Endometriosis & Adenomyosis by yurtgc548

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									Endometriosis
   & Adenomyosis
       Zhao aimin                     M.D., Ph.D., Professor
                    Department Of Obstetrics & Gynecology
        Renji Hospital Affiliated to SJTU School of Medicine
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Endometriosis



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Definition:
    Abnormal growth of endometrial
    tissue outside the uterine cavity.




                                         3
Incidence and Prevalence:

• Increase significantly
• Range from 1~ 50%
        General population:1~ 2%
        Infertile women:30~ 50%
• Occurs primarily in women in 25~ 45s



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Pathogenesis:
• Implantation Theory
  Retrograde Menustration Theory
   Sampson,1921
• Lymphatic and Vascular Dissemination Theory
   Javert,1952
• Coelomic Theory
   Meyer
• Genetic Theory
• Immune System Dysfunction(immunologic theory)
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Genetic factors:
• Familial clustering of endometriosis is a common
  clinical observation.
• In families with endometriosis,the disease is
  often confined to the maternal line,and is 7 times
  more common in first-degree relatives than in the
  general population.
• In future studies,evaluation of DNA
  polymorphism may identify specific genes
  involved in the development of endometriosis.
                                                   6
Immunologic Theory:
•    Lose control of immunologic balance
•    Both cellular immunity and humoral immunity
     change.
1)   Macrophage↑ release IL–1、IL–6、TNF、EGF、
     FGF etc.      stimulate T、B lymphocyte proliferation
     and activation
2)   Activity of killer cell(NK cell and T cell)↓
3)   Produce anti–endometrium antibody
4)   Abnormal expression of CAMs(cell adhesion
     molecules)

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• The pathogenesis
  is unclear.
• multifactor




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Pathology
 – macroscopic appearance(1):
• The commonest sites:
1. Ovary(chocolate cyst)
2. Peritoneum of the recto–vaginal cul–de–
   sac of the Pouch of Douglas
3. Utero–sacral ligaments
4. Sigmoid colon
5. Broad ligament
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  This is a section through an enlarnged 12 cm ovary to
demonstrate a cystic cavity filled with old blood typical for
endometriosis with formation of an endometriotic, or
"chocolate", cyst.

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11
Pathology
– macroscopic appearance (2):
•    Less common sites:
1.   Cervix
2.   Round ligament
3.   Urinary system(bladder、ureter)
4.   Umbilicus
5.   Appendix
6.   Laparotomy scars
                                      12
Multiple appearances of
endometriosis implants:
•   Brownish,discolored peritoneum
•   Superficial peritoneal ecchymosis
•   Raised,reddish,superficial nodules
•   Reddish–blue invasive nodules
•   Fibrotic,whitish nodules
•   Raised,glossy,translucent blobs
•   Patchy,white opacified peritoneum
•   Reddish or bluish ovarian cysts
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Grossly, in areas of endometriosis the blood is darker and gives the
small foci of endometriosis the gross appearance of "powder burns".
Small foci are seen here just under the serosa of the posterior uterus in
the pouch of Douglas. Such areas of endometriosis can be seen and
obliterated by cauterization via laparoscopy.
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Upon closer view, these five small areas of
endometriosis have a reddish-brown to
bluish appearance.
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Pathology
  – microscopic appearance
• Histomorphologically similar to eutopic
  endometrium Eutopic endometrium Ectopic endometrium
                 在位子宫内膜              异位子宫内膜

• Four major components:
                endometrial glands
                endometrial stroma
                fibrosis
                hemorrhage
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Clinical Manifestation




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Symptoms:
• Pain
                             dysmenorrhea
  progressive dysmenorrhea       痛经

  dyspareunia                dyspareunia
                               性交痛

  painful defecation
• Menstrual disturbance
• infertility

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Signs:
• Enlargement of the ovaries,fixed
• Fixed retroversion of the uterus
• Tender nodules within the pelvis
Cannot be diagnosed by PV alone.
Should always be considered when patients have
 symptoms referable to the pelvic cavity.

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Very variable
Vary with the focus location
Often bear no relation to the
 extent of the disease
Quite often deposits are found
 incidentally in women who
 have no symptoms.
(25% have no symptoms)



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Diagnosis:
• History
• PV examination
• Laparoscopy(golden standard)
• Ultrasonography(B–type ultrasound)
• CA–125↑ (< 200U/ml;normal value
  35U/ml)
• Anti–endometrium antibody(+)
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Staging systems:
• In the AFS-r(1985)staging system,points are
  assigned for severity of endometriosis based on
  the size and depth of the implant and for the
  severity of adhesions.
• The points are summed and the patients are
  assigned to one to four stages:
Stage I — minimal disease, 1~5 points
Stage II — mild disease,         6~15 points
Stage III — moderate disease,16~40 points
Stage IV — severe disease, ≥ 40 points
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Differential diagnosis:
• Malignant ovary tumours
• Pelvic inflammatory masses
• Adenomyosis




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Treatment




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Expectant therapy:

•    Indications:with very limited disease
    (whose symptoms are minimal or nonexistent)

•    If trying to get pregnant,the best way is
     to accept laparoscopic therapy as early as
     possible.


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Medical therapy:
• Indications:chronic pelvic pain
              severe dysmenorrhea
              no require to get pregnant
              no ovarian cyst formation
• Hormone–inhibition therapy


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Drugs:
• Danazol:pseudomenopause therapy
• Gestrinone
• GnRH – a:medical oophorectomy
              add – back therapy
• Mifepristone RU486
• Progestogens:pseudopregnancy therapy

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Surgical therapy(1):
• Indications(1)adnexal mass
              (2)pelvic pain
              (3)infertility
• Approaches:
   (1) trans – abdominal
   (2) laparoscopic

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Surgical therapy(2):
Methods:
 Conservative surgery
1) preserve the fecundity
2) preserve the ovarian function
 Definitive surgery:
   hysterectomy + salpingo–oophorectomy

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Combination
medical–surgical treatment:
Three–step:      surgery


              medical therapy


          second look(laparoscopy)

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 It is important to
 individualize the
 choice of therapy.
 Therapy must be
  tailored to
• the degree of
  symptomatology
• the patient’s age
• her desire to
  maintain fertility
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Prognosis:
• With proper treatment,the prognosis is good for
  relief of pain and enhancement of fertility in mild
  to moderate endometriosis.
• In most cases,hormonal therapy is temporarily
  effective in controlling symptoms and arresting
  growth but is generally less effective than surgery
  in increasing fertility.
• The recurrent rate is very high.

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Prevention:
• Avoid possible augmentation of menstrual
  reflux.
• Taking oral contraceptive is recommended.
• Isolation and irrigation of the operative site.



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Critical points(1):
• The pathogenesis is poorly understood,but
  emerging evidence supports the causative role of
  retrograde menstruation and implantation of
  endometrial tissue.
• Endometriosis is a common in women with pelvic
  pain or infertility.
• Laparoscopy is the optimal technique to diagnose
  pelvic endometriosis.

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 Critical points(2):
• In most cases,surgical therapy at the time of
  initial diagnosis effectively relieves pain and may
  enhance fertility.
• Alternatively,medical therapy with progestins、
  danazol、gestrinone or GnRH-a will ameliorate
  pelvic pain,but they do not enhance fertility.
• Endometriosis is a recurrent disease,and
  definitive treatment with removal of pelvic organs
  may be necessary.

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Adenomyosis




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Definition:
  A benign uterine condition in which
  endometrial glands and stroma are
  found deep in the myometrium.



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Etiology:
• Basal endometrial hyperplasia invading a
  hyperplastic myometrial stroma.
• Four primary theories:
  Heredity
  Trauma
  Hyperestrogenemia
  Viral transmission
                                             38
Pathology
  — gross appearance:
• Usually hyperemic with thickened
  walls
• The foci are frequently scattered
  diffusely throughout the myometrium.
• Occasionally,may be more
  circumscribed,with the formation of
  a distinct nodule,an adenomyoma.
         Adenomyosis   Adenomyoma
         子宫肌腺症         子宫肌腺瘤
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The thickened and spongy appearing myometrial
wall of this sectioned uterus is typical of
adenomyosis. There is also a small white
leiomyoma at the lower left.
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Clinical features(1):
• Symptomatic adenomyosis occurs primarily
  in parous women over the age of 40 .
 (30~ 50)
• Classic symptoms:
              secondary dysmenorrhea
              abnormal uterine bleeding



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Clinical features(2):
• Most common physical sign:
     a diffusely enlarged uterus ,
    (rarely exceeds 12 weeks’ gestation in size)
 particularly tender during menstruation



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Diagnosis:
•   History
•   Pelvic examinations
•   Ultrasonography
•   Serum markers:CA-125↑



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Treatment:
• Hormone therapy
• Hysterectomy,the only uniformly
  successful treatment for adenomyosis,
  is necessary.



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Thanks for Your Attention




        Zhao aimin M.D., Ph.D., Professor
                    Department of Obstetrics & Gynecology
        Renji Hospital Affiliated to SJTU School of Medicine
                                                      45

								
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