子宮內(nèi)膜異位癥英語(yǔ)課件

子宮內(nèi)膜異位癥和子宮腺肌病

（endometriosisandadenomyosis）

Objectives（教學(xué)目的）1. Familiarizetheprevailingtheoriesonpossiblecausesandpathogenesisofendometriosis。（熟悉子宮內(nèi)膜異位癥可能的病因和發(fā)病機(jī)制）2. Mastertheclinicalfeatures,diagnosisanddifferentialdiagnosisofendometriosis（掌握子宮內(nèi)膜異位癥的臨床特點(diǎn)、診療及鑒別診療）Objectives（教學(xué)目的）3. Understandtheprinciplesofthetreatmentstrategyofendometriosis。（了解子宮內(nèi)膜異位癥治療策略的原則）主要內(nèi)容Maincontent

Pathogenesis病因和發(fā)病機(jī)制Pathologicalfeatures病理特點(diǎn)Clinicalfindings臨床體現(xiàn)Diagnosis診療Differentialdiagnosis鑒別診療Treatment治療子宮內(nèi)膜異位性疾?。?/p>

子宮內(nèi)膜異位癥（endometriosis，EM）子宮腺肌病(adenomyosis)

定義：DefinitionAgynecologicalconditioninwhichendometrialcellsappearandgrowoutsidetheuterinecavity。

（endometriosis,EM）具有生長(zhǎng)功能的子宮內(nèi)膜出現(xiàn)在子宮體以外身體其他部位，生長(zhǎng)、侵蝕、周期性出血稱子宮內(nèi)膜異位癥，簡(jiǎn)稱內(nèi)異癥發(fā)生部位

ovarian（卵巢）peritonea（腹膜）deepinfiltratingendometriosis(DIE)異位子宮內(nèi)膜能夠侵犯全身任何部位，絕大多數(shù)位于盆腔臟器和腹膜。最常見(jiàn)的被侵犯部位是子宮骶韌帶及卵巢

IncidencerateTheendometriosisincidenceofFertilewomenis76%，Hormonedependentdisease，生育年齡婦女是內(nèi)異癥高發(fā)人群約占76%，是一種激素依賴性疾病。Incidencerate1.Recurringpelvicpain，20%-90%

慢性盆腔疼痛及痛經(jīng)，2.Infertility，40%，不孕3.dyspareunia，pain，性交不適，疼痛4.Menstrualdisturbances，月經(jīng)紊亂15%-30%Thecharacteristicsofendometriosis

子宮內(nèi)膜異位癥特點(diǎn)Diverseclinicalmanifestations臨床體現(xiàn)多樣Histologicallybenign組織學(xué)上良性Buthyperplasia,infiltration,metastasisandrecurrenceof"malignant"behavior,causingextensiveadhesion但有增生、浸潤(rùn)、轉(zhuǎn)移及復(fù)發(fā)等“惡性”行為，引起廣泛粘連Growthishormonallydependent生長(zhǎng)的激素依賴性11

Etiologyandpathogenesis

一、病因和發(fā)病機(jī)制

Nosingletheoryexplainsallcasesofendometriosis.發(fā)病機(jī)制不清，提出了多種學(xué)說(shuō)Mechanismsummory

EndometrialimplantationtheoryhasbeenrecognizedSampson'stheoryofhemorhedraltransplantingandtranscoelomicmetaplasiaistheleadingtheory以sampson的經(jīng)血逆流種植及體腔上皮化生學(xué)說(shuō)為主導(dǎo)理論.Endomyelitisdeterminism在位內(nèi)膜決定論.

EMRetrogrademenstruation種植學(xué)說(shuō)Coelomicmetaplasia體腔上皮化生Inductiontheory誘導(dǎo)學(xué)說(shuō)Geneticfactors遺傳因素Immuneandinflammatory免疫與炎癥因素Endomyelitisdeterminism在位內(nèi)膜決定論Etiology:theories

Etiologicalstudy病因?qū)W研究種植學(xué)說(shuō)：Sampsonfirstputforwardthetheoryofmenstrualbloodrefluflowin19211923年Sampson最早提出經(jīng)血逆流學(xué)說(shuō)Endometrialimplantationtheoryhasbeenrecognized種植學(xué)說(shuō)內(nèi)膜種植學(xué)說(shuō)已為人們所公認(rèn)Etiologicalstudy病因?qū)W研究1.Endometrialglandularepitheliumandstromalcellsmayreverseflowduringmenstruation2.Throughthetubalintothepelviccavity,implantedintheovaryandadjacentpelvicperitoneumandcontinuetogrow,spread,theformationofpelvicdysplasia經(jīng)期時(shí)子宮內(nèi)膜腺上皮和間質(zhì)細(xì)胞可隨經(jīng)血逆流，經(jīng)輸卵管進(jìn)入盆腔，種植于卵巢和鄰近的盆腔腹膜并在該處繼續(xù)生長(zhǎng)、蔓延，形成盆腔內(nèi)異癥TheBasicpathologicalchangesofendometriosis

基本病理變化Implantationofendometrialcellstotheperitonealsurfacecanleadtoaspectrumofdiseaseseveritywiththemostseverecausingextensivepelvicadhesionsandanatomicdistortion.將子宮內(nèi)膜細(xì)胞移植到腹膜表面可能造成一系列嚴(yán)重的疾病，其中最嚴(yán)重的是廣泛的盆腔粘連和解剖變形Eightypercentinvolvedoneovaryandfiftypercentinvolvedbothovaries80％累及一側(cè)卵巢，50％累及雙側(cè)卵巢17TheClassificationofendometriosis

常見(jiàn)盆腔內(nèi)異癥分類Ectopicendometriumwiththechangeofovarianhormoneperiodicbleeding,resultingintheproliferationofsurroundingfibroustissueandcysts,adhesionformation,purplebrownspotsorvesiclesinthelesionarea,eventuallydevelopintodifferentsizeofpurplebrownsolidnodulesormass.異位子宮內(nèi)膜隨卵巢激素變化發(fā)生周期性出血，造成周圍纖維組織增生和囊腫、粘連形成，在病變區(qū)出現(xiàn)紫褐色斑點(diǎn)或小泡，最終發(fā)展為大小不等的紫褐色實(shí)質(zhì)性結(jié)節(jié)或包塊.18TheClassificationofendometriosisFormationofasingleormultiplecysts,thecapsulefortheoldbleedinglikechocolatecalledovarianchocolatecyst,thesurfacewasgreyishblue

卵巢Microlesiontype:red,purple,blue,orbrownspotsorvesiclesonthesuperficialsurfaceoftheovary微小病灶型：卵巢淺表皮層的紅色、紫藍(lán)色或褐色斑點(diǎn)或小泡經(jīng)典病灶型：形成單個(gè)或多種的囊腫，囊內(nèi)為陳舊出血呈巧克力樣稱卵巢巧克力囊腫，表面呈灰藍(lán)色；Uterinesacralligament,rectumuterinedepression,uterineposteriorwalllowersegmentoftheheterotopic,lowposition,easytooccur宮骶韌帶、直腸子宮陷凹、子宮后壁下段異位癥，位置低，好發(fā)部位Earlylesion:localscatteredpurple-brownhemorrhagicspotsorgranularnodules.Thelesiondeveloped：Theposteriorwalloftheuterusadheredtotheanteriorwalloftherectum病變?cè)缙冢壕植可⒃谧虾稚鲅c(diǎn)或顆粒狀結(jié)節(jié)病變發(fā)展：子宮后壁與直腸前壁粘連，直腸子宮陷凹變淺、消失、表面有紫藍(lán)色結(jié)節(jié)經(jīng)典或微小的腹膜子宮內(nèi)膜異位病灶A(yù)：經(jīng)典的黑色皺縮病變伴有血管增生及橘紅色囊泡B：紅色息肉樣病灶伴血管增生A:thetypicalblackwrinkledlesionisaccompaniedbyvascularhyperplasiaandorangevesiclesB:redpolypoidlesionwithvascularhyperplasia卵巢子宮內(nèi)膜異位癥24A：淺表卵巢子宮內(nèi)膜異位癥B：淺表卵巢子宮內(nèi)膜異位癥及子宮內(nèi)膜異位囊腫在粘連分解術(shù)前的腹腔鏡下所見(jiàn)C：腹腔鏡下子宮及右卵巢的黑紅色子宮內(nèi)膜異位囊腫D、E：卵巢子宮內(nèi)膜異位囊腫剔除術(shù)A:superficialovarianendometriosisB:superficialovarianendometriosisandendometriosiscystwereseenunderlaparoscopebeforeadhesolysisC:blackandredendometriosiscystofuterusandrightovaryunderlaparoscopeD,E:removalofovarianendometriosiscyst

鏡檢：microscopicpathologicfeatures異位病灶中可見(jiàn)：Endometrialglandinterstitialcellulosebleeding

子宮內(nèi)膜腺體間質(zhì)纖維素出血

Malignanttransformationofectopicintimaisrare,andtheincidenceislessthan1%Characteristicsofbiologicalbehavior-invasivegrowth,damagetosurroundingtissues,distantmetastasisandrecurrenceThecauseofthemalignantchangeisnotclearDiagnosticcriteriaformalignanttransformationClearcellcarcinomaandendometrioidcarcinomaEvilchange惡變異位內(nèi)膜極少發(fā)生惡變，發(fā)生率低于1%生物學(xué)行為的特點(diǎn)-浸潤(rùn)性種植生長(zhǎng)、對(duì)周圍組織的破壞、遠(yuǎn)處轉(zhuǎn)移和易復(fù)發(fā)惡變病因不明確惡變?cè)\療原則透明細(xì)胞癌和子宮內(nèi)膜樣癌Clinicalfindings臨床體現(xiàn)Pain：疼痛Infertility：不孕Dyspareunia：性交不適Paramenia：月經(jīng)異常Othersymptom其他癥狀個(gè)別無(wú)癥狀

paincharacter

1.Painfulcharacteristic:sendsubsequentlydysmenorrhea,pelvicpain,sexualintercourseispainful2.Thepainfulpart;Moreinthemiddleofthelowerabdomenandlumbosacraldepartmentorradiationtoperineum,anus,thigh.3.Thedegreeofpain:andlesionsizeisnotnecessarilyproportional,andthesitehasacertainrelationship

Infertility：不孕

PelvicanatomyisabnormalChangeofmicroenvironmentinpelviccavityMenstrualdisorderOvariandysfunction盆腔解剖構(gòu)造異常盆腔內(nèi)微環(huán)境變化月經(jīng)失調(diào)卵巢功能異常Dyspareunia:性交不適Paincausedbyabumporuterinecontractionduringintercourse,Itisdeepsexcommonlypainful,menstruationcomesbeforemenstruationsexualintercourseispainfulthemostapparent30Paramenia月經(jīng)異常Incidence:15%~30%increaseinmenstrualvolume,prolongedmenstrualperiodormenstrualdrippingnotfullorearlymenstrualspotting發(fā)生率：15%～30%經(jīng)量增多、經(jīng)期延長(zhǎng)或月經(jīng)淋漓不盡或經(jīng)前期點(diǎn)滴出血31Othersymptoms其他癥狀腸道內(nèi)異病灶膀胱內(nèi)異病灶輸尿管異位病灶手術(shù)瘢痕異位病灶32DifferentlesionsinintestinaltractAdifferentlesioninthebladderEctopicureterallesionSurgicalscarectopiclesionExamination體征1.Pelvicmass:chocolatecystofovary2.Uterineposteriorfixation,severelylimitedmovement3.Palacralligament,posterioruterinewallnodulestenderness4.Purplebluenodulesandspotsonvulva,vaginaandcervix1．

盆腔包塊：卵巢巧克力囊腫2．

子宮后位固定，活動(dòng)嚴(yán)重受限3．

宮骶韌帶、子宮后壁結(jié)節(jié)觸痛4.外陰、陰道、宮頸紫藍(lán)色結(jié)節(jié)，斑點(diǎn)診療DiagnosisLaparoscopyandlaparotomyaretheaccuratemethodsofdiagnosis.Basisisfocalmorphology,notbeprovedcompletelybypathology。(Goldstandard)腹腔鏡檢驗(yàn)及開(kāi)腹探查術(shù)是診療的精確措施。根據(jù)是病灶形態(tài)，不一定全部經(jīng)病理證明Non-surgicaldiagnosticcriteriaincluded:pain,infertility,pelvicexamination,b-ultrasound,CA125,Positivepredictivevalue.非手術(shù)診療原則涉及：疼痛、不育、盆腔檢驗(yàn)、B超、CA125.5項(xiàng)中有3項(xiàng)陽(yáng)性都有很高的陽(yáng)性預(yù)測(cè)值.B超顯示卵巢巧克力囊腫Differentialdiagnosis

鑒別診療OvarianmalignancyPelvicinflammatorymassadenomyosis卵巢惡性腫瘤盆腔炎性包塊子宮腺肌病36子宮內(nèi)膜異位癥的分期（修正的AFS分期法1.若輸卵管全部包入應(yīng)改為16分2.Ⅰ期（微型）1～5分；Ⅱ期（輕型）6～15分；Ⅲ期（中型）16～40分；Ⅳ期（重型）>40分治療TreatmentObjective：ReduceandremovelesionsPainreliefandcontrolTreatmentandfertilitypromotionPreventandreducerecurrence縮減和清除病灶減輕和控制疼痛治療和增進(jìn)生育預(yù)防和降低復(fù)發(fā)ageFertilityrequirementsSymptomseverityDegreeofthelesionAlwaystreatPatientswillThedoctorisAmedicalinstitutionIndividualizedtreatmentThepaininfertilityEndometriosiscystFundamentalconsiderationsforthetreatmentofendosarphyExpectationmanagementmedicalmanagementsurgicalmanagementconjointmanagement藥物治療

medicalmanagement1）Non-steroidalanti-inflammatorydrugshavemanyeffectsinrelievingfeverandpainandanti-inflammatory。非甾體類抗炎藥2）pseudopregnancytherapy假孕療法Combinationoralcontraceptivesworkbysuppressingovulationandpossiblybycausingcervicalandendometrialchangesthatreducethelikelihoodofimplantation.口服避孕藥降低垂體促性腺激素水平，并造成類似妊娠的人工閉經(jīng)。

pseudopregnancytherapy假孕療法progestinByinhibitingthesecretionofpituitarygonadotropin,falsepregnancyiscaused.Medroxyprogesterone30mg/dayfor6months孕激素經(jīng)過(guò)克制垂體促性腺激素的分泌，造成假孕。甲羥孕酮30mg/日，連用6個(gè)月。Gonadotropin-releasinghormoneagonist

（

(（GnRH-a）

ThesyntheticdecapeptidecompoundhasthesameeffectastheinternalGnRHandpromotesthereleaseofpituitaryLHandFSH,butitsaffinitytoGnRHreceptorishundredsoftimeshigherthanthenaturalone,inhibitsthesecretionofgonadotropinbythepituitary,leadingtoasignificantdecreaseinthelevelofovarianhormoneandtemporaryamenorrhea.Leuprin3.75mg,1time/28days,3-6timesGoserelin3.6mg,1time/28days,3-6times人工合成的十肽類化合物，其作用與體內(nèi)GnRH相同，增進(jìn)垂體LH和FSH的釋放，但其對(duì)GnRH受體的親和力較天然高百倍，克制垂體分泌促性腺激素，造成卵巢激素水平明顯下降，出現(xiàn)臨時(shí)性閉經(jīng)。5）促性腺激素釋放激素激動(dòng)劑（GnRH-a）人工合成的十肽類化合物，其作用與體內(nèi)GnRH相同，增進(jìn)垂體LH和FSH的釋放，但其對(duì)GnRH受體的親和力較天然高百倍，克制垂體分泌促性腺激素，造成卵巢激素水平明顯下降，出現(xiàn)臨時(shí)性閉經(jīng)。亮丙瑞林3.75mg，1次/28天，3-6次戈舍瑞林3.6mg，1次/28天，3-6次surgicalmanagement手術(shù)治療Indicationofoperation:PainaccessorymassinfertileOperationmethod:transabdominalsurgerylaparoscopicsurgeryOperativeprocedure:operationtopreservereproductivefunctionOvarianpreservationsurgeryRadicalsurgeryLaparoscopicchocolatecystremovalofovary腹腔鏡下卵巢巧克力囊腫剝除術(shù)Provention1.Preventmenstrualbloodflow2.Drugcontraception3.AvoidiatrogenicplantingIatrogenicendometrium1.預(yù)防經(jīng)血倒流2.藥物避孕3.防止醫(yī)源性引起種植醫(yī)源性異位內(nèi)膜EMKnowledgePointSummaryEndometriosisisabenignandinvasivediseasethatoftenoccursinwomenduringchildbearingyearsCommonsymptomsarepain,infertility,menstrualdisorders,abdominaldiscomfortTypicalsignsarepelvictenderness

nodulesorchocolatecystsoftheovariesLaparoscopyorlaparotomyisthegold

standardforEMdiagnosisEndometriosisisrelatedtoovarianhormoneandishormone-dependentdisease,easytorelapse.二、子宮腺肌病（adenomyosis）Adenomyosisoccurswhentheendometriuminvadesthemyometrium.Mostofthemareaged30to50.About15%werecomplicatedwithendometriosis,andabouthalfwerecomplicatedwithuterinefibroids.當(dāng)子宮內(nèi)膜侵入子宮肌層時(shí)稱為子宮腺肌病。多發(fā)生于30歲~50歲經(jīng)產(chǎn)婦。約15%合并內(nèi)異癥，約半數(shù)合并子宮肌瘤。Etiologyandpathogenesis

病因和機(jī)制Etiology：Multiplepregnancy，delivery,inducedabortion，chronicendometritisTheendometrialbasallayerwasdamagedPathogenesis：Theunderlyinglayeroftheendometriumlackssubmucosa,whichisindirectcontactwiththemusclelayerandlackstheprotectiveeffectofthesubmucosa.Asaresult,theendometriumiseasytoinvadethemusclelayerinanatomicalstructure基底層的子宮內(nèi)膜侵入肌層生長(zhǎng)造成，屢次妊娠及分娩、人工流產(chǎn)、慢性子宮內(nèi)膜炎等造成子宮內(nèi)膜基底層損傷。內(nèi)膜基底層缺乏黏膜下層，內(nèi)膜直接與肌層接觸，缺乏黏膜下層的保護(hù)作用，使得在解剖構(gòu)造上子宮內(nèi)膜易于侵入肌層pat