Endometriosis ＆ Adenomyosis - 上海交通大学医学院精 …(PPT-45)

Endometriosis＆AdenomyosisZhaoaiminM.D.,Ph.D.,ProfessorDepartmentOfObstetrics&GynecologyRenjiHospitalAffiliatedtoSJTUSchoolofMedicineEndometriosisDefinition:Abnormalgrowthofendometrialtissueoutsidetheuterinecavity.IncidenceandPrevalence:IncreasesignificantlyRangefrom1～50%Generalpopulation:1～2%Infertilewomen:30～50%Occursprimarilyinwomenin25～45sPathogenesis:ImplantationTheoryRetrogradeMenustrationTheorySampson，1921LymphaticandVascularDisseminationTheoryJavert，1952CoelomicTheoryMeyerGeneticTheoryImmuneSystemDysfunction（immunologictheory）Geneticfactors：Familialclusteringofendometriosisisacommonclinicalobservation.Infamilieswithendometriosis，thediseaseisoftenconfinedtothematernalline，andis7timesmorecommoninfirst-degreerelativesthaninthegeneralpopulation.Infuturestudies，evaluationofDNApolymorphismmayidentifyspecificgenesinvolvedinthedevelopmentofendometriosis.ImmunologicTheory：LosecontrolofimmunologicbalanceBothcellularimmunityandhumoralimmunitychange.Macrophage↑releaseIL–1、IL–6、TNF、EGF、FGFetc.stimulateT、BlymphocyteproliferationandactivationActivityofkillercell（NKcellandTcell）↓Produceanti–endometriumantibodyAbnormalexpressionofCAMs（celladhesionmolecules）Thepathogenesisisunclear.multifactorPathology–macroscopicappearance（1）：Thecommonestsites：Ovary（chocolatecyst）Peritoneumoftherecto–vaginalcul–de–sacofthePouchofDouglasUtero–sacralligamentsSigmoidcolonBroadligamentThisisasectionthroughanenlarnged12cmovarytodemonstrateacysticcavityfilledwitholdbloodtypicalforendometriosiswithformationofanendometriotic,or"chocolate",cyst.Pathology–macroscopicappearance（2）：Lesscommonsites：CervixRoundligamentUrinarysystem（bladder、ureter）UmbilicusAppendixLaparotomyscarsMultipleappearancesofendometriosisimplants：Brownish，discoloredperitoneumSuperficialperitonealecchymosisRaised，reddish，superficialnodulesReddish–blueinvasivenodulesFibrotic，whitishnodulesRaised，glossy，translucentblobsPatchy，whiteopacifiedperitoneumReddishorbluishovariancystsGrossly,inareasofendometriosisthebloodisdarkerandgivesthesmallfociofendometriosisthegrossappearanceof"powderburns".SmallfociareseenherejustundertheserosaoftheposterioruterusinthepouchofDouglas.Suchareasofendometriosiscanbeseenandobliteratedbycauterizationvialaparoscopy.Uponcloserview,thesefivesmallareasofendometriosishaveareddish-browntobluishappearance.Pathology–microscopicappearanceHistomorphologicallysimilartoeutopicendometriumFourmajorcomponents：endometrialglandsendometrialstromafibrosishemorrhageEctopicendometrium异位子宫内膜Eutopicendometrium在位子宫内膜ClinicalManifestationSymptoms：PainprogressivedysmenorrheadyspareuniapainfuldefecationMenstrualdisturbanceinfertilitydysmenorrhea痛经dyspareunia性交痛Signs：Enlargementoftheovaries，fixedFixedretroversionoftheuterusTendernoduleswithinthepelvisCannotbediagnosedbyPValone.Shouldalwaysbeconsideredwhenpatientshavesymptomsreferabletothepelviccavity.VeryvariableVarywiththefocuslocationOftenbearnorelationtotheextentofthediseaseQuiteoftendepositsarefoundincidentallyinwomenwhohavenosymptoms.（25%havenosymptoms）Diagnosis：HistoryPVexaminationLaparoscopy（goldenstandard）Ultrasonography（B–typeultrasound）CA–125↑（＜200U/ml；normalvalue35U/ml）Anti–endometriumantibody（+）Stagingsystems：IntheAFS-r（1985）stagingsystem，pointsareassignedforseverityofendometriosisbasedonthesizeanddepthoftheimplantandfortheseverityofadhesions.Thepointsaresummedandthepatientsareassignedtoonetofourstages：StageI—minimaldisease，1～5pointsStageII—milddisease，6～15pointsStageIII—moderatedisease，16～40pointsStageIV—severedisease，≥40pointsDifferentialdiagnosis：MalignantovarytumoursPelvicinflammatorymassesAdenomyosisTreatmentExpectanttherapy：Indications：withverylimiteddisease（whosesymptomsareminimalornonexistent）Iftryingtogetpregnant，thebestwayistoacceptlaparoscopictherapyasearlyaspossible.Medicaltherapy：Indications：chronicpelvicpainseveredysmenorrheanorequiretogetpregnantnoovariancystformationHormone–inhibitiontherapyDrugs：Danazol：pseudomenopausetherapyGestrinoneGnRH–a：medicaloophorectomyadd–backtherapyMifepristoneRU486Progestogens：pseudopregnancytherapySurgicaltherapy（1）：Indications（1）adnexalmass（2）pelvicpain（3）infertilityApproaches：(1)trans–abdominal(2)laparoscopicSurgicaltherapy（2）：Methods：ConservativesurgerypreservethefecunditypreservetheovarianfunctionDefinitivesurgery：hysterectomy+salpingo–oophorectomyCombinationmedical–surgicaltreatment：Three–step：surgerymedicaltherapysecondlook（laparoscopy）Itisimportanttoindividualizethechoiceoftherapy.Therapymustbetailoredtothedegreeofsymptomatologythepatient’sageherdesiretomaintainfertilityPrognosis：Withpropertreatment，theprognosisisgoodforreliefofpainandenhancementoffertilityinmildtomoderateendometriosis.Inmostcases，hormonaltherapyistemporarilyeffectiveincontrollingsymptomsandarrestinggrowthbutisgenerallylesseffectivethansurgeryinincreasingfertility.Therecurrentrateisveryhigh.Prevention：Avoidpossibleaugmentationofmenstrualreflux.Takingoralcontraceptiveisrecommended.Isolationandirrigationoftheoperativesite.Criticalpoints（1）：Thepathogenesisispoorlyunderstood，butemergingevidencesupportsthecausativeroleofretrogrademenstruationandimplantationofendometrialtissue.Endometriosisisacommoninwomenwithpelvicpainorinfertility.Laparoscopyistheoptimaltechniquetodiagnosepelvicendometriosis.Criticalpoints（2）：Inmostcases，surgicaltherapyatthetimeofinitialdiagnosiseffectivelyrelievespainandmayenhancefertility.Alternatively，medicaltherapywithprogestins、danazol、gestrinoneorGnRH-awillamelioratepelvicpain，buttheydonotenhancefertility.Endometriosisisarecurrentdisease，anddefinitivetreatmentwithremovalofpelvicorgansmaybenecessary.AdenomyosisDefinition：Abenignuterineconditioninwhichendometrialglandsandstromaarefounddeepinthemyometrium.Etiology：Basalendometrialhyperplasiainvadingahyperplasticmyometrialstroma.Fourprimarytheories：HeredityTraumaHyperestrogenemiaViraltransmissionPathology—grossappearance：UsuallyhyperemicwiththickenedwallsThefociarefrequentlyscattereddiffuselythroughoutthemyometrium.Occasionally，maybemorecircumscribed，withtheformationofadistinctnodule，anadenomyoma.Adenomyosis子宫肌腺症Adenomyoma子宫肌腺瘤Thethickenedandspongyappearingmyometrialwallofthissectioneduterusistypicalofadenomyosis.Thereisalsoasmallwhiteleiomyomaatthelowerleft.Clinicalfeatures（1）：Symptomaticadenomyosisoccursprimarilyinparouswomenovertheageof40.（30～50）Classicsymptoms：secondarydysmenorrheaabnormaluterinebleedingClinicalfeatures（2）：Mostcommonphysicalsign：adiffuselyenlargeduterus，(rarelyexceeds12weeks’gestationinsize)particularlytenderduringmenstruationDiagnosis：HistoryPelvicexaminationsUltrasonographySerummarkers：CA-125↑Treatment：HormonetherapyHysterectomy，theonlyuniformlysuccessfultreatmentforadenomyosis，isnecessary.ZhaoaiminM.D.,Ph.D.,ProfessorDepartmentofObstetrics&GynecologyRenjiHospitalAffiliatedtoSJTUSchoolofMedicineThanksforYourAttention