子宫内膜异位症(endometriosis)张喜

1、 definition common sites of endometriosis the most common sites： uterosacral ligament rectouterine pouch ovary others： uterine serosa fallopian tube sigmoid colon (乙状结肠) outside of the pelvis : umbilicus(脐) , bladder, kidney prevalence present in 10%-15% of women in reproductive age group, especiall

2、y from age 25 to 45 normally not seen before age 15 or after menopause early and more childbearing latest study: more frequent menses (cycle length 27 days ) and prolonged menstrual flow ( 1 week) 2 times risk theories of sources of ectopic endometrium endometrial implanting theory ( (种植学说种植学说) ) sa

3、mpson 1921 endometrium transfer implant grow retrograde menstruation (经血逆流) theory transport by lymph and vein iatrogenic ( (医源性的医源性的) ) implantation theories of source of ectopic endometrium metaplasia theory(化生学说) inducement theory（诱导学说） factors related with endometriosis genetic abnormalities ：hi

4、gh risk in first-degree relatives immunologic factors : increased concentrations of white blood cells, cytokines, and growth factors il-6、il-8、tnf-、mcp-1 inflammation: ems lesions chronic pelvic inflammation pathology ectopic endometrium hemorrhage proliferation of fibrous tissue adhesions dark blue

5、 or dark brown spots scarring nodules or cysts gross appearance : ovarian endometriosis red, blue, or brown spots endometriomas chocolate cysts gross appearance : peritoneal endometriosis common sites： uterosacral ligament、rectouterine pouch upurple spots udark brown spots ured lesions uwhite lesion

6、s uperitoneum lack peritoneal endometriosis peritoneal endometriosis cervix umbilicus(脐) ： endometrial glands endometrial stroma fibrin red blood cells and hemosiderin（含铁血黄素） 2 findings to be diagnosed symptoms： dysmenorrhoea（痛经）（痛经） and chronic pelvic pain the most typical symptom：secondary dysmeno

7、rrhea that worsens over time dyspareunia（性交痛）（性交痛） abnormal uterine bleeding heavy menses, prolonged menstruation or premenstrual spotting infertility：40% of patients acute abdomen: inter-cyst hemorrhage(囊内出血), or rupture symptoms： others： diarrhoea（腹泻） constipation（便秘） bloody stool painful urinatio

8、n bloody urine backache causes 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 pelvic examination： fixed retroverted uterine tender nodules on ute

9、rosacral ligament or rectouterine pouch tender and fixed adnexal masses 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 diagnosis clinical cla

10、ssification revised american fertility society (r-afs), 1985 useful for: assessment of severity selection of therapeutic regimen comparison prognosis r-afs differential diagnosis ovarian tumor ascites（腹水）（腹水）, solid or mixed, b ultrasound image, ca-125100 iu/ml abdominal inflammatory mass history of

11、 infection, fever, not cyclic, treatment with antibiotics effectively adenomyosis (子宫腺肌病子宫腺肌病) medial, severe pain, uterus slightly enlarged treatment principles of treatment： treatment should be individualized according to the age, severity of the condition and desire for childbearing. with mild sy

12、mptom: expectant therapy with childbearing desire: mild-condition: medication severe-condition: fertility preservation surgery no childbearing desire : surgical treatment: ovary preservation or radical surgery treatment expectant therapy follow-up symptoms management：nsaids（非甾体类抗炎药）（非甾体类抗炎药） treatme

13、nt medication objective: cause atrophic changes in the ectopic endometrium （使异位内膜萎缩）（使异位内膜萎缩） medication pseudopregnancy therapy oral contraceptives：a pill once daily for 6-12 m progestins： medroxyprogesterone （醋酸甲孕酮）（醋酸甲孕酮）30mg daily megestrol （甲地孕酮）（甲地孕酮） 40mg daily norethindrone （炔诺酮）（炔诺酮） 5mg da

14、ily side effects: intermittent breakthrough bleeding, nausea, breast tenderness, fluid retention, weight gain medication pseudomenopause therapy gnrh-a mechanism: medical hypophysectomy (药物性垂体切除) / medical oophorectomy (药物性卵巢切除) leuprorelin （亮丙瑞林，抑那通）（亮丙瑞林，抑那通）3.75mg goserelin （戈舍瑞林，诺雷德）（戈舍瑞林，诺雷德）3.

15、6mg tryptorelin （曲普瑞林，达菲林）（曲普瑞林，达菲林） 3.75mg m / h, 1 inj/q28d, start d1 medication gnrh-a side effects: (1) menopausal symptoms : hot flashes, dryness in vagina, loss of libido(性欲性欲) (2) osteoporosis medication pseudomenopause therapy danazol a derivative of 17-ethinyltestosterone （17-乙炔睾酮衍生物）乙炔睾酮衍生

16、物） mechanism: directly suppressing ovarian steroidogenesis （甾体激素生成） direct inhibiting the growth of endometrium 400-600 mg/d for 6 months medication danazol side effects: acne, deepening of the voice, oily skin, headache, hot flashes, loss of libido, weight gain medication others： gestrinone （孕三烯酮）

17、mifepristone（米非司酮） surgical treatment purposes： diagnosis and classification excise or destroy all endometriotic tissue remove all adhesions, restore pelvic anatomy enhance fecundity relieve pain surgical treatment laparoscopy + medicine golden standard of treatment surgical treatment modes of surgi

18、cal operation: (1) fertility preservation (2) ovarian function preservation (3) radical surgery (4) surgery for pain relief treatment combination of medication and surgery treatment for patients with infertility prevention prevent retrograde flow of menses contraception with medicine avoid iatrogenic (医源性医源性) implantation of the ectopic endometrium adenomyosis adenomyosis is defined by the presence of endometrial glands and stroma within the myometrium. it is associated with myometrial hypertrophy and proliferation. pathogenesis histological confirmati