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1、EndometriosisWomens Hospital,School of Medicine Zhejiang University Prof.Lin Jun,Definition,Endometriosis is usually defined as the presence of endometrial-like tissue,that is,glands and stroma,outside the endometrium in uterine cavity and myometrium.,Common sites of endometriosis,The most common si
2、tes：uterosacral ligamentrectouterine pouch ovaryOthers：uterine serosafallopian tubesigmoid colon(乙状结肠)outside of the pelvis:Umbilicus(脐),bladder,kidney,Prevalence,present in 10%-15%of women in reproductive age group,especially from age 25 to 45normally not seen before age 15 or after menopauseearly
3、and more childbearinglatest study:more frequent menses(cycle length 27 days)and prolonged menstrual flow(1 week)2 times risk,Pathogenesis,Theories of sources of ectopic endometrium Endometrial implanting theory(种植学说)Sampson 1921 endometrium transfer implant grow retrograde menstruation(经血逆流)theory t
4、ransport by lymph and vein iatrogenic(医源性的)implantation,Pathogenesis,Theories of source of ectopic endometrium metaplasia theory(化生学说)inducement theory（诱导学说）,Pathogenesis,Factors related with endometriosisGenetic Abnormalities：high risk in first-degree relatives Immunologic Factors:increased concent
5、rations of white blood cells,cytokines,and growth factors IL-6、IL-8、TNF-、MCP-1 inflammation:EMs lesions chronic pelvic inflammation,Pathology,ectopic endometrium hemorrhage proliferation of fibrous tissue adhesions dark blue or dark brown spots scarring nodules or cysts,Gross appearance:,ovarian end
6、ometriosis red,blue,or brown spots endometriomas chocolate cysts,Gross appearance:,peritoneal endometriosiscommon sites：uterosacral ligament、rectouterine pouch,purple spotsdark brown spotsred lesionswhite lesionsperitoneum lack,peritoneal endometriosis,peritoneal endometriosis,cervix,umbilicus(脐),Th
7、e microscopic findings：,endometrial glands endometrial stroma fibrinred blood cells and hemosiderin（含铁血黄素）2 findings to be diagnosed,Clinical Findings,symptoms：dysmenorrhoea（痛经）and chronic pelvic pain the most typical symptom：secondary dysmenorrhea that worsens over time dyspareunia（性交痛）abnormal ute
8、rine bleeding heavy menses,prolonged menstruation or premenstrual spottinginfertility：40%of patients acute abdomen:inter-cyst hemorrhage(囊内出血),or rupture,Clinical Findings,symptoms：others：,diarrhoea（腹泻）constipation（便秘）bloody stool painful urination bloody urine backache,Causes of infertility,1)Mecha
9、nical reason2)Environmental change in the peritoneal cavity3)Abnormal immune function4)Abnormal ovarian function(anovulation,LPD,Lufs)5)Increase in spontaneous abortion,Clinical Findings,Pelvic Examination：fixed retroverted uterinetender nodules on uterosacral ligament or rectouterine pouch tender a
10、nd fixed adnexal masses,Diagnosis,historypelvic examinationlaparoscopy golden diagnosis standard diagnosis,classification treatmentultrasound,(CT and MRI,expensive)serum CA125 but usually 100IU/ml anti-endometrium antibody,Diagnosis,Clinical classificationRevised American Fertility Society(r-AFS),19
11、85Useful for:Assessment of severity Selection of therapeutic regimen Comparison Prognosis,r-AFS,Differential Diagnosis,Ovarian tumor ascites（腹水）,solid or mixed,B ultrasound image,CA-125100 IU/ml Abdominal inflammatory mass history of infection,fever,not cyclic,treatment with antibiotics effectively
12、Adenomyosis(子宫腺肌病)medial,severe pain,uterus slightly enlarged,Treatment,Principles of treatment：Treatment should be individualized according to the age,severity of the condition and desire for childbearing.With mild symptom:expectant therapyWith childbearing desire:mild-condition:medication severe-c
13、ondition:fertility preservation surgeryNo childbearing desire:Surgical treatment:ovary preservation or radical surgery,Treatment,Expectant Therapy Follow-upsymptoms management：NSAIDs（非甾体类抗炎药）,Treatment,MedicationObjective:cause atrophic changes in the ectopic endometrium（使异位内膜萎缩）,Medication,Pseudopr
14、egnancy therapy oral contraceptives：a pill once daily for 6-12 m progestins：medroxyprogesterone（醋酸甲孕酮）30mg dailymegestrol（甲地孕酮）40mg dailynorethindrone（炔诺酮）5mg daily Side effects:Intermittent breakthrough bleeding,nausea,breast tenderness,fluid retention,weight gain,Medication,Pseudomenopause therapy
15、GnRH-a Mechanism:Medical hypophysectomy(药物性垂体切除)/Medical oophorectomy(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,1 inj/q28d,start d1,Medication,GnRH-a Side effects:(1)Menopausal symptoms:hot flashes,dryness in vagina,loss of libido(性欲)(2)Osteoporosis,M
16、edication,Pseudomenopause therapy Danazol A derivative of 17-ethinyltestosterone（17-乙炔睾酮衍生物）Mechanism:Directly suppressing ovarian steroidogenesis（甾体激素生成）Direct inhibiting the growth of endometrium 400-600 mg/d for 6 months,Medication,Danazol Side effects:acne,deepening of the voice,oily skin,headac
17、he,hot flashes,loss of libido,weight gain,Medication,others：gestrinone（孕三烯酮）mifepristone（米非司酮）,Surgical treatment,Purposes：diagnosis and classification excise or destroy all endometriotic tissue remove all adhesions,restore pelvic anatomy enhance fecundity relieve pain,Surgical treatment,laparoscopy
18、+medicine golden standard of treatment,Surgical treatment,Modes of surgical operation:(1)Fertility preservation(2)Ovarian function preservation(3)Radical surgery(4)Surgery for pain relief,Treatment,Combination of medication and surgery surgery+medication medication+surgery+medicationTreatment for pa
19、tients with infertility,Prevention,Prevent retrograde flow of mensesContraception with medicine Avoid iatrogenic(医源性)implantation of the ectopic endometrium,Adenomyosis,Definition,Adenomyosis is defined by the presence of endometrial glands and stroma within the myometrium.It is associated with myom
20、etrial hypertrophy and proliferation.,Endometriosis Adenomyosis,Pathogenesis histological confirmation Sites of lesionsClinical findings,Adenomyosis is thought to be unrelated to endometriosis.,Clinical findings,Multiparas（40 y）were most commonly affected.Symptoms：prolonged and heavy menses Dysmenorrhea that worsens over timePelvic exam：enlargement of uterustenderness,Diagnosis,Typical symptoms and signsHistopathologic examination standard of the diagnosisB ultrasound would suggest the disease.,Treatment,1.Medication：GnRH-a2.Surgical treatment:total hysterectomy,Thank you!,
