子宫内膜异位症(endometriosis)-张喜

Endometriosis

Women’sHospital,SchoolofMedicineZhejiangUniversity

Prof.LinJun

Definition

Endometriosis

isusuallydefinedasthepresenceofendometrial-liketissue,thatis,glandsandstroma,outsidetheendometriuminuterinecavityandmyometrium.

Commonsitesofendometriosis

Themostcommonsites：uterosacralligamentrectouterinepouchovaryOthers：uterineserosafallopiantubesigmoidcolon(乙状结肠)outsideofthepelvis:Umbilicus(脐),bladder,kidneyPrevalencepresentin10%-15%ofwomeninreproductiveagegroup,especiallyfromage25to45normallynotseenbeforeage15oraftermenopauseearlyandmorechildbearinglateststudy:morefrequentmenses(cyclelength≤27days)andprolongedmenstrualflow(≥1week)2timesrisk

Pathogenesis

Theoriesofsourcesofectopicendometrium

Endometrialimplantingtheory(种植学说)

——Sampson1921

endometrium

transfer→implant→grow⒈retrogrademenstruation(经血逆流)theory⒉transportbylymphandvein⒊iatrogenic(医源性的)implantationPathogenesisTheoriesofsourceofectopicendometriummetaplasiatheory(化生学说)inducementtheory〔诱导学说〕

Pathogenesis

FactorsrelatedwithendometriosisGeneticAbnormalities：highriskinfirst-degreerelatives

ImmunologicFactors:increasedconcentrationsofwhitebloodcells,cytokines,andgrowthfactors——IL-6、IL-8、TNF-α、MCP-1

inflammation:EMslesions→chronicpelvicinflammation

Pathologyectopicendometrium↓hemorrhage↓proliferationoffibroustissue＆adhesions↓darkblueordarkbrownspots↓scarringnodulesorcystsGrossappearance:ovarianendometriosis

red,blue,orbrownspotsendometriomas——chocolatecystsGrossappearance:peritonealendometriosiscommonsites：uterosacralligament、rectouterinepouch

purplespotsdarkbrownspotsredlesionswhitelesionsperitoneumlackperitonealendometriosisperitonealendometriosiscervixumbilicus(脐)

Themicroscopicfindings

：endometrialglandsendometrialstromafibrinredbloodcellsandhemosiderin〔含铁血黄素〕≥2findingstobediagnosedClinicalFindings

symptoms：dysmenorrhoea〔痛经〕andchronicpelvicpainthemosttypicalsymptom：secondarydysmenorrheathatworsensovertimedyspareunia〔性交痛〕abnormaluterinebleedingheavymenses,prolongedmenstruationorpremenstrualspottinginfertility：40%ofpatientsacuteabdomen:inter-cysthemorrhage(囊内出血),orruptureClinicalFindingssymptoms：

others：diarrhoea〔腹泻〕constipation〔便秘〕bloodystoolpainfulurinationbloodyurinebackacheCausesofinfertility1)Mechanicalreason2)Environmentalchangeintheperitonealcavity3)Abnormalimmunefunction4)Abnormalovarianfunction(anovulation,LPD,Lufs)5)IncreaseinspontaneousabortionClinicalFindingsPelvicExamination：fixedretroverteduterinetendernodulesonuterosacralligamentorrectouterinepouchtenderandfixedadnexalmasses

Diagnosishistorypelvicexaminationlaparoscopy——goldendiagnosisstandard

diagnosis,classification＆treatmentultrasound,(CTandMRI,expensive)serumCA125↑butusually＜100IU/ml

anti-endometriumantibody

DiagnosisClinicalclassificationRevisedAmericanFertilitySociety(r-AFS),1985Usefulfor:

AssessmentofseveritySelectionoftherapeuticregimenComparisonPrognosisr-AFSDifferentialDiagnosisOvariantumorascites〔腹水〕,solidormixed,Bultrasoundimage,CA-125>100IU/mlAbdominalinflammatorymasshistoryofinfection,fever,notcyclic,treatmentwithantibioticseffectivelyAdenomyosis(子宫腺肌病)medial,severepain,uterusslightlyenlargedTreatmentPrinciplesoftreatment：Treatmentshouldbeindividualizedaccordingtotheage,severityoftheconditionanddesireforchildbearing.Withmildsymptom:

expectanttherapyWithchildbearingdesire:mild-condition:medicationsevere-condition:fertilitypreservationsurgeryNochildbearingdesire:

Surgicaltreatment:ovarypreservationorradicalsurgeryTreatmentExpectantTherapyFollow-upsymptomsmanagement：NSAIDs〔非甾体类抗炎药〕

TreatmentMedicationObjective:causeatrophicchangesintheectopicendometrium〔使异位内膜萎缩〕MedicationPseudopregnancytherapy⒈oralcontraceptives：apilloncedailyfor6-12m⒉progestins：medroxyprogesterone〔醋酸甲孕酮〕30mgdailymegestrol〔甲地孕酮〕40mgdailynorethindrone〔炔诺酮〕5mgdailySideeffects:Intermittentbreakthroughbleeding,nausea,breasttenderness,fluidretention,weightgainMedicationPseudomenopausetherapy⒈GnRH-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,startd1Medication⒈GnRH-aSideeffects:(1)Menopausalsymptoms:hotflashes,drynessinvagina,lossoflibido(性欲)(2)OsteoporosisMedicationPseudomenopausetherapy⒉DanazolAderivativeof17-α-ethinyltestosterone〔17-α乙炔睾酮衍生物〕Mechanism:Directlysuppressingovariansteroidogenesis〔甾体激素生成〕Directinhibitingthegrowthofendometrium400-600mg/dfor6monthsMedication⒉DanazolSideeffects:acne,deepeningofthevoice,oilyskin,headache,hotflashes,lossoflibido,weightgainMedicationothers：gestrinone〔孕三烯酮〕mifepristone〔米非司酮〕Surgicaltreatment

Purposes：⑴diagnosisandclassification⑵exciseordestroyallendometriotictissue⑶removealladhesions,restorepelvicanatomy⑷enhancefecundity⑸relievepainSurgicaltreatmentlaparoscopy+medicine

goldenstandardoftreatmentSurgicaltreatment

Modesofsurgicaloperation:(1)Fertilitypreservation(2)Ovarianfunctionpreservation(3)Radicalsurgery(4)SurgeryforpainreliefTreatment

Combinationofmedicationandsurgerysurgery+medicationmedication+surgery+medicationTreatmentforpatientswithinfertilityPreventionPreventretrogradeflowofmensesContraceptionwithmedicineAvoidiatrogenic(医源性)implantationoftheectopicendometrium

Adenomyosis

Definition

Adenomyosisisdefinedbythepresenceofendometrialg