子宫内膜异位.ppt

1,Endometriosis Adenomyosis,Zhao aimin M.D., Ph.D., Professor Department Of Obstetrics & Gynecology Renji Hospital Affiliated to SJTU School of Medicine,2,Endometriosis,3,Definition: Abnormal growth of endometrial tissue outside the uterine cavity.,4,Incidence and Prevalence:,Increase significantly Range from 1 50% General population:1 2% Infertile women:30 50% Occurs primarily in women in 25 45s,5,Pathogenesis:,Implantation Theory Retrograde Menustration Theory Sampson，1921 Lymphatic and Vascular Dissemination Theory Javert，1952 Coelomic Theory Meyer Genetic Theory Immune System Dysfunction（immunologic theory）,6,Genetic factors：,Familial clustering of endometriosis is a common clinical observation. In families with endometriosis，the disease is often confined to the maternal line，and is 7 times more common in first-degree relatives than in the general population. In future studies，evaluation of DNA polymorphism may identify specific genes involved in the development of endometriosis.,7,Immunologic Theory：,Lose control of immunologic balance Both cellular immunity and humoral immunity change. Macrophage release IL1、IL6、TNF、EGF、FGF etc. stimulate T、B lymphocyte proliferation and activation Activity of killer cell（NK cell and T cell） Produce antiendometrium antibody Abnormal expression of CAMs（cell adhesion molecules）,8,The pathogenesis is unclear. multifactor,9,Pathology macroscopic appearance（1）：,The commonest sites： Ovary（chocolate cyst） Peritoneum of the rectovaginal culdesac of the Pouch of Douglas Uterosacral ligaments Sigmoid colon Broad ligament,10,This is a section through an enlarnged 12 cm ovary to demonstrate a cystic cavity filled with old blood typical for endometriosis with formation of an endometriotic, or “chocolate“, cyst.,11,12,Pathology macroscopic appearance （2）：,Less common sites： Cervix Round ligament Urinary system（bladder、ureter） Umbilicus Appendix Laparotomy scars,13,Multiple appearances of endometriosis implants：,Brownish，discolored peritoneum Superficial peritoneal ecchymosis Raised，reddish，superficial nodules Reddishblue invasive nodules Fibrotic，whitish nodules Raised，glossy，translucent blobs Patchy，white opacified peritoneum Reddish or bluish ovarian cysts,14,Grossly, in areas of endometriosis the blood is darker and gives the small foci of endometriosis the gross appearance of “powder burns“. Small foci are seen here just under the serosa of the posterior uterus in the pouch of Douglas. Such areas of endometriosis can be seen and obliterated by cauterization via laparoscopy.,15,Upon closer view, these five small areas of endometriosis have a reddish-brown to bluish appearance.,16,Pathology microscopic appearance,Histomorphologically similar to eutopic endometrium Four major components： endometrial glands endometrial stroma fibrosis hemorrhage,Ectopic endometrium 异位子宫内膜,Eutopic endometrium 在位子宫内膜,17,Clinical Manifestation,18,Symptoms：,Pain progressive dysmenorrhea dyspareunia painful defecation Menstrual disturbance infertility,dysmenorrhea 痛经,dyspareunia 性交痛,19,Signs：,Enlargement of the ovaries，fixed Fixed retroversion of the uterus Tender nodules within the pelvis Cannot be diagnosed by PV alone. Should always be considered when patients have symptoms referable to the pelvic cavity.,20,Very variable Vary with the focus location Often bear no relation to the extent of the disease Quite often deposits are found incidentally in women who have no symptoms. （25% have no symptoms）,21,Diagnosis：,History PV examination Laparoscopy（golden standard） Ultrasonography（Btype ultrasound） CA125 （ 200U/ml；normal value 35U/ml） Antiendometrium antibody（+）,22,Staging systems：,In the AFS-r（1985）staging system，points are assigned for severity of endometriosis based on the size and depth of the implant and for the severity of adhesions. The points are summed and the patients are assigned to one to four stages： Stage I minimal disease， 15 points Stage II mild disease， 615 points Stage III moderate disease，1640 points Stage IV severe disease， 40 points,23,Differential diagnosis：,Malignant ovary tumours Pelvic inflammatory masses Adenomyosis,24,Treatment,25,Expectant therapy：,Indications：with very limited disease （whose symptoms are minimal or nonexistent） If trying to get pregnant，the best way is to accept laparoscopic therapy as early as possible.,26,Medical therapy：,Indications：chronic pelvic pain severe dysmenorrhea no require to get pregnant no ovarian cyst formation Hormoneinhibition therapy,27,Drugs：,Danazol：pseudomenopause therapy Gestrinone GnRH a：medical oophorectomy add back therapy Mifepristone RU486 Progestogens：pseudopregnancy therapy,28,Surgical therapy（1）：,Indications（1）adnexal mass （2）pelvic pain （3）infertility Approaches： (1) trans abdominal (2) laparoscopic,29,Surgical therapy（2）：,Methods： Conservative surgery preserve the fecundity preserve the ovarian function Definitive surgery： hysterectomy + salpingooophorectomy,30,Combination medicalsurgical treatment：,Threestep：,surgery,medical therapy,second look（laparoscopy）,31,It is important to individualize the choice of therapy. Therapy must be tailored to the degree of symptomatology the patients age her desire to maintain fertility,32,Prognosis：,With proper treatment，the prognosis is good for relief of pain and enhancement of fertility in mild to moderate endometriosis. In most cases，hormonal therapy is temporarily effective in controlling symptoms and arresting growth but is generally less effective than surgery in increasing fertility. The recurrent rate is very high.,33,Prevention：,Avoid possible augmentation of menstrual reflux. Taking oral contraceptive is recommended. Isolation and irrigation of the operative site.,34,Critical points（1）：,The pathogenesis is poorly understood，but emerging evidence supports the causative role of retrograde menstruation and implantation of endometrial tissue. Endometriosis is a common in women with pelvic pain or infertility. Laparoscopy is the optimal technique to diagnose pelvic endometriosis.,35,Critical points（2）：,In most cases，surgical therapy at the time of initial diagnosis effectively relieves pain and may enhance fertility. Alternatively，medical therapy with progestins、danazol、gestrinone or GnRH-a will ameliorate pelvic pain，but they do not enhance fertility. Endometriosis is a recurrent disease，and definitive treatment with removal of pelvic organs may be necessary.,36,Adenomyosis,37,Definition：,A benign uterine condition in which endometrial glands and stroma are found deep in the myometrium.,38,Etiology：,Basal endometrial hyperplasia invading a hyperplastic myometrial stroma. Four primary theories： Heredity Trauma Hyperestrogenemia Viral transmission,39,Pathology gross appearance：,Usually hyperemic with thickened walls The foci are frequently scattered diffusely throughout the myometrium. Occasionally，may be more circumscribed，with the formation of a distinct nodule，an adenomyoma.,Adenomyosis 子宫肌腺症,Adenomyoma 子宫肌腺瘤,40,The thickened and spongy appearing myometrial wall of this sectioned