子宫内膜异位症课件

Endometriosis

子宫内膜异位症子宫内膜异位症-21.定义[Definition]

Activeendometrium(具有活性的子宫内膜)isfoundinlocationsotherthantheliningoftheuterinecavity.(出现在子宫体以外部位)

Cyclicbleeding(周期性的出血)mayoccurintheislets(岛,病灶)ofendometriosisaswellasinthenormalendometrium,formingendometrioticleisions(内膜异位病灶)anddevelopingsomesymptomssuchaspainanddisfunctionoforgansinvolved.(病变发展可出现疼痛及器官的功能异常)子宫内膜异位症-2Figure7.1showsthesitesatwhichendometriosismayoccur.

子宫内膜异位症-22.病因及发病机理[Etiologyandpathogenesis]1)Retrogrademenstruationorimplantation(经血逆流/种植学说)minutefragmentsofendometrium(子宫內膜碎屑)passalongthefallopiantubes(输卵管)duringmenstruationandspillintothepelvicpartoftheperitonealcavity(盆腹腔),becomingimplantedonthesurfaceoftheovary,intherectovaginalpouch(子宫直肠陷凹)orinsomeothersituations,anddevelopingintoendometriosis.子宫内膜异位症-2

Endometriosisinabdominalscar(腹部伤口andumbilical(脐部的）endometriosisarethecasesinpointofimplantationtheory(种植学说).Thesemayfollowanopera-tionforendometriosis,myomectomy(肌瘤摘除术,iftheuterinecavityisopened).子宫内膜异位症-22)Serosalmetaplasia（体腔上皮化生学说）TheMullerinducts(苗勒氏管)areoriginallyDerived(起源)fromaninfoldingofthe

embryoniccoelom(胚胎体腔的内折).Asweknow,theMullerinductswilllaterformthefallopiantubes(输卵管),uterusanduppervagina(阴道).anditissuggestedthatendometriosismayresultfrommataplasiaoftheperitoneal

endothelialcells(腹膜间皮细胞,alsooriginatedfromembryoniccoelom)inthepelviccavity.子宫内膜异位症-23.(病理)[Pathology]Thepathologicappearanceofendome-triosisvariesgreatlydependingonthelocationandextentofthedisease.(病变的程度和部位)

Thetwobasicfeatures:(两个基本特征))Cyclicbleedingintheendometrioticsite(异位病灶周期性出血）,Surroundedbyazoneoffibrosisandcontractureor“puckering”

(病灶周围组织皱缩/纤维化改变)子宫内膜异位症-2病理特征:

早期无色素病灶:火焰状红色灶腺样息肉紫褐色斑点或小泡中晚期紫蓝色结节巧克力囊肿子宫内膜异位症-2Theovaryisthemostcommonsiteofimplantation(approximately50%).Thecysts(endometrioma,内膜异位囊肿)varyindiameterfrom1to25mm.Ovarianinvolvementisalmostalwaysbilateral.Thelargerovarianendometrioma,filledwitholddarkhemolyzedblood,areoftenreferredtoas“chocolatecysts(巧克力囊肿)’.子宫内膜异位症-2子宫内膜异位症-2子宫内膜异位症-2子宫内膜异位症-2Endometrioticfociinsitesotherthantheovaryareusuallysmallerandmorenumerous

子宫骶韧带子宫直肠陷凹子宫后壁下段盆腔腹膜子宫内膜异位症-2子宫内膜异位症-2子宫内膜异位症-2

2)MicroscopicPathologicFeatures:

Theclassicmicrosocopicpictureofendometriosisconsistsofendometrialglandsendometrialstroma(内膜间质细胞)hemosiderin-laden(含铁血黄素沉着)macrophagessurroundinginflammatorycellsandfibrosis(周围纤维结缔组织增生)无色素早期可见到典型的异位内膜组织发生恶变机会少

子宫内膜异位症-2Pain

Painisthemostcommonsymptom.Itismostlycharacterizedbysecon-daryandprogressivedysmenorrhea(痛经,cyclicpaininphasewithmenses).Itcanalsocausedyspareunia(性交痛，painduringorfollowinginter-course),chronicpelvicpain(慢性盆腔痛)andlowbackpain(腰背部痛).4.[ClinicalFeatures]子宫内膜异位症-22)Infertility:30%~40%pelvicadhesionsmaypreventtheovumfromenteringthefallopiantube;ovarianadhesionsmaypreventreleaseoftheovumfromthefollicle;子宫内膜异位症-23)Pelvicexamination(体征)

轻症无明显体征

典型

1子宫后倾固定

2子宫骶韧带子宫直肠陷凹子宫后壁下段可扪及大小不等的结节,有触痛

3一侧或双侧扪到囊实性包块,壁厚,不活动,有轻压痛

4宫颈内膜异位可见紫蓝色小点子宫直肠陷凹内膜异位可在阴道后穹窿扪及或见到紫蓝色突起,质地偏硬,经期增大,触痛明显子宫内膜异位症-2D.RuptureofendometriomaSuddenruptureofanendometriomamayoccuratanytime.Ruptureshouldbesuspectedinanypatientwithknownendometriosiswhopresentsasanacuteabdominalemergency(急腹症).Theremaybeachemicalperitonitis(腹膜炎)duetoirritationcausedbybloodproducts.子宫内膜异位症-25.[Diagnosis](诊断)History:secondaryandprogressivepainPhysicalsigns:implantsofnodular,firm,fixed,anddiscreteSpecialexaminations:Ultrasonagraphicscanning(超声)Laparoscopy(腹腔镜)CA125

子宫内膜异位症-26.Treatment1)Follow-upIfthepatienthasnosymptomorendometriosisisanincidentaldiscoverythereisnoneedtoinsistonanytreatment,althoughthepatientshouldbereexaminedperiodically.Forthesepatients,re-assuranceandmildanalgesics(止痛)areofteneffective.

子宫内膜异位症-22)localtreatmentIftherearesymptoms,adiagnosisofintraperitonealendometriosishastobeconfirmedbylaparoscopyorlaparotomy(剖腹探查).Ifthelesionsarenotextensive,localablative(病灶局部清除)treatmentwithdiathermy(电热疗法)orlasermaythenbecarriedout.子宫内膜异位症-23)HormonaltherapyThebasisofhormonalmethodstreatingendometriosisisthesuppressionofcyclicalovarianfunctionandhencemenstruation.Thereareseveralwaysofachievingthisandthechoiceoftreatmentmaybeinfluencedbythepatient’stolerenceofside-effects.

子宫内膜异位症-2A.Pseudopregnancy(假孕疗法)Progestogensmaybegiveninlargedosesfor9-12monthstosuppressmenstruationandproduceastateoftenreferredtoaspseudopregnancy.Breastenlargement,abdominaldistensionandwaterretentionarecommonside-effects.子宫内膜异位症-2B.psudoamenorrhea(假绝经疗法)

a)Afrequentlyusedagentisdanazol.Thisisaweakandrogenwithsomeinhibitoryactionontheovary,anditcausesendometrialatrophy(内膜萎缩).However,itisexpensiveandcancausesevereside-effectsinsomewomen,e.g.weight-gain,masculinization(男性化)anddeepeningofthevoice,whichmayevenbepermanent.子宫内膜异位症-2b)GnRH-a

GnRH-acancompletelysuppresstheovarianfunctionandmenstruation.Andinturnthemainside-effectsincludeflushing(潮热)andvaginaldryness(阴道灼热）causedbylowestrogenlevel.Whilelong-termusemayresultinbonelossfromestrogendeficiency.子宫内膜异位症-2

4)surgicaltreatmentConservativesurgicaltreatment

(保守手