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EndometriosisEndometriosis
Women’s Hospital, School of Medicine Zhejiang Women’s Hospital, School of Medicine Zhejiang UniversityUniversity
Prof. Lin JunProf. Lin Jun
EndometriosisEndometriosis
Women’s Hospital, School of Medicine Zhejiang Women’s Hospital, School of Medicine Zhejiang UniversityUniversity
Prof. Lin JunProf. Lin Jun
DefinitionDefinition
EndometriosisEndometriosis is usually defined as the is usually defined as the
presence of endometrial-like tissue, that presence of endometrial-like tissue, that
is, glands and stroma, outside the is, glands and stroma, outside the
endometrium endometrium
in uterine cavity and myometrium. in uterine cavity and myometrium.
EndometriosisEndometriosis is usually defined as the is usually defined as the
presence of endometrial-like tissue, that presence of endometrial-like tissue, that
is, glands and stroma, outside the is, glands and stroma, outside the
endometrium endometrium
in uterine cavity and myometrium. in uterine cavity and myometrium.
Common sites of endometriosisCommon sites of endometriosis
The most common sites :• uterosacral ligament• rectouterine pouch • ovary
Others :• uterine serosa• fallopian tube• sigmoid colon
outside of the pelvis :• Umbilicus , bladder, kidney
The most common sites :• uterosacral ligament• rectouterine pouch • ovary
Others :• uterine serosa• fallopian tube• sigmoid colon
outside of the pelvis :• Umbilicus , bladder, kidney
PrevalencePrevalence• present in 10%-15% of women in
reproductive age group, especially from age 25 to 45
• normally not seen before age 15 or after menopause
• less and late childbearing
• latest study: more frequent menses (cycle length ≤ 27 days ) and prolonged menstrual flow (≥ 1 week) 2 times risk
• present in 10%-15% of women in reproductive age group, especially from age 25 to 45
• normally not seen before age 15 or after menopause
• less and late childbearing
• latest study: more frequent menses (cycle length ≤ 27 days ) and prolonged menstrual flow (≥ 1 week) 2 times risk
PathogenesisPathogenesis PathogenesisPathogenesis Theories of sources of ectopic endometrium
• Implantation theory ——Sampson 1921
endometrium transfer → implant →grow
⒈retrograde menstruation theory
⒉iatrogenic implantation
⒊ transport by lymph and vein
Theories of sources of ectopic endometrium
• Implantation theory ——Sampson 1921
endometrium transfer → implant →grow
⒈retrograde menstruation theory
⒉iatrogenic implantation
⒊ transport by lymph and vein
PathogenesisPathogenesisPathogenesisPathogenesis
Theories of source of ectopic endometrium
• metaplasia theory of coelomic epithelium
• induction theory
Theories of source of ectopic endometrium
• metaplasia theory of coelomic epithelium
• induction theory
PathogenesisPathogenesis PathogenesisPathogenesis Factors related with endometriosis
• Genetic Factors : high risk in first-degree
relatives
• Immunologic Factors
• Inflammation
• Character of uterine eutopic endometrium
Factors related with endometriosis
• Genetic Factors : high risk in first-degree
relatives
• Immunologic Factors
• Inflammation
• Character of uterine eutopic endometrium
Pathology Pathology
ectopic endometrium ↓hemorrhage ↓proliferation of fibrous tissue & adhesions ↓dark blue or dark brown spots ↓scarring nodules or cysts
ectopic endometrium ↓hemorrhage ↓proliferation of fibrous tissue & adhesions ↓dark blue or dark brown spots ↓scarring nodules or cysts
PathologyPathology
• Ovarian endometriosis
• Peritoneal endometriosis
• Deep infiltrating endometriosis
• others
• Ovarian endometriosis
• Peritoneal endometriosis
• Deep infiltrating endometriosis
• others
Gross appearance :Gross appearance :
ovarian endometriosis • red, blue, or brown spots • endometriomas —— chocolate cysts
ovarian endometriosis • red, blue, or brown spots • endometriomas —— chocolate cysts
Gross appearance :Gross appearance :
peritoneal endometriosiscommon sites : uterosacral ligament 、 rectouterine
pouch
peritoneal endometriosiscommon sites : uterosacral ligament 、 rectouterine
pouch
purple spotsdark brown spotsred lesionswhite lesionsperitoneum lack
purple spotsdark brown spotsred lesionswhite lesionsperitoneum lack
peritoneal endometriosisperitoneal endometriosis
peritoneal endometriosisperitoneal endometriosis
cervix cervix umbilicus
umbilicus
The microscopic findingsThe microscopic findings :The microscopic findingsThe microscopic findings :
• endometrial glands • endometrial stroma • fibrin• red blood cells and hemosiderin
≥2 findings to be diagnosed
• endometrial glands • endometrial stroma • fibrin• red blood cells and hemosiderin
≥2 findings to be diagnosed
Clinical FindingsClinical Findings Clinical FindingsClinical Findings
symptoms :• dysmenorrhoea and chronic pelvic pain the most typical symptom : secondary dysmenorrhea
that worsens over time
• dyspareunia• abnormal uterine bleeding heavy menses, prolonged menstruation or premenstrual
spotting
• infertility : 50% of patients
• acute abdomen: inter-cyst hemorrhage, or rupture
symptoms :• dysmenorrhoea and chronic pelvic pain the most typical symptom : secondary dysmenorrhea
that worsens over time
• dyspareunia• abnormal uterine bleeding heavy menses, prolonged menstruation or premenstrual
spotting
• infertility : 50% of patients
• acute abdomen: inter-cyst hemorrhage, or rupture
Clinical FindingsClinical FindingsClinical FindingsClinical Findings
symptoms :
others :
symptoms :
others :diarrhoea
constipation
bloody stool
painful urination
bloody urine
backache
diarrhoea
constipation
bloody stool
painful urination
bloody urine
backache
Causes of infertilityCauses of infertility
1) Mechanical reason
2) Environmental change in the peritoneal cavity
3) Abnormal immune function
4) Abnormal ovarian function (anovulation,LPD,
LUFS)
5) Increase in spontaneous abortion
1) Mechanical reason
2) Environmental change in the peritoneal cavity
3) Abnormal immune function
4) Abnormal ovarian function (anovulation,LPD,
LUFS)
5) Increase in spontaneous abortion
Clinical FindingsClinical FindingsClinical FindingsClinical Findings
Pelvic Examination :• fixed retroverted uterine
• tender nodules on uterosacral ligament or rectouterine pouch
• tender and fixed adnexal masses
Pelvic Examination :• fixed retroverted uterine
• tender nodules on uterosacral ligament or rectouterine pouch
• tender and fixed adnexal masses
Diagnosis Diagnosis
• history
• pelvic examination
• laparoscopy —— golden diagnosis standard
diagnosis, classification & treatment
• ultrasound, (CT and MRI, expensive)
• serum CA125 ↑but usually < 100IU/ml
• anti-endometrium antibody
• history
• pelvic examination
• laparoscopy —— golden diagnosis standard
diagnosis, classification & treatment
• ultrasound, (CT and MRI, expensive)
• serum CA125 ↑but usually < 100IU/ml
• anti-endometrium antibody
DiagnosisDiagnosis
Clinical classification
Revised American Fertility Society (r-AFS), 1985
Useful for:• Assessment of severity• Selection of therapeutic regimen• Comparison• Prognosis
Clinical classification
Revised American Fertility Society (r-AFS), 1985
Useful for:• Assessment of severity• Selection of therapeutic regimen• Comparison• Prognosis
r-AFSr-AFS
Differential DiagnosisDifferential Diagnosis
• Ovarian tumor ascites, solid or mixed, B ultrasound image,
CA-125>100 IU/ml
• Abdominal inflammatory mass history of infection, fever, not cyclic, treatment
with antibiotics effectively
• Adenomyosis medial, severe pain, uterus slightly enlarged
• Ovarian tumor ascites, solid or mixed, B ultrasound image,
CA-125>100 IU/ml
• Abdominal inflammatory mass history of infection, fever, not cyclic, treatment
with antibiotics effectively
• Adenomyosis medial, severe pain, uterus slightly enlarged
Treatment Treatment
Principles of treatment :Treatment should be individualized according to the age,
severity of the condition and desire for childbearing.
• With mild symptom: expectant therapy
• With childbearing desire:
mild-condition: medication
severe-condition: fertility preservation surgery
• No childbearing desire :
Surgical treatment: ovary preservation or radical surgery
Principles of treatment :Treatment should be individualized according to the age,
severity of the condition and desire for childbearing.
• With mild symptom: expectant therapy
• With childbearing desire:
mild-condition: medication
severe-condition: fertility preservation surgery
• No childbearing desire :
Surgical treatment: ovary preservation or radical surgery
TreatmentTreatment
Expectant Therapy
• Follow-up
• symptoms management : NSAIDs
Expectant Therapy
• Follow-up
• symptoms management : NSAIDs
TreatmentTreatment
Medication
Objective:
cause atrophic changes in the ectopic
endometrium
Medication
Objective:
cause atrophic changes in the ectopic
endometrium
MedicationMedication
Pseudopregnancy therapy
⒈ oral contraceptives : a pill once daily for 6-12 m
⒉ progestins :• medroxyprogesterone 30mg daily
• megestrol 40mg daily
• norethindrone 5mg daily Side effects: Intermittent breakthrough bleeding, nausea, breast
tenderness, fluid retention, weight gain
Pseudopregnancy therapy
⒈ oral contraceptives : a pill once daily for 6-12 m
⒉ progestins :• medroxyprogesterone 30mg daily
• megestrol 40mg daily
• norethindrone 5mg daily Side effects: Intermittent breakthrough bleeding, nausea, breast
tenderness, fluid retention, weight gain
MedicationMedication
Pseudomenopause therapy
⒈GnRH-a
Mechanism: Medical hypophysectomy / Medical oophorectomy
• leuprorelin 3.75mg• goserelin 3.6mg• tryptorelin 3.75mg m / H, 1 inj/q28d, start d1
Pseudomenopause therapy
⒈GnRH-a
Mechanism: Medical hypophysectomy / Medical oophorectomy
• leuprorelin 3.75mg• goserelin 3.6mg• tryptorelin 3.75mg m / H, 1 inj/q28d, start d1
MedicationMedication
⒈GnRH-a
Side effects:
(1) Menopausal symptoms :
hot flashes, dryness in vagina, loss of libido
(2) Osteoporosis
⒈GnRH-a
Side effects:
(1) Menopausal symptoms :
hot flashes, dryness in vagina, loss of libido
(2) Osteoporosis
MedicationMedication
Pseudomenopause therapy
⒉ Danazol A derivative of 17-α-ethinyltestosterone Mechanism:• Directly suppressing ovarian steroidogenesis • Direct inhibiting the growth of endometrium
400-600 mg/d for 6 months
Pseudomenopause therapy
⒉ Danazol A derivative of 17-α-ethinyltestosterone Mechanism:• Directly suppressing ovarian steroidogenesis • Direct inhibiting the growth of endometrium
400-600 mg/d for 6 months
MedicationMedication
⒉ Danazol
Side effects:
acne, deepening of the voice, oily skin,
headache, hot flashes, loss of libido,
weight gain
⒉ Danazol
Side effects:
acne, deepening of the voice, oily skin,
headache, hot flashes, loss of libido,
weight gain
MedicationMedication
others :
• gestrinone• mifepristone
others :
• gestrinone• mifepristone
Surgical treatmentSurgical treatment
Purposes :
⑴ diagnosis and classification
⑵ excise or destroy all endometriotic tissue
⑶ remove all adhesions, restore pelvic anatomy
⑷ enhance fecundity
⑸ relieve pain
Purposes :
⑴ diagnosis and classification
⑵ excise or destroy all endometriotic tissue
⑶ remove all adhesions, restore pelvic anatomy
⑷ enhance fecundity
⑸ relieve pain
Surgical treatmentSurgical treatment
laparoscopy + medicine
golden standard of treatment
laparoscopy + medicine
golden standard of treatment
Surgical treatmentSurgical treatment
Modes of surgical operation:
(1) Fertility preservation
(2) Ovarian function preservation
(3) Radical surgery
(4) Surgery for pain relief
Modes of surgical operation:
(1) Fertility preservation
(2) Ovarian function preservation
(3) Radical surgery
(4) Surgery for pain relief
TreatmentTreatment
Combination of medication and surgery
• surgery + medication surgery + medication
• medication + surgery + medicationmedication + surgery + medication
Treatment for patients with infertility
Combination of medication and surgery
• surgery + medication surgery + medication
• medication + surgery + medicationmedication + surgery + medication
Treatment for patients with infertility
PreventionPrevention
• Prevent retrograde flow of menses
• Contraception with medicine
• Avoid iatrogenic implantation of the
ectopic endometrium
• Prevent retrograde flow of menses
• Contraception with medicine
• Avoid iatrogenic implantation of the
ectopic endometrium
Adenomyosis
Adenomyosis
DefinitionDefinitionDefinitionDefinition
• Adenomyosis is defined by the presence
of endometrial glands and stroma within
the myometrium. It is associated with
myometrial hypertrophy and proliferation.
• Adenomyosis is defined by the presence
of endometrial glands and stroma within
the myometrium. It is associated with
myometrial hypertrophy and proliferation.
Endometriosis Endometriosis && AdenomyosisAdenomyosisEndometriosis Endometriosis && AdenomyosisAdenomyosis
• Pathogenesis & histological confirmation
• Sites of lesions• Clinical
findings
• Pathogenesis & histological confirmation
• Sites of lesions• Clinical
findings
Adenomyosis is thought to be unrelated to Adenomyosis is thought to be unrelated to endometriosisendometriosis..
Adenomyosis is thought to be unrelated to Adenomyosis is thought to be unrelated to endometriosisendometriosis..
Clinical findingsClinical findings
Multiparas (> 40 y ) were most commonly affected.
Symptoms :• prolonged and heavy menses • Dysmenorrhea that worsens over time
Pelvic exam :• enlargement of uterus• tenderness
Multiparas (> 40 y ) were most commonly affected.
Symptoms :• prolonged and heavy menses • Dysmenorrhea that worsens over time
Pelvic exam :• enlargement of uterus• tenderness
DiagnosisDiagnosisDiagnosisDiagnosis
• Typical symptoms and signsTypical symptoms and signs
• Histopathologic examination Histopathologic examination
—— —— standard of the diagnosisstandard of the diagnosis
• B ultrasound would suggest the disease.B ultrasound would suggest the disease.
• Typical symptoms and signsTypical symptoms and signs
• Histopathologic examination Histopathologic examination
—— —— standard of the diagnosisstandard of the diagnosis
• B ultrasound would suggest the disease.B ultrasound would suggest the disease.
TreatmentTreatmentTreatmentTreatment
1. Medication : GnRH-a
2. Surgical treatment : total hysterectomy
1. Medication : GnRH-a
2. Surgical treatment : total hysterectomy
Thank you !Thank you !