子宮內(nèi)膜異位(Endometriosis)-趙愛課件

Endometriosis

＆Adenomyosis

Zhaoaimin

M.D.,Ph.D.,ProfessorDepartmentOfObstetrics&GynecologyRenjiHospitalAffiliatedtoSJTUSchoolofMedicine1Endometriosis

＆AdenomEndometriosis2Endometriosis2Definition:Abnormalgrowthofendometrialtissueoutsidetheuterinecavity.3Definition:3IncidenceandPrevalence:IncreasesignificantlyRangefrom1～50%Generalpopulation:1～2%Infertilewomen:30～50%Occursprimarilyinwomenin25～45s4IncidenceandPrevalence:IncrePathogenesis:ImplantationTheoryRetrogradeMenustrationTheorySampson，1921LymphaticandVascularDisseminationTheoryJavert，1952CoelomicTheoryMeyerGeneticTheoryImmuneSystemDysfunction（immunologictheory）5Pathogenesis:ImplantationTheGeneticfactors：Familialclusteringofendometriosisisacommonclinicalobservation.Infamilieswithendometriosis，thediseaseisoftenconfinedtothematernalline，andis7timesmorecommoninfirst-degreerelativesthaninthegeneralpopulation.Infuturestudies，evaluationofDNApolymorphismmayidentifyspecificgenesinvolvedinthedevelopmentofendometriosis.6Geneticfactors：FamilialclustImmunologicTheory：LosecontrolofimmunologicbalanceBothcellularimmunityandhumoralimmunitychange.Macrophage↑releaseIL–1、IL–6、TNF、EGF、FGFetc.stimulateT、BlymphocyteproliferationandactivationActivityofkillercell（NKcellandTcell）↓

Produceanti–endometriumantibodyAbnormalexpressionofCAMs（celladhesionmolecules）7ImmunologicTheory：LosecontroThepathogenesisisunclear.multifactor8Thepathogenesisisunclear.8Pathology

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macroscopicappearance（1）：Thecommonestsites：Ovary（chocolatecyst）Peritoneumoftherecto–vaginalcul–de–sacofthePouchofDouglasUtero–sacralligamentsSigmoidcolonBroadligament9Pathology

–macroscopicappe

Thisisasectionthroughanenlarnged12cmovarytodemonstrateacysticcavityfilledwitholdbloodtypicalforendometriosiswithformationofanendometriotic,or"chocolate",cyst.10101111Pathology

–macroscopicappearance（2）：Lesscommonsites：CervixRoundligamentUrinarysystem（bladder、ureter）UmbilicusAppendixLaparotomyscars12Pathology

–macroscopicappeaMultipleappearancesof

endometriosis

implants：Brownish，discoloredperitoneumSuperficialperitonealecchymosisRaised，reddish，superficialnodulesReddish–blueinvasivenodulesFibrotic，whitishnodulesRaised，glossy，translucentblobsPatchy，whiteopacifiedperitoneumReddishorbluishovariancysts13Multipleappearancesofendome

Grossly,inareasofendometriosisthebloodisdarkerandgivesthesmallfociofendometriosisthegrossappearanceof"powderburns".SmallfociareseenherejustundertheserosaoftheposterioruterusinthepouchofDouglas.Suchareasofendometriosiscanbeseenandobliteratedbycauterizationvialaparoscopy.1414Uponcloserview,thesefivesmallareasofendometriosishaveareddish-browntobluishappearance.1515Pathology

–microscopicappearanceHistomorphologicallysimilartoeutopicendometriumFourmajorcomponents：endometrialglandsendometrialstromafibrosishemorrhageEctopicendometrium異位子宮內(nèi)膜Eutopicendometrium在位子宮內(nèi)膜16Pathology

–microscopicapClinicalManifestation17ClinicalManifestation17Symptoms：PainprogressivedysmenorrheadyspareuniapainfuldefecationMenstrualdisturbanceinfertilitydysmenorrhea痛經(jīng)dyspareunia性交痛18Symptoms：PaindysmenorrheadyspaSigns：Enlargementoftheovaries，fixedFixedretroversionoftheuterusTendernoduleswithinthepelvisCannotbediagnosedbyPValone.Shouldalwaysbeconsideredwhenpatientshavesymptomsreferabletothepelviccavity.19Signs：EnlargementoftheovariVeryvariableVarywiththefocuslocationOftenbearnorelationtotheextentofthediseaseQuiteoftendepositsarefoundincidentallyinwomenwhohavenosymptoms.（25%havenosymptoms）20Veryvariable20Diagnosis：HistoryPVexaminationLaparoscopy（goldenstandard）Ultrasonography（B–typeultrasound）CA–125↑（＜200U/ml；normalvalue35U/ml）Anti–endometriumantibody（+）21Diagnosis：History21Stagingsystems：IntheAFS-r（1985）stagingsystem，pointsareassignedforseverityofendometriosisbasedonthesizeanddepthoftheimplantandfortheseverityofadhesions.Thepointsaresummedandthepatientsareassignedtoonetofourstages：StageI—minimaldisease，1～5pointsStageII—milddisease，6～15pointsStageIII—moderatedisease，16～40pointsStageIV—severedisease，≥40points22Stagingsystems：IntheAFS-r（1Differentialdiagnosis：MalignantovarytumoursPelvicinflammatorymassesAdenomyosis23Differentialdiagnosis：MalignaTreatment24Treatment24Expectanttherapy：Indications：withverylimiteddisease（whosesymptomsareminimalornonexistent）Iftryingtogetpregnant，thebestwayistoacceptlaparoscopictherapyasearlyaspossible.25Expectanttherapy：Indications：Medicaltherapy：Indications：chronicpelvicpainseveredysmenorrheanorequiretogetpregnantnoovariancystformationHormone–inhibitiontherapy26Medicaltherapy：Indications：chDrugs：Danazol：pseudomenopausetherapyGestrinoneGnRH–a：medicaloophorectomyadd–backtherapyMifepristoneRU486Progestogens：pseudopregnancytherapy27Drugs：Danazol：pseudomenopauseSurgicaltherapy（1）：Indications（1）adnexalmass（2）pelvicpain（3）infertilityApproaches：(1)trans–abdominal(2)laparoscopic28Surgicaltherapy（1）：IndicationSurgicaltherapy（2）：Methods：ConservativesurgerypreservethefecunditypreservetheovarianfunctionDefinitivesurgery：hysterectomy+salpingo–oophorectomy29Surgicaltherapy（2）：Methods：29Combination

medical–surgicaltreatment：Three–step：

surgerymedicaltherapysecondlook（laparoscopy）30Combination

medical–surgicalItisimportanttoindividualizethechoiceoftherapy.Therapymustbetailoredto

thedegreeofsymptomatologythepatient’sageherdesiretomaintainfertility31ItisimportanttoindividualPrognosis：Withpropertreatment，theprognosisisgoodforreliefofpainandenhancementoffertilityinmildtomoderateendometriosis.Inmostcases，hormonaltherapyistemporarilyeffectiveincontrollingsymptomsandarrestinggrowthbutisgenerallylesseffectivethansurgeryinincreasingfertility.Therecurrentrateisveryhigh.32Prognosis：32Prevention：Avoidpossibleaugmentationofmenstrualreflux.Takingoralcontraceptiveisrecommended.Isolationandirrigationoftheoperativesite.33Prevention：AvoidpossibleaugmCritical

points（1）：Thepathogenesisispoorlyunderstood，butemergingevidencesupportsthecausativeroleofretrogrademenstruationandimplantationofendometrialtissue.Endometriosisisacommoninwomenwithpelvicpainorinfertility.Laparoscopyistheoptimaltechniquetodiagnosepelvicendometriosis.34Criticalpoints（1）：ThepathogeCritical

points（2）：Inmostcases，surgicaltherapyatthetimeofinitialdiagnosiseffectivelyrelievespainandmayenhancefertility.Alternatively，medicaltherapywithprogestins、danazol、gestrinoneorGnRH-awillamelioratepelvicpain，buttheydonotenhancefertility.Endometriosisisarecurrentdisease，anddefinitivetreatmentwithremovalofpelvicorgansmaybenecessary.35Criticalpoints（2）：InmostcasAdenomyosis36Adenomyosis36Definition：

Abenignuterineconditioninwhichendometrialglandsandstromaarefounddeepinthemyometrium.37Definition：AbenignuterineEtiology：Basalendometrialhyperplasiainvadingahyperplasticmyometrialstroma.Fourprimarytheories：HeredityTraumaHyperestrogenemiaViraltransmission38Etiology：BasalendometrialhypPathology

—grossappearance：UsuallyhyperemicwiththickenedwallsThefociarefrequentlyscattereddiffuselythroughoutthemyometrium.Occasionally，maybemorecircumscribed，withtheformationofadistinctnodule，anadenomyoma.Adenomyosis子宮肌腺癥Adenomyoma子宮肌腺瘤39Pathology

—grossappearan

Thethickenedandspongyappearingmyometrialwallofthissectioneduterusistypicalofadenomyosis.Thereisalsoasmallwhiteleiomyomaatthelowerleft.4040Clinicalfeatures（1）：Symptomaticadenomyosisoccursprimarilyinparouswomenovertheageof40.（30～50）Classicsymptoms：

secondarydys