssyndrom)PelvicendometriosisTreatment:HysterectomyHormonaltherapy:hasnotbeensuccessfulGnRH-a:temporaryreliefeOralcontraceptivesmayexacerbatethesymptomsPrevention:Adenomyosiscannotbeprevented
