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Endometriosis Disease
2009.5.5
Xiaoli ChenDepartment of Obstetrics and
Gynecology
EndometriosisEndometriosisEndometriosisEndometriosis
AdenomyosisAdenomyosis
Endometriosis
• A condition in which the tissue that normally lines the uterus grows in other areas of the body, causing pain, irregular bleeding, and frequently infertility.
Characteristics
• Common in reproductive-age women
• Estrogen dependence• Genetic disease• Immunologic disease• Inflammatory disease• Benign diseases, malignant
behavior
PathogenesisPathogenesisPathogenesisPathogenesis
Pathogenesis
• Not clear.
• 4 theories proposed: - Retrograde menstruation theory - Coelomic metaplasia theory - Lymphatic or vascular dissemination theory - Immunology theory
• No single theory can account for the location of endometriosis in all cases.
Pathology
Pathology: Classification of Common
Pelvic Endometriosis• Ovarian endometriosis
– Minimal: superficial minimal
– Classic: cyst
• Peritoneal endometriosis
– Pigmentation: classic indigo or brown ectopic tubercles 。
– Non-pigmentation : early focus
Pathology: Microscopic Examination
• Endometrial tissue (glands and
stroma)
• Fibrin and red cell
• Hemosiderin
Clinical presentation• Symptoms
• Dysmenorrhea (progressive)• Chronic pelvic pain• Dyspareunia• Pain caused by rupture of endometrioma• Infertility• Menstrual disturbance• Painful defecation
Clinical presentation
•Signs
• Fixed,retroverted uterus• Enlargement of the ovaries• Tender nodular uterosacral
ligament
Diagnosis
Diagnosis
• Medical history
• Gynecological examination
• Auxiliary examination
– laparoscopy
– Imaging
– laboratory
Diagnosis: Medical History
• Menstruation
• Reproduction
• Family history
• Operation history
• Relationship of dysmenorrhea and
gynecological operation
Diagnosis: Gynecological Examination
• Bimanual or trimanual examination
– Uterus
– Mass
– Tenderness nodes
Diagnosis: Laparoscopy
• The best method for diagnosis
• Diagnosis by direct inspect
• Pathological confirmation needed
• Treatment at the same time
Diagnosis: Imaging
• B-mode sonography
– Sensitivity 97 % , specificity 96 % .
– Mass: location, size, content, blood
supply, etc.
Diagnosis: Imaging
• CT or MRI
– Provide additional and
confirmatory information
– More costly
Diagnosis: Laboratory
• CA125
– Slightly elevated in moderate or
severe patients.
– Limited on sensitivity and specificity.
– No single use for diagnosis.
Diagnosis: Laboratory
• Anti-endometrium antibody
– Negative in most of normal women.
– Positive rate over 60 % in endometriosis
patients.
– Positive means active ectopic endometrium.
– Not popular used in clinic.
Differential
Diagnosis
Differential Diagnosis
• Diseases
– Malignant tumor of
ovary
– Pelvic
inflammatory mass
– Adenomyosis
Aspects History
Gyn Examintion
B-mode
ultrasonography
Lab research
Treatment
• Expectant therapy• Medical treatment - Pseudomenopause therapy
- Danazol - GnRH agonists - Pseudopregnancy therapy
• Surgical treatment
Medical Oophorectomy - GnRH agonists
• Mechanism: - Desensitization of the pituitary - Medical hypophysectomy →medical oophrectomy
• Drugs used: - Leuprorelin 3.75mg/28 Days D5 - Goserelin/Zoladex 3.6mg/28 Days D5 - Triptorelin/Decapreptyl 3.75mg/28 Days D5
• Side dffects: - (1)Menopausal symptoms: hot flashes, dryness in vagina, loss of libido - (2)Osteoporosis
• Add-Back Therapy
Pseudomenopause therapy- Danazol
• Synthetic steroid - 17α-ethinyltestosterone Derivative• Mechanism: - Directly suppressing ovarian steroidogenesis - Direct inhibiting endometrial growth
• Doses: - 400-800 mg/day for 6 months
• Side effects: - Hypoestrogenic environment: decreased breast size, atrophic vaginitis, hot flashes, emotional
swings - Virilism
Pseudopregnancy therapy- Progestogen
• Mechanism:– Inhibition of uterine contraction– Inhibition on growth of the endometrium
• Doses: Medroxyprogesterone 20-50mg/day 6 months• Side effects : weight, fluid retention,
breakthrough bleeding, depression
Surgery· Diagnostic surgery
· no attempt to treat any of the endometriosis
· Very conservative surgery· treatment of a very large, obvious, or treatable
area of endometriosis
· Aggressive surgery· removes all the endo while preserving the organs· maintains fertility
· Radical surgery· removal of the reproductive organs· hysterectomy
Treatment -- infertility
• Minimal disease - pregnancy rate without treatment after 5 years is 90% • severe disease - proceed to laparoscopy• woman over 35 yrs old - proceed with treatment• Medical therapy is of limited value• Assisted reproduction
Lifestyle• Exercise • Eating well and getting enough
rest• Practicing relaxation techniques
such as yoga and meditation
Recurrences• May recur with medical therapy or
surgical therapy• GnRH agonists or Danazol - Minimal disease – 37%, - severe disease – 74% • Surgery – 40% after 5 years • 56% of all patients after 7 years
Adenomyosis
• Definition of Adenomyosis:
– Presence of functioning endometrial glands and stroma in the myometrium.
• Myometrial cells around become hypertrophy and hyperplasia compensatively
Basic Concepts
Pathogenesis
Pathogenesis
• The pathogenesis is not known.
• Propose by Cullen in 1908, the
theory of direct growth of the basal
layer of endometrium into the
myometrium is widely accepted.
Pathogenesis
• Estrogen has been implicated as a
stimulus to the development of
adenomyosis.
• The symptomatic improvement that
occurs with the onset of menopause
supports this concept.
Pathogenesis
• Induction Factors
– Inheritance
– Trauma (curettage / cesarean section )
– Hyperestrogenemia
– Virus infection
Pathology
Pathology• Macroanatomy
– Uterus enlarges uniformly, like a ball.
– Usually not bigger than 12 weeks of gestation.
– Thick muscle fiber and micro vesicle seen in myomerium.
– Some grew like myoma, called adenomyoma.
Pathology
• Microscopic examination– Endometrial glands and stroma in
the myometrium, scattered like islands.
– Ectopic glands usually in proliferate phase.
– Local secretory changes seen
occasionally.
Symptoms and Signs
• Hypermenorrhea 50%• Dysmenorrhea 30%• Symmetrically enlarged uterus - Improved ultrasound: preoperative
diagnosis
- MRI: negative/equivocal sonogram presence of leiomyomas
Diagnosis
• Primary diagnosis– Classic symptoms and signs.– B-mode ultrasonography and CT
is helpful in diagnosis.• Confirmative diagnosis
– Pathological examination.
DiagnosisDiffer from• Pregnancy: pregnancy test, ultrasound• Submucous leiomyomas: hysteroscopy• Endometrial cancer: endometrial
biopsy• Myoma: ultrasound• Endometriosis:ultrasound
Complications and Prevention
• Chronic severe anemia• Primary adenocarcinoma
★Adenomyosis can’t be prevented.
Treatment
Treatment: Medication
• No medication is radical
• Mild symptoms
– NSAID
– Oral contraceptive pills
• Young, pregnancy-desiring, close to menopause
– Try GnRHa
Treatment: Surgery
• Suitable for patients with :– Severe symptoms
– Relatively old age
– No desire for pregnancy
– No effect by medication
Treatment: Surgery
• Methods– Total hysterectomy– Adenomyoma resection
•Young with pregnancy desiring•Prone to recurrence
– Laparoscopic uterosacral nerve ablation / Presacral neurectomy•Pain relief rate: 80 %
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