子宫内膜异位症Endometriosis喜.ppt

EndometriosisWomensHospital,SchoolofMedicineZhejiangUniversityProf.LinJun,Definition,Endometriosisisusuallydefinedasthepresenceofendometrial-liketissue,thatis,glandsandstroma,outsidetheendometriuminuterinecavityandmyometrium.,Commonsitesofendometriosis,Themostcommonsites：uterosacralligamentrectouterinepouchovaryOthers：uterineserosafallopiantubesigmoidcolon(乙状结肠)outsideofthepelvis:Umbilicus(脐),bladder,kidney,Prevalence,presentin10%-15%ofwomeninreproductiveagegroup,especiallyfromage25to45normallynotseenbeforeage15oraftermenopauseearlyandmorechildbearinglateststudy:morefrequentmenses(cyclelength27days)andprolongedmenstrualflow(1week)2timesrisk,Pathogenesis,TheoriesofsourcesofectopicendometriumEndometrialimplantingtheory(种植学说)Sampson1921endometriumtransferimplantgrowretrogrademenstruation(经血逆流)theorytransportbylymphandveiniatrogenic(医源性的)implantation,Pathogenesis,Theoriesofsourceofectopicendometriummetaplasiatheory(化生学说)inducementtheory（诱导学说）,Pathogenesis,FactorsrelatedwithendometriosisGeneticAbnormalities：highriskinfirst-degreerelativesImmunologicFactors:increasedconcentrationsofwhitebloodcells,cytokines,andgrowthfactorsIL-6、IL-8、TNF-、MCP-1inflammation:EMslesionschronicpelvicinflammation,Pathology,ectopicendometriumhemorrhageproliferationoffibroustissueadhesionsdarkblueordarkbrownspotsscarringnodulesorcysts,Grossappearance:,ovarianendometriosisred,blue,orbrownspotsendometriomaschocolatecysts,Grossappearance:,peritonealendometriosiscommonsites：uterosacralligament、rectouterinepouch,purplespotsdarkbrownspotsredlesionswhitelesionsperitoneumlack,peritonealendometriosis,peritonealendometriosis,cervix,umbilicus(脐),Themicroscopicfindings：,endometrialglandsendometrialstromafibrinredbloodcellsandhemosiderin（含铁血黄素）2findingstobediagnosed,ClinicalFindings,symptoms：dysmenorrhoea（痛经）andchronicpelvicpainthemosttypicalsymptom：secondarydysmenorrheathatworsensovertimedyspareunia（性交痛）abnormaluterinebleedingheavymenses,prolongedmenstruationorpremenstrualspottinginfertility：40%ofpatientsacuteabdomen:inter-cysthemorrhage(囊内出血),orrupture,ClinicalFindings,symptoms：others：,diarrhoea（腹泻）constipation（便秘）bloodystoolpainfulurinationbloodyurinebackache,Causesofinfertility,1)Mechanicalreason2)Environmentalchangeintheperitonealcavity3)Abnormalimmunefunction4)Abnormalovarianfunction(anovulation,LPD,Lufs)5)Increaseinspontaneousabortion,ClinicalFindings,PelvicExamination：fixedretroverteduterinetendernodulesonuterosacralligamentorrectouterinepouchtenderandfixedadnexalmasses,Diagnosis,historypelvicexaminationlaparoscopygoldendiagnosisstandarddiagnosis,classificationtreatmentultrasound,(CTandMRI,expensive)serumCA125butusually100IU/mlanti-endometriumantibody,Diagnosis,ClinicalclassificationRevisedAmericanFertilitySociety(r-AFS),1985Usefulfor:AssessmentofseveritySelectionoftherapeuticregimenComparisonPrognosis,r-AFS,DifferentialDiagnosis,Ovariantumorascites（腹水）,solidormixed,Bultrasoundimage,CA-125100IU/mlAbdominalinflammatorymasshistoryofinfection,fever,notcyclic,treatmentwithantibioticseffectivelyAdenomyosis(子宫腺肌病)medial,severepain,uterusslightlyenlarged,Treatment,Principlesoftreatment：Treatmentshouldbeindividualizedaccordingtotheage,severityoftheconditionanddesireforchildbearing.Withmildsymptom:expectanttherapyWithchildbearingdesire:mild-condition:medicationsevere-condition:fertilitypreservationsurgeryNochildbearingdesire:Surgicaltreatment:ovarypreservationorradicalsurgery,Treatment,ExpectantTherapyFollow-upsymptomsmanagement：NSAIDs（非甾体类抗炎药）,Treatment,MedicationObjective:causeatrophicchangesintheectopicendometrium（使异位内膜萎缩）,Medication,Pseudopregnancytherapyoralcontraceptives：apilloncedailyfor6-12mprogestins：medroxyprogesterone（醋酸甲孕酮）30mgdailymegestrol（甲地孕酮）40mgdailynorethindrone（炔诺酮）5mgdailySideeffects:Intermittentbreakthroughbleeding,nausea,breasttenderness,fluidretention,weightgain,Medication,PseudomenopausetherapyGnRH-aMechanism:Medicalhypophysectomy(药物性垂体切除)/Medicaloophorectomy(药物性卵巢切除)leuprorelin（亮丙瑞林，抑那通）3.75mggoserelin（戈舍瑞林，诺雷德）3.6mgtryptorelin（曲普瑞林，达菲林）3.75mgm/H,1inj/q28d,startd1,Medication,GnRH-aSideeffects:(1)Menopausalsymptoms:hotflashes,drynessinvagina,lossoflibido(性欲)(2)Osteoporosis,Medication,PseudomenopausetherapyDanazolAderivativeof17-ethinyltestosterone（17-乙炔睾酮衍生物）Mechanism:Directlysuppressingovariansteroidogenesis（甾体激素生成）Directinhibitingthegrowthofendometrium400-600mg/dfor6months,Medication,DanazolSideeffects:acne,deepeningofthevoice,oilyskin,headache,hotflashes,lossoflibido,weightgain,Medication,others：gestrinone（孕三烯酮）mifepristone（米非司酮）,Surgicaltreatment,Purposes：diagnosisandclassificationexciseordestroyallendometriotictissueremovealladhesions,restorepelvicanatomyenhancefecundityrelievepain,Surgicaltreatment,laparoscopy+medicinegoldenstandardoftreatment,Surgicaltreatment,Modesofsurgicaloperation:(1)Fertilitypreservation(2)Ovarianfunctionpreservation(3)Radicalsurgery(4)Surgeryforpainrelief,Treatment,Combinationofmedicationandsurgerysurgery+medicationmedication+surgery+medicationTreatmentforpatientswithinfertility,Prevention,PreventretrogradeflowofmensesContraceptionwithmedicineAvoidiatrogenic(医源性)implantationoftheectopicendometrium,Adenomyosis,Definition,Adenomyosisisdefinedbythepresenceofendometrialglandsandstromawithinthemyometrium.Itisassociatedwithmyometrialhypertrophyandproliferation.,EndometriosisAdenomyosis,PathogenesishistologicalconfirmationSitesoflesionsClinicalfindings,Adenomyosisisthoughttobeunrelatedtoendometriosis.,Clinicalfindings,Multiparas（40y）weremostcommonlyaffected.Symptoms：prolong