子宮內膜異位癥課件

Endometriosis

Women’sHospital,SchoolofMedicineZhejiangUniversity

Prof.LinJun

子宮內膜異位癥Definition

Endometriosis

isusuallydefinedasthepresenceofendometrial-liketissue,thatis,glandsandstroma,outsidetheendometriuminuterinecavityandmyometrium.子宮內膜異位癥

Commonsitesofendometriosis

Themostcommonsites：uterosacralligamentrectouterinepouchovaryOthers：uterineserosafallopiantubesigmoidcolon(乙狀結腸)outsideofthepelvis:Umbilicus(臍),bladder,kidney子宮內膜異位癥Prevalencepresentin10%-15%ofwomeninreproductiveagegroup,especiallyfromage25to45normallynotseenbeforeage15oraftermenopauseearlyandmorechildbearinglateststudy:morefrequentmenses(cyclelength≤27days)andprolongedmenstrualflow(≥1week)2timesrisk子宮內膜異位癥

Pathogenesis

Theoriesofsourcesofectopicendometrium

Endometrialimplantingtheory(種植學說)

——Sampson1921

endometrium

transfer→implant→grow⒈retrogrademenstruation(經血逆流)theory⒉transportbylymphandvein⒊iatrogenic(醫(yī)源性的)implantation子宮內膜異位癥PathogenesisTheoriesofsourceofectopicendometrium

metaplasiatheory(化生學說)inducementtheory（誘導學說）子宮內膜異位癥

Pathogenesis

FactorsrelatedwithendometriosisGeneticAbnormalities：highriskinfirst-degreerelatives

ImmunologicFactors:increasedconcentrationsofwhitebloodcells,cytokines,andgrowthfactors——IL-6、IL-8、TNF-α、MCP-1

inflammation:EMslesions→chronicpelvicinflammation

子宮內膜異位癥Pathologyectopicendometrium↓hemorrhage↓proliferationoffibroustissue＆adhesions↓darkblueordarkbrownspots↓scarringnodulesorcysts子宮內膜異位癥Grossappearance:ovarianendometriosis

red,blue,orbrownspotsendometriomas——chocolatecysts子宮內膜異位癥Grossappearance:peritonealendometriosiscommonsites：uterosacralligament、rectouterinepouch

purplespotsdarkbrownspotsredlesionswhitelesionsperitoneumlack子宮內膜異位癥peritonealendometriosis子宮內膜異位癥peritonealendometriosis子宮內膜異位癥cervixumbilicus(臍)

子宮內膜異位癥Themicroscopicfindings

：endometrialglandsendometrialstromafibrinredbloodcellsandhemosiderin（含鐵血黃素）≥2findingstobediagnosed子宮內膜異位癥ClinicalFindings

symptoms：dysmenorrhoea（痛經）

andchronicpelvicpainthemosttypicalsymptom：secondarydysmenorrheathatworsensovertime

dyspareunia（性交痛）abnormaluterinebleeding

heavymenses,prolongedmenstruationorpremenstrualspottinginfertility：40%ofpatients

acuteabdomen:inter-cysthemorrhage(囊內出血),orrupture子宮內膜異位癥ClinicalFindingssymptoms：

others：diarrhoea（腹瀉）constipation（便秘）bloodystoolpainfulurinationbloodyurinebackache子宮內膜異位癥Causesofinfertility1)Mechanicalreason2)Environmentalchangeintheperitonealcavity3)Abnormalimmunefunction4)Abnormalovarianfunction(anovulation,LPD,Lufs)5)Increaseinspontaneousabortion子宮內膜異位癥ClinicalFindingsPelvicExamination：fixedretroverteduterinetendernodulesonuterosacralligamentorrectouterinepouchtenderandfixedadnexalmasses

子宮內膜異位癥Diagnosishistorypelvicexaminationlaparoscopy——goldendiagnosisstandard

diagnosis,classification＆treatmentultrasound,(CTandMRI,expensive)serumCA125↑butusually＜100IU/ml

anti-endometriumantibody

子宮內膜異位癥DiagnosisClinicalclassificationRevisedAmericanFertilitySociety(r-AFS),1985Usefulfor:

AssessmentofseveritySelectionoftherapeuticregimenComparisonPrognosis子宮內膜異位癥r-AFS子宮內膜異位癥DifferentialDiagnosis

Ovariantumor

ascites（腹水）,solidormixed,Bultrasoundimage,CA-125>100IU/ml

Abdominalinflammatorymass

historyofinfection,fever,notcyclic,treatmentwithantibioticseffectivelyAdenomyosis(子宮腺肌病)

medial,severepain,uterusslightlyenlarged子宮內膜異位癥TreatmentPrinciplesoftreatment：Treatmentshouldbeindividualizedaccordingtotheage,severityoftheconditionanddesireforchildbearing.Withmildsymptom:

expectanttherapyWithchildbearingdesire:mild-condition:medicationsevere-condition:fertilitypreservationsurgeryNochildbearingdesire:

Surgicaltreatment:ovarypreservationorradicalsurgery子宮內膜異位癥TreatmentExpectantTherapy

Follow-upsymptomsmanagement：NSAIDs（非甾體類抗炎藥）

子宮內膜異位癥TreatmentMedicationObjective:causeatrophicchangesintheectopicendometrium（使異位內膜萎縮）子宮內膜異位癥MedicationPseudopregnancytherapy⒈oralcontraceptives：apilloncedailyfor6-12m⒉progestins：medroxyprogesterone（醋酸甲孕酮）30mgdailymegestrol（甲地孕酮）40mgdailynorethindrone（炔諾酮）5mgdaily

Sideeffects:Intermittentbreakthroughbleeding,nausea,breasttenderness,fluidretention,weightgain子宮內膜異位癥MedicationPseudomenopausetherapy⒈GnRH-aMechanism:Medicalhypophysectomy(藥物性垂體切除)/Medicaloophorectomy(藥物性卵巢切除)leuprorelin（亮丙瑞林，抑那通）3.75mggoserelin（戈舍瑞林，諾雷德）3.6mgtryptorelin（曲普瑞林，達菲林）3.75mg

m/H,1inj/q28d,startd1子宮內膜異位癥Medication⒈GnRH-aSideeffects:(1)Menopausalsymptoms:hotflashes,drynessinvagina,lossoflibido(性欲)(2)Osteoporosis子宮內膜異位癥MedicationPseudomenopausetherapy⒉DanazolAderivativeof17-α-ethinyltestosterone（17-α乙炔睪酮衍生物）

Mechanism:Directlysuppressingovariansteroidogenesis（甾體激素生成）Directinhibitingthegrowthofendometrium

400-600mg/dfor6months子宮內膜異位癥Medication⒉DanazolSideeffects:acne,deepeningofthevoice,oilyskin,headache,hotflashes,lossoflibido,weightgain子宮內膜異位癥Medicationothers：gestrinone（孕三烯酮）mifepristone（米非司酮）子宮內膜異位癥Surgicaltreatment

Purposes：⑴diagnosisandclassification⑵exciseordestroyallendometriotictissue⑶removealladhesions,restorepelvicanatomy⑷enhancefecundity⑸relievepain子宮內膜異位癥Surgicaltreatmentlaparoscopy+medicine

goldenstandardoftreatment子宮內膜異位癥Surgicaltreatment

Modesofsurgicaloperation:(1)Fertilitypreservation(2)Ovarianfunctionpreservation(3)Radicalsurgery(4)Surgeryforpainrelief子宮內膜異位癥Treatment

Combinationofmedicationandsurgerysurgery+medicationmedication+surgery+medicationTreatmentforpatientswithinfertility子宮內膜異位癥PreventionPreventretrogradeflowofmensesContraceptionwithmedicineAvoidiatrogenic(醫(yī)源性)implantationoftheectopicendometrium子宮內膜異位癥

Adenomyosis

子宮內膜異位癥Definition

Adenomyosisisdefinedbythepresenceofendometrialglandsandstromawithinthe