妇产科-子宫内膜异位症

子宫内膜异位症EndometriosisEMTDefinition“Presenceofendometrialtissueoutsidetheliningoftheuterinecavity”or

“Proliferationofendometriuminanysiteotherthantheuterinemucosa”定义子宫内膜异位症——具有生长功能的子宫内膜组织（腺体和间质）出现在子宫腔被覆粘膜及宫体肌层以外的身体其他部位时。Age:commoninreproductiveperiodTrueIncidenceUnknown:?10-15%&30–50%infertility.DoesNOTDiscriminatebyRace.Histology:EndometrialGlandswithStroma+/-InflammatoryReaction.Herdietary(↑↑amongsisters).EpidemiologyAgeatDiagnosis<196%19–2524%26–3552%36–4515%>453%发病率年龄25—45岁妇女居多；明显上升趋势，育龄妇女多见；80%有明显痛经，

50%合倂不孕；妊娠可暂时阻止此病发展；与遗传有关；可出现身体的各个部位，卵巢多见。-Pelvic-ExtrapelvicUmbilicus.Scars(Lap.).Lungs&plura.Others.SitesUterine=Adenomyosis(50%).Extraut:-Ovary30%-Pelvicperitoneum10%.-F.tube.-Vagina.-Bladder&rectum.-Pelviccolon.-Ligaments.PelvicEndometriosisIntroductionWhydoesendometriosishappen?

EndometrialimplantationtheoryRetrogradeVascularandlymphaticMechanicalImmunologicalandgenetictheoryCompositetheoryTheoriesofhistiogenesisPathogenesisEctopictransplantationtheory(异位种植学说）

(DirectImplantation)

70-90%womenhaveretrogrademenstruation(经血逆流).Viableendometrialcellsexistintheperitonealfluidinmorethan50%womanduringmenstruation.Implantationofmenstrualtissuehasbeendemonstratedexperimentally(inthemonkeys)andiatrogenic(医源性的)implantationoccurs(e.g.endometriosisinthescarofabdominalwallafteranabdominalcesareansection).Oftenpelvicdepositsofendometriosisoccurclosetotheendsofthefallopiantubes.MetaplasiaofCoelomicEpithelium(体腔上皮化生学说)Serosa(浆膜)andperitoneum(腹膜)originatefrommultipotentcoelomicepitheliumPredisposingfactorsGeneticinfluencesIncidenceis6.9%infirst-graderelativesofpatientswithendometriosiscomparedwith1%inacontrolgroup.Incidenceis75%ifoneofthetwinsistershasendometriosis.ImmunedeficiencyMonkeyswithspontaneousendometriosiswerefoundtohaveloweredcell-mediatedresponsetoautologous(自体的)endometrialtissue.Pathogenesis发病机制

1

子宫内膜种植学说：异位内膜来源于在位的子宫内膜。

经血逆流医源性种植

淋巴及静脉播散学说：远离盆腔的EM

2体腔上皮化生学说：异位内膜来源于盆腔腹膜的体腔上皮化生临床依据?

3诱导学说：异位内膜释放某种物质，如生长因子、巨噬细胞等4相关因素：遗传因素、免疫因素、炎症因素在位内膜的特性：在位内膜决定论determinantofuterineeutopicendometrium在位内膜的特点：功能活跃，血管增生及侵袭力强，易于种植

发病机制EM是个遗传性疾病；EM是个免疫性疾病；EM是个炎症性疾病；EM是个由于出血性疾病；EM是个器官依赖性疾病；EM是个激素依赖性疾病；Histology:Endometriosisoftheovary:-Theovaryisenlargedandcystic.-Surfaceburntmatchheadappearance.-Tunicaalbuginea--->thickened.Chocolateortarrycysts.EndometrialGlandswithStroma+/-InflammatoryReaction病理特点：广泛性和多形（多样）性。主要变化：异位内膜随卵巢激素的变化发生周期性出血，伴纤维组织增生和粘连形成。

紫褐色斑点

小泡

紫蓝色结节

囊肿病理卵巢子宫内膜异位症腹膜子宫内膜异位症深部侵润型内异症其他部位的内异症PathologyGrossappearancePathologyGrossappearanceEndometrioma(子宫内膜异位囊肿）Chocolatecyst(巧克力囊肿）PathologyGrossappearance病理——镜下检查病灶中子宫内膜腺体，子宫内膜间质，纤维素和红细胞/含铁血红素。反复出血，结构破坏，仅有少量内膜间质细胞，即可确诊断；手术及肉眼典型，仅在卵巢壁中发现红细胞或含铁血黄素巨噬细胞，应视内异症。MicroscopicappearancePathologyMicroscopicappearanceSiderocyte(含铁血黄素细胞)Clinical

FeaturesSymptomsandsignsvaryaccordingtositeoflesions.25%asymptomatic.MenstrualpainorlowerabdominalpainDyspareunia(性交痛)InfertilityAbnormaluterinebleedingPaincausedbyruptureofendometriomaSymptomsandsignsinothersystemscausedbyendometriosis

InfertilityInpatientswithinfertility,incidenceofendometriosisis25%-35%.Inpatientswithendometriosis,infertilityrateis40%.Causes:1)Mechanicalreason2)EnvironmentalchangeintheperitonealcavityActivitychangesofmacrophageAutoimmuneinjuryIncreaseinprostaglandinsClinical

FeaturesCauses(Continued):3)AbnormalovarianfunctionOvulationdefects:17-27%Inadequatedevelopmentofcorporalutea(黄体)Luteinizedunrupturedfolliclesyndrome,LUFS(未破裂卵泡黄素化综合征):18-79%4)Increaseinspontaneousabortion:40%(vs.normal15%)ClinicalFeaturesInfertility

Menstrualdisorders

15-30%Heavymenses,prolongedmenstruationorpremenstrualspotting.Causes:Damageofovariancortexandadhesionresultsinovariandysfunction,anovulationanddysfunctionofcorporalutea.ClinicalFeaturesSigns

RetrovertedandfixeduterusTendernodulesinrectouterinepouch,uterosacralligament,posteriorwall(lowersegment)andrectovaginalseptumFixedmassalongthesideofuterusClinicalFeatures临床表现1症状（25%患者无症状）疼痛：痛经和持续性下腹痛；继发性、非正比；月经失调：15—30%经量经期点滴出血；不孕：50%其他；囊肿破裂，肠道，膀胱，腹壁……。2体征DiagnosisLaparoscopy(“GoldStandard)LaparotomyInconclusive:CA-125,PelvicExam,History,ImagingStudiesBiopsyPreferableOverVisualInspectionClinicalclassificationRevisedAmericanFertilitySociety(R-AFS),1985Usefulfor:AssessmentofseveritySelectionoftherapeuticregimenComparisonPrognosisDiagnosis诊断——辅助检查病史妇科检查辅助检查：B型超声盆腔核磁+强化CA125测定：<100U/ml；监测指标；抗子宫内膜抗体：60%以上呈阳性。腹腔镜检查：金标准，确诊，分期。DiagnosisBultrasound临床分期1973年Acosta轻、中、重；1985年美国生育协会RAFS分期标准：病灶大小、粘连程度、直肠窝封闭情况。临床意义：病变类型（腹膜、卵巢、深部）病变活动状态（红色、白色）

RAFS分期

1.Ovariancysts.2.Pelvicinflammatorydisease.3.OthercausesofnodularityinDouglaspouchastuberculousperitoni­tisandmetastasesofovariancancer.4.Causesofhaematuria,bleedingperrectumandacuteabdominalpainifthepatientispresentedbyoneofthesesymptoms.5.Asymmetricalenlargeduterus.Differentialdiagnosis鉴别诊断卵巢恶性肿瘤：诊断不明，尽快手术；盆腔炎性包块：抗炎有效；子宫腺肌症：可同时存在；治疗——目标任何卵巢肿物均应除外恶性缩小和去除病灶减轻和控制疼痛减少卵巢损伤，保护卵泡治疗和促进生育预防和减少复发子宫内膜异位症的药物治疗短效避孕药:高效孕激素:丹那唑:17ą—乙炔睾丸酮衍生物(假绝经疗法)孕三烯酮:19—去甲睾酮甾类药物,抗雌,抗孕,GnRHą:合成的十肽类化合物.PainManagement:MedicalTherapyNSAIDsOCPs(Continuous)ProgestinsDanazolGnRH-aGnRH-a+Add-BackTherapyMisc:Opoids,TCAs,SSRIs卵巢抑制是最好的治疗GnRHa

降调节

垂体FSHLH

卵巢E(低雌激素状态)

“反向添加”治疗

什么是“反向添加”治疗在用GnRHa的同时补充雌激素

2—3个月后补多少?

抑制血管神经症状30pg/ml抑制骨丢失20—40pg/mlEM生长>40pg/ml窗口剂量Treatment

PrinciplesoftreatmentTreatmentshouldbeindividualizedaccordingtothepatient’sage,severityoftheconditionanddesireforchildbearing.Forthosewithmildsymptom:expectanttherapyForthosewhodesirechildbearing:ifconditionismild:medicaltreatmentifconditionissevere:fertilitypreservationsurgeryForthosewhodonotdesirechildbearing:Surgicaltreatment:ovarypreservationorradical

ExpectantTherapyEndometriosistendstoimproveduringpregnancyandmenopause.Follow-upandsymptomsmanagementwithprostaglandinsynthetaseinhibitors(前列腺素合成酶抑制剂)suchas:a)Indomethacin(吲哚美辛)/Indocin(消炎痛)25mgtidp.o.b)Naproxen(萘普生)c)Ibuprofen(布洛芬)300mgtipp.o.d)Diclofenacpotassium(双氯芬酸钾片)/Kaflan(凯扶兰)25-50mgtidp.o.TreatmentTreatment

MedicaltreatmentObjective:causeatrophicchangesintheectopicendometriumProgestins(孕激素)Mechanism:InhibitionofuterinecontractionInhibitionongrowthoftheendometrium1.Pseudopregnancy(假孕)withoralcontraceptives

Atabletoncedailyfor6-12days

2.PseudopregnancywithProgestins(孕激素)

Medicaltreatment

Drugs(Progestins)usedDerivatives(衍生物)fromhydroxyprogesterone(羟孕酮)：(1)Medroxyprogesteroneacetate/provera(醋酸甲羟孕酮/醋酸甲孕酮/安宫黄体酮）30mgdaily(2)Megestrol(甲地孕酮/妇宁片)40mgdaily(3)Longactingdrugsa)Depo-provera(醋酸甲羟孕酮避孕针)150mgmonthlyb)Hydroxyprogesterone(羟孕酮)250mgoncefor2weeksTreatment

Medicaltreatment

Drugs(Progestins)usedDerivativesfrom19-demethyltestosterone(1)Norethindrone(炔诺酮)5mgdaily(2)Gestrinone(孕三烯酮/内美通)2.5mgtwiceaweekTreatmentwithprogestinsusuallylast6months.Sideeffects:Intermittentbreakthroughbleeding,nausea,breasttenderness,fluidretention,weightgainTreatment

Medicaltreatment

Danazol（达/丹那唑）AveryfrequentlyuseddrugforendometriosisAweakandrogenAderivativeof17-α-ethinyltestosterone(17-α乙炔睾酮）Mechanism:AnantigonadotrophicagentDirectlysuppressingovariansteroidogenesis(甾体激素生成）

DirectinhibitingendometrialgrowthTreatment

MedicaltreatmentDoses:400-800mg/dayfor6monthsSideeffects:Hypoestrogenicenvironment:deceasedbreastsize,atrophicvaginitis,hotflashes,emotionalswings.Virilism(男性化):weightgain,growthoffacialhair,acne,oilyskin,etc.Treatment

Medicaltreatment

GnRHa(促性腺激素释放激素激动剂)Mechanism:DesensitizationofthepituitaryMedicalhypophysectomy(药物性垂体切除)→Medicaloophorectomy(药物性卵巢切除)Drugsused:Leuprorelin(亮丙瑞林/抑那通）3.75mg,Triptorelin/Decapreptyl(曲谱瑞林/达必佳/达菲林)3.75mg,Goserelin/Zoladex（戈舍瑞林/诺雷德）3.6mg,injection,oncepermonthTreatment

Treatment

MedicaltreatmentSideeffects:(1)Menopausalsymptoms(绝经期症状):hotflashes,drynessinvagina,lossoflibido(2)Osteoporosis(骨质疏松)Expensive子宫内膜异位症的手术治疗

术式范围适应征有效率复发率保守性手术剥除“巧囊”、切或烧病灶年轻（保留生育功能）分离粘连，卵管整型渴望生育80—90%50%轻、中度40%半根治手术切除子宫、卵巢病变，保较年轻（保留卵巢功能）留一侧卵巢。无生育要求80%20%中、重度5%根治性手术切除子宫、双侧附件年龄较大可见病变无生育要求95%0-1%重度

SurgicaltreatmentIndications:(1)Failedmedicaltreatment(2)Largeendmetrioma(largerthan5-6cm)Modesofsurgicaloperation(1)Fertili