Transcript Endometriosis Disease Xiaoli Chen Department of Obstetrics and Gynecology 2009.5.5 Endometriosis Adenomyosis Endometriosis • A condition in which the tissue that normally lines the uterus grows in other.

Endometriosis
Disease
Xiaoli Chen
Department of Obstetrics and
Gynecology
2009.5.5
Endometriosis
Adenomyosis
Endometriosis
• A condition in which the tissue that normally
lines the uterus grows in other areas of the
body, causing pain, irregular bleeding, and
frequently infertility.
Characteristics
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Common in reproductive-age women
Estrogen dependence
Genetic disease
Immunologic disease
Inflammatory disease
Benign diseases, malignant behavior
Pathogenesis
Pathogenesis
• Not clear.
• 4 theories proposed:
- Retrograde menstruation theory
- Coelomic metaplasia theory
- Lymphatic or vascular dissemination theory
- Immunology theory
• No single theory can account for the
location of endometriosis in all cases.
Pathology
Pathology: Classification of Common
Pelvic Endometriosis
• Ovarian endometriosis
– Minimal: superficial minimal
– Classic: cyst
• Peritoneal endometriosis
– Pigmentation: classic indigo or
brown ectopic tubercles。
– Non-pigmentation ：early focus
Pathology: Microscopic Examination
• Endometrial tissue (glands and stroma)
• Fibrin and red cell
• Hemosiderin
Clinical presentation
• Symptoms
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Dysmenorrhea (progressive)
Chronic pelvic pain
Dyspareunia
Pain caused by rupture of endometrioma
Infertility
Menstrual disturbance
Painful defecation
Clinical presentation
• Signs
• Fixed,retroverted uterus
• Enlargement of the ovaries
• Tender nodular uterosacral ligament
Diagnosis
Diagnosis
• Medical history
• Gynecological examination
• Auxiliary examination
– laparoscopy
– Imaging
– laboratory
Diagnosis: Medical History
• Menstruation
• Reproduction
• Family history
• Operation history
• Relationship of dysmenorrhea and
gynecological operation
Diagnosis: Gynecological Examination
• Bimanual or trimanual examination
– Uterus
– Mass
– Tenderness nodes
Diagnosis: Laparoscopy
• The best method for diagnosis
• Diagnosis by direct inspect
• Pathological confirmation needed
• Treatment at the same time
Diagnosis: Imaging
• B-mode sonography
– Sensitivity 97％, specificity 96％.
– Mass: location, size, content, blood
supply, etc.
Diagnosis: Imaging
• CT or MRI
– Provide additional and confirmatory
information
– More costly
Diagnosis: Laboratory
• CA125
– Slightly elevated in moderate or severe
patients.
– Limited on sensitivity and specificity.
– No single use for diagnosis.
Diagnosis: Laboratory
• Anti-endometrium antibody
– Negative in most of normal women.
– Positive rate over 60％ in endometriosis
patients.
– Positive means active ectopic endometrium.
– Not popular used in clinic.
Differential
Diagnosis
Differential Diagnosis
• Diseases
– Malignant tumor of
ovary
– Pelvic inflammatory
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Aspects
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History
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Gyn Examintion
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B-mode
ultrasonography
mass
– Adenomyosis
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Lab research
Treatment
• Expectant therapy
• Medical treatment
- Pseudomenopause therapy
- Danazol
- GnRH agonists
- Pseudopregnancy therapy
• Surgical treatment
Medical Oophorectomy - GnRH agonists
• Mechanism:
- Desensitization of the pituitary
- Medical hypophysectomy →medical oophrectomy
• Drugs used:
- Leuprorelin 3.75mg/28 Days D5
- Goserelin/Zoladex 3.6mg/28 Days D5
- Triptorelin/Decapreptyl 3.75mg/28 Days
D5
• Side dffects:
- (1)Menopausal symptoms:
hot flashes, dryness in vagina, loss of libido
- (2)Osteoporosis
• Add-Back Therapy
Pseudomenopause therapy- Danazol
• Synthetic steroid
- 17α-ethinyltestosterone Derivative
• Mechanism:
- Directly suppressing ovarian steroidogenesis
- Direct inhibiting endometrial growth
• Doses:
- 400-800 mg/day for 6 months
• Side effects:
- Hypoestrogenic environment: decreased breast
size, atrophic vaginitis, hot flashes, emotional swings
- Virilism
Pseudopregnancy therapy- Progestogen
• Mechanism:
– Inhibition of uterine contraction
– Inhibition on growth of the endometrium
• Doses:
Medroxyprogesterone 20-50mg/day
6 months
• Side effects : weight, fluid retention,
breakthrough bleeding, depression
Surgery
· Diagnostic surgery
· no attempt to treat any of the endometriosis
· Very conservative surgery
· treatment of a very large, obvious, or treatable
area of endometriosis
· Aggressive surgery
· removes all the endo while preserving the organs
· maintains fertility
· Radical surgery
· removal of the reproductive organs
· hysterectomy
Treatment -- infertility
• Minimal disease - pregnancy rate without
treatment after 5 years is 90%
• severe disease - proceed to laparoscopy
• woman over 35 yrs old - proceed with
treatment
• Medical therapy is of limited value
• Assisted reproduction
Lifestyle
• Exercise
• Eating well and getting enough rest
• Practicing relaxation techniques such
as yoga and meditation
Recurrences
• May recur with medical therapy or
surgical therapy
• GnRH agonists or Danazol
- Minimal disease – 37%,
- severe disease – 74%
• Surgery – 40% after 5 years
• 56% of all patients after 7 years
Adenomyosis
Basic Concepts
• Definition of Adenomyosis:
– Presence of functioning endometrial
glands and stroma in the myometrium.
• Myometrial cells around become
hypertrophy and hyperplasia
compensatively
Pathogenesis
Pathogenesis
• The pathogenesis is not known.
• Propose by Cullen in 1908, the theory
of direct growth of the basal layer
of endometrium into the myometrium
is widely accepted.
Pathogenesis
• Estrogen has been implicated as a stimulus to
the development of adenomyosis.
• The symptomatic improvement that occurs
with the onset of menopause supports this
concept.
Pathogenesis
• Induction Factors
– Inheritance
– Trauma (curettage / cesarean section )
– Hyperestrogenemia
– Virus infection
Pathology
Pathology
• Macroanatomy
– Uterus enlarges uniformly, like a ball.
– Usually not bigger than 12 weeks of
gestation.
– Thick muscle fiber and micro vesicle
seen in myomerium.
– Some grew like myoma, called
adenomyoma.
Pathology
• Microscopic examination
– Endometrial glands and stroma in the
myometrium, scattered like islands.
– Ectopic glands usually in proliferate
phase.
– Local secretory changes seen
occasionally.
Symptoms and Signs
• Hypermenorrhea 50%
• Dysmenorrhea
30%
• Symmetrically enlarged uterus
- Improved ultrasound: preoperative diagnosis
- MRI: negative/equivocal sonogram
presence of leiomyomas
Diagnosis
• Primary diagnosis
– Classic symptoms and signs.
– B-mode ultrasonography and CT is
helpful in diagnosis.
• Confirmative diagnosis
– Pathological examination.
Diagnosis
Differ from
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Pregnancy: pregnancy test, ultrasound
Submucous leiomyomas: hysteroscopy
Endometrial cancer: endometrial biopsy
Myoma: ultrasound
Endometriosis:ultrasound
Complications and
Prevention
• Chronic severe anemia
• Primary adenocarcinoma
★Adenomyosis can’t be prevented.
Treatment
Treatment: Medication
• No medication is radical
• Mild symptoms
– NSAID
– Oral contraceptive pills
• Young, pregnancy-desiring, close to
menopause
– Try GnRHa
Treatment: Surgery
• Suitable for patients with：
– Severe symptoms
– Relatively old age
– No desire for pregnancy
– No effect by medication
Treatment: Surgery
• Methods
– Total hysterectomy
– Adenomyoma resection
• Young with pregnancy desiring
• Prone to recurrence
– Laparoscopic uterosacral nerve
ablation / Presacral neurectomy
• Pain relief rate: 80％