子宫内膜异位症课件

Endometriosis

Women’sHospital,SchoolofMedicineZhejiangUniversity

Prof.LinJun

子宫内膜异位症Definition

Endometriosis

isusuallydefinedasthepresenceofendometrial-liketissue,thatis,glandsandstroma,outsidetheendometriuminuterinecavityandmyometrium.子宫内膜异位症

Commonsitesofendometriosis

Themostcommonsites：uterosacralligamentrectouterinepouchovaryOthers：uterineserosafallopiantubesigmoidcolon(乙状结肠)outsideofthepelvis:Umbilicus(脐),bladder,kidney子宫内膜异位症Prevalencepresentin10%-15%ofwomeninreproductiveagegroup,especiallyfromage25to45normallynotseenbeforeage15oraftermenopauseearlyandmorechildbearinglateststudy:morefrequentmenses(cyclelength≤27days)andprolongedmenstrualflow(≥1week)2timesrisk子宫内膜异位症

Pathogenesis

Theoriesofsourcesofectopicendometrium

Endometrialimplantingtheory(种植学说)

——Sampson1921

endometrium

transfer→implant→grow⒈retrogrademenstruation(经血逆流)theory⒉transportbylymphandvein⒊iatrogenic(医源性的)implantation子宫内膜异位症PathogenesisTheoriesofsourceofectopicendometrium

metaplasiatheory(化生学说)inducementtheory（诱导学说）子宫内膜异位症

Pathogenesis

FactorsrelatedwithendometriosisGeneticAbnormalities：highriskinfirst-degreerelatives

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

inflammation:EMslesions→chronicpelvicinflammation

子宫内膜异位症Pathologyectopicendometrium↓hemorrhage↓proliferationoffibroustissue＆adhesions↓darkblueordarkbrownspots↓scarringnodulesorcysts子宫内膜异位症Grossappearance:ovarianendometriosis

red,blue,orbrownspotsendometriomas——chocolatecysts子宫内膜异位症Grossappearance:peritonealendometriosiscommonsites：uterosacralligament、rectouterinepouch

purplespotsdarkbrownspotsredlesionswhitelesionsperitoneumlack子宫内膜异位症peritonealendometriosis子宫内膜异位症peritonealendometriosis子宫内膜异位症cervixumbilicus(脐)

子宫内膜异位症Themicroscopicfindings

：endometrialglandsendometrialstromafibrinredbloodcellsandhemosiderin（含铁血黄素）≥2findingstobediagnosed子宫内膜异位症ClinicalFindings

symptoms：dysmenorrhoea（痛经）

andchronicpelvicpainthemosttypicalsymptom：secondarydysmenorrheathatworsensovertime

dyspareunia（性交痛）abnormaluterinebleeding

heavymenses,prolongedmenstruationorpremenstrualspottinginfertility：40%ofpatients

acuteabdomen:inter-cysthemorrhage(囊内出血),orrupture子宫内膜异位症ClinicalFindingssymptoms：

others：diarrhoea（腹泻）constipation（便秘）bloodystoolpainfulurinationbloodyurinebackache子宫内膜异位症Causesofinfertility1)Mechanicalreason2)Environmentalchangeintheperitonealcavity3)Abnormalimmunefunction4)Abnormalovarianfunction(anovulation,LPD,Lufs)5)Increaseinspontaneousabortion子宫内膜异位症ClinicalFindingsPelvicExamination：fixedretroverteduterinetendernodulesonuterosacralligamentorrectouterinepouchtenderandfixedadnexalmasses

子宫内膜异位症Diagnosishistorypelvicexaminationlaparoscopy——goldendiagnosisstandard

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

anti-endometriumantibody

子宫内膜异位症DiagnosisClinicalclassificationRevisedAmericanFertilitySociety(r-AFS),1985Usefulfor:

AssessmentofseveritySelectionoftherapeuticregimenComparisonPrognosis子宫内膜异位症r-AFS子宫内膜异位症DifferentialDiagnosis

Ovariantumor

ascites（腹水）,solidormixed,Bultrasoundimage,CA-125>100IU/ml

Abdominalinflammatorymass

historyofinfection,fever,notcyclic,treatmentwithantibioticseffectivelyAdenomyosis(子宫腺肌病)

medial,severepain,uterusslightlyenlarged子宫内膜异位症TreatmentPrinciplesoftreatment：Treatmentshouldbeindividualizedaccordingtotheage,severityoftheconditionanddesireforchildbearing.Withmildsymptom:

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

Surgicaltreatment:ovarypreservationorradicalsurgery子宫内膜异位症TreatmentExpectantTherapy

Follow-upsymptomsmanagement：NSAIDs（非甾体类抗炎药）

子宫内膜异位症TreatmentMedicationObjective:causeatrophicchangesintheectopicendometrium（使异位内膜萎缩）子宫内膜异位症MedicationPseudopregnancytherapy⒈oralcontraceptives：apilloncedailyfor6-12m⒉progestins：medroxyprogesterone（醋酸甲孕酮）30mgdailymegestrol（甲地孕酮）40mgdailynorethindrone（炔诺酮）5mgdaily

Sideeffects:Intermittentbreakthroughbleeding,nausea,breasttenderness,fluidretention,weightgain子宫内膜异位症MedicationPseudomenopausetherapy⒈GnRH-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）3.75mg

m/H,1inj/q28d,startd1子宫内膜异位症Medication⒈GnRH-aSideeffects:(1)Menopausalsymptoms:hotflashes,drynessinvagina,lossoflibido(性欲)(2)Osteoporosis子宫内膜异位症MedicationPseudomenopausetherapy⒉DanazolAderivativeof17-α-ethinyltestosterone（17-α乙炔睾酮衍生物）

Mechanism:Directlysuppressingovariansteroidogenesis（甾体激素生成）Directinhibitingthegrowthofendometrium

400-600mg/dfor6months子宫内膜异位症Medication⒉DanazolSideeffects:acne,deepeningofthevoice,oilyskin,headache,hotflashes,lossoflibido,weightgain子宫内膜异位症Medicationothers：gestrinone（孕三烯酮）mifepristone（米非司酮）子宫内膜异位症Surgicaltreatment

Purposes：⑴diagnosisandclassification⑵exciseordestroyallendometriotictissue⑶removealladhesions,restorepelvicanatomy⑷enhancefecundity⑸relievepain子宫内膜异位症Surgicaltreatmentlaparoscopy+medicine

goldenstandardoftreatment子宫内膜异位症Surgicaltreatment

Modesofsurgicaloperation:(1)Fertilitypreservation(2)Ovarianfunctionpreservation(3)Radicalsurgery(4)Surgeryforpainrelief子宫内膜异位症Treatment

Combinationofmedicationandsurgerysurgery+medicationmedication+surgery+medicationTreatmentforpatientswithinfertility子宫内膜异位症PreventionPreventretrogradeflowofmensesContraceptionwithmedicineAvoidiatrogenic(医源性)implantationoftheectopicendometrium子宫内膜异位症

Adenomyosis

子宫内膜异位症Definition

Adenomyosisisdefinedbythepresenceofendometrialglandsandstromawithinthe