子宫内膜异位症Endometriosisppt课件

EndometriosisEndometriosisWomens Hospital,School of Medicine Zhejiang UniversityWomens Hospital,School of Medicine Zhejiang UniversityWomens Hospital,School of Medicine Zhejiang University Prof.Lin JunProf.Lin JunProf.Lin Jun子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜11 EndometriosisWDefinitionDefinition Endometriosis Endometriosis is usually defined as the is usually defined as the is usually defined as the presence of endometrial-like tissue,that is,presence of endometrial-like tissue,that is,presence of endometrial-like tissue,that is,glands and stroma,outside the endometrium glands and stroma,outside the endometrium glands and stroma,outside the endometrium in uterine cavity and myometrium.in uterine cavity and myometrium.in uterine cavity and myometrium.子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜22Definition 子宫内膜异位症EndometrioCommon sites of endometriosisCommon sites of endometriosisThe most common sitesThe most common sites：uterosacral ligamentuterosacral ligament rectouterine pouch rectouterine pouch ovaryovaryOthersOthers：uterine serosauterine serosa fallopian tubefallopian tube sigmoid colon(sigmoid colon(乙状结肠乙状结肠)outside of the pelvisoutside of the pelvis:Umbilicus(Umbilicus(脐脐),bladder,kidney),bladder,kidney子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜33Common sites of endometriosiPrevalencePrevalence present in 10%-15%of women in reproductive present in 10%-15%of women in reproductive age group,especially from age 25 to 45age group,especially from age 25 to 45 normally not seen before age 15 or after normally not seen before age 15 or after menopausemenopause early and more childbearingearly and more childbearing latest study:more frequent menses(cycle latest study:more frequent menses(cycle length 27 days)and prolonged menstrual length 27 days)and prolonged menstrual flow(1 week)2 times riskflow(1 week)2 times risk子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜44Prevalencepresent in 10%-15%o PathogenesisPathogenesis Theories of sources of ectopic endometriumTheories of sources of ectopic endometrium Endometrial implanting theory Endometrial implanting theory(种植学说种植学说种植学说种植学说)Sampson 1921Sampson 1921 endometrium endometrium transfer implant growtransfer implant grow retrograde menstruation(retrograde menstruation(经血逆流经血逆流)theory)theory transport by lymph and vein transport by lymph and vein iatrogenic iatrogenic(医源性的医源性的医源性的医源性的)implantation implantation子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜55 Pathogenesis Theories of sourPathogenesisPathogenesisTheories of source of ectopic endometriumTheories of source of ectopic endometrium metaplasia theory(metaplasia theory(化生学说化生学说)inducement theoryinducement theory（诱导学说）（诱导学说）子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜66PathogenesisTheories of sourc PathogenesisPathogenesis Factors related with endometriosisFactors related with endometriosis Genetic Abnormalities Genetic Abnormalities：high risk in first-degree relativeshigh risk in first-degree relatives Immunologic Factors:Immunologic Factors:increased concentrations of white increased concentrations of white blood cells,cytokines,and growth factors blood cells,cytokines,and growth factors IL-6 IL-6、IL-8IL-8、TNF-TNF-、MCP-1MCP-1 inflammation:inflammation:EMs lesions chronic pelvic inflammationEMs lesions chronic pelvic inflammation 子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜77 Pathogenesis Factors related Pathology Pathology ectopic endometrium ectopic endometrium hemorrhagehemorrhage proliferation of fibrous tissue proliferation of fibrous tissue adhesions adhesions dark blue or dark brown spots dark blue or dark brown spots scarring nodules or cysts scarring nodules or cysts 子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜88Pathology ectopic endometrium Gross appearance:Gross appearance:ovarian endometriosisovarian endometriosis red,blue,or brown spots red,blue,or brown spots endometriomas chocolate cysts endometriomas chocolate cysts子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜99Gross appearance:ovarian endoGross appearance:Gross appearance:peritoneal endometriosisperitoneal endometriosiscommon sitescommon sites：uterosacral ligament uterosacral ligament、rectouterine pouchrectouterine pouch uupurple spotspurple spotsuudark brown spotsdark brown spotsuured lesionsred lesionsuuwhite lesionswhite lesionsuuperitoneum lack peritoneum lack 子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜1010Gross appearance:peritoneal eperitoneal endometriosisperitoneal endometriosis子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜1111peritoneal endometriosis子宫内膜异位peritoneal endometriosisperitoneal endometriosis子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜1212peritoneal endometriosis子宫内膜异位cervix cervix umbilicusumbilicus(脐脐)子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜1313cervix umbilicus(脐)子宫内膜异位症EndoThe microscopic findingsThe microscopic findings ：endometrial glands endometrial glands endometrial stroma endometrial stroma fibrinfibrin red blood cells and hemosiderinred blood cells and hemosiderin（含铁血黄素）（含铁血黄素）2 findings to be diagnosed2 findings to be diagnosed子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜1414The microscopic findings：子宫内膜Clinical FindingsClinical Findings symptomssymptoms：dysmenorrhoeadysmenorrhoea（痛经）（痛经）（痛经）（痛经）and and chronic pelvic pain chronic pelvic pain the most typical symptomthe most typical symptom：secondary dysmenorrhea that worsens secondary dysmenorrhea that worsens over timeover time dyspareuniadyspareunia（性交痛）（性交痛）（性交痛）（性交痛）abnormal uterine bleeding abnormal uterine bleeding heavy menses,prolonged menstruation or premenstrual spotting heavy menses,prolonged menstruation or premenstrual spotting infertilityinfertility：40%of patients40%of patients acute abdomen:acute abdomen:inter-cyst hemorrhage(inter-cyst hemorrhage(囊内出血囊内出血),or rupture),or rupture子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜1515Clinical Findings symptoms：子宫内Clinical FindingsClinical Findingssymptomssymptoms：othersothers：diarrhoeadiarrhoea（腹泻）（腹泻）constipationconstipation（便秘）（便秘）bloody stool bloody stool painful urination painful urination bloody urine bloody urine backachebackache子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜1616Clinical Findingssymptoms：diarCauses of infertilityCauses of infertility1)Mechanical reason1)Mechanical reason2)Environmental change in the peritoneal cavity2)Environmental change in the peritoneal cavity3)Abnormal immune function3)Abnormal immune function4)Abnormal ovarian function 4)Abnormal ovarian function(anovulation,LPD,Lufs)(anovulation,LPD,Lufs)5)Increase in spontaneous abortion5)Increase in spontaneous abortion子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜1717Causes of infertility1)MechanClinical FindingsClinical FindingsP Pelvic Examinationelvic Examination：fixed retroverted uterinefixed retroverted uterine tender nodules on uterosacral ligament or tender nodules on uterosacral ligament or rectouterine pouch rectouterine pouch tender and fixed adnexal masses tender and fixed adnexal masses 子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜1818Clinical FindingsPelvic ExaminDiagnosis Diagnosis historyhistory pelvic examinationpelvic examination laparoscopy golden diagnosis standardlaparoscopy golden diagnosis standard diagnosis,classification diagnosis,classification treatmenttreatment ultrasound,(ultrasound,(CT and MRI,expensive)CT and MRI,expensive)serum CA125 serum CA125 but usually but usually 100IU/ml100IU/ml anti-endometrium antibody anti-endometrium antibody 子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜1919Diagnosis history子宫内膜异位症EndomeDiagnosisDiagnosisClinical classificationClinical classificationRevised American Fertility Society(r-AFS),1985Revised American Fertility Society(r-AFS),1985Useful for:Useful for:Assessment of severityAssessment of severity Selection of therapeutic regimen Selection of therapeutic regimen Comparison Comparison Prognosis Prognosis子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜2020DiagnosisClinical classificatir-AFSr-AFS子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜2121r-AFS子宫内膜异位症Endometriosis张喜21Differential DiagnosisDifferential Diagnosis Ovarian tumorOvarian tumor ascitesascites（腹水）（腹水）（腹水）（腹水）,solid or mixed,B ultrasound image,solid or mixed,B ultrasound image,CA-125100 IU/mlCA-125100 IU/ml Abdominal inflammatory massAbdominal inflammatory mass history of infection,fever,not cyclic,treatment with history of infection,fever,not cyclic,treatment with antibiotics effectivelyantibiotics effectively Adenomyosis Adenomyosis(子宫腺肌病子宫腺肌病子宫腺肌病子宫腺肌病)medial,severe pain,uterus slightly enlargedmedial,severe pain,uterus slightly enlarged子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜2222Differential Diagnosis OvarianTreatment Treatment Principles of treatmentPrinciples of treatment：Treatment should be individualized according to the age,Treatment should be individualized according to the age,severity of the condition and desire for childbearing.severity of the condition and desire for childbearing.With mild symptom:With mild symptom:expectant therapyexpectant therapy With childbearing desire:With childbearing desire:mild-condition:mild-condition:medicationmedication severe-condition:severe-condition:fertility preservation surgeryfertility preservation surgery No childbearing desire:No childbearing desire:Surgical treatment:ovary preservation or radical surgerySurgical treatment:ovary preservation or radical surgery子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜2323Treatment Principles of treatmTreatmentTreatmentExpectant TherapyExpectant Therapy Follow-upFollow-up symptoms managementsymptoms management：NSAIDsNSAIDs（非甾体类抗炎药）（非甾体类抗炎药）（非甾体类抗炎药）（非甾体类抗炎药）子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜2424TreatmentExpectant Therapy 子宫内TreatmentTreatmentMedicationMedicationObjective:Objective:cause atrophic changes in the ectopic endometriumcause atrophic changes in the ectopic endometrium（使异位内膜萎缩）（使异位内膜萎缩）（使异位内膜萎缩）（使异位内膜萎缩）子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜2525TreatmentMedication子宫内膜异位症EndoMedicationMedicationPseudopregnancy therapyPseudopregnancy therapy oral contraceptives oral contraceptives：a pill once daily for 6-12 ma pill once daily for 6-12 m progestins progestins：medroxyprogesterone medroxyprogesterone（醋酸甲孕酮）（醋酸甲孕酮）（醋酸甲孕酮）（醋酸甲孕酮）30mg daily30mg daily megestrol megestrol（甲地孕酮）（甲地孕酮）（甲地孕酮）（甲地孕酮）40mg daily 40mg daily norethindrone norethindrone（炔诺酮）（炔诺酮）（炔诺酮）（炔诺酮）5mg daily 5mg daily Side effects:Side effects:Intermittent breakthrough bleeding,nausea,breast Intermittent breakthrough bleeding,nausea,breast tenderness,fluid retention,weight gaintenderness,fluid retention,weight gain子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜2626MedicationPseudopregnancy therMedicationMedicationPseudomenopause therapyPseudomenopause therapyGnRH-a GnRH-a Mechanism:Mechanism:Medical hypophysectomy(Medical hypophysectomy(药物性垂体切除药物性垂体切除)/Medical oophorectomy(/Medical oophorectomy(药物性卵巢切除药物性卵巢切除)leuprorelin leuprorelin（亮丙瑞林，抑那通）（亮丙瑞林，抑那通）（亮丙瑞林，抑那通）（亮丙瑞林，抑那通）3.75mg3.75mg goserelin goserelin（戈舍瑞林，诺雷德）（戈舍瑞林，诺雷德）（戈舍瑞林，诺雷德）（戈舍瑞林，诺雷德）3.6mg3.6mg tryptorelin tryptorelin（曲普瑞林，达菲林）（曲普瑞林，达菲林）（曲普瑞林，达菲林）（曲普瑞林，达菲林）3.75mg 3.75mg m/H,1 inj/q28d,start d1 m/H,1 inj/q28d,start d1 子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜2727MedicationPseudomenopause therMedicationMedicationGnRH-a GnRH-a Side effects:Side effects:(1)Menopausal symptoms:(1)Menopausal symptoms:hot flashes,dryness in vagina,loss of libido(hot flashes,dryness in vagina,loss of libido(性欲性欲性欲性欲)(2)Osteoporosis (2)Osteoporosis子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜2828MedicationGnRH-a 子宫内膜异位症EndomMedicationMedicationPseudomenopause therapyPseudomenopause therapy Danazol Danazol A derivative of 17-ethinyltestosterone A derivative of 17-ethinyltestosterone（17-17-乙炔睾酮衍生物）乙炔睾酮衍生物）乙炔睾酮衍生物）乙炔睾酮衍生物）Mechanism:Mechanism:Directly suppressing ovarian steroidogenesis Directly suppressing ovarian steroidogenesis（甾体激素生成）（甾体激素生成）Direct inhibiting the growth of endometriumDirect inhibiting the growth of endometrium 400-600 mg/d for 6 months400-600 mg/d for 6 months子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜2929MedicationPseudomenopause therMedicationMedication Danazol Danazol Side effects:Side effects:acne,deepening of the voice,oily skin,headache,acne,deepening of the voice,oily skin,headache,hot flashes,loss of libido,weight gainhot flashes,loss of libido,weight gain子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜3030Medication子宫内膜异位症EndometriosisMedicationMedicationothersothers：gestrinone gestrinone（孕三烯酮）（孕三烯酮）mifepristonemifepristone（米非司酮）（米非司酮）子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜3131Medicationothers：子宫内膜异位症EndomeSurgical treatmentSurgical treatmentPurposesPurposes：diagnosis and classification diagnosis and classification excise or destroy all endometriotic tissue excise or destroy all endometriotic tissue remove all adhesions,restore pelvic anatomy remove all adhesions,restore pelvic anatomy enhance fecundity enhance fecundity relieve pain relieve pain子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜3232Surgical treatmentPurposes：子宫Surgical treatmentSurgical treatmentlaparoscopy+medicinelaparoscopy+medicine golden standard of treatmentgolden standard of treatment子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜3333Surgical treatmentlaparoscopy Surgical treatmentSurgical treatmentModes of surgical operation:Modes of surgical operation:(1)Fertility preservation(1)Fertility preservation(2)Ovarian function preservation(2)Ovarian function preservation(3)Radical surgery(3)Radical surgery(4)Surgery for pain relief(4)Surgery for pain relief子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜3434Surgical treatmentModes of suTreatmentTreatment Combination of medication and surgery Combination of medication and surgery surgery+medication surgery+medication surgery+medication medication+surgery+medicationmedication+surgery+medicationmedication+surgery+medicationTreatment for patients with infertilityTreatment for patients with infertility子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜3535Treatment Combination of medicPreventionPrevention Prevent retrograde flow of mensesPrevent retrograde flow of menses Contraception with medicine Contraception with medicine Avoid iatrogenic(Avoid iatrogenic(医源性医源性医源性医源性)implantation of the)implantation of the ectopic endometriumectopic endometrium子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜3636PreventionPrevent retrograde f Adenomyosis Adenomyosis 子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜3737 子宫内膜异位症Endometriosis张DefinitionDefinition Adenomyosis is defined by the presence of Adenomyosis is defined by the presence of endometrial glands and stroma within the endometrial glands and stroma within the myometrium.It is associated with myometrial myometrium.It is associated with myometrial hypertrophy and proliferation.hypertrophy and proliferation.子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜3838Definition子宫内膜异位症EndometriosisEndometriosis Endometriosis Adenomyosis Adenomyosis Pathogenesis Pathogenesis histological histological confirmation confirmation Sites of lesionsSites of lesions Clinical findingsClinical findingsAdenomyosis is thought to be unrelated to endometriosisAdenomyosis is thought to be unrelated to endometriosisAdenomyosis is thought to be unrelated to endometriosis.子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜3939Endometriosis AdenomyosisAdeClinical findingsClinical findingsMultiparasMultiparas（4040 y y）were most commonly affected.were most commonly affected.SymptomsSymptoms：prolonged and heavy menses prolonged and heavy menses DysmenorrheaDysmenorrhea that worsens over timethat worsens over timePelvic examPelvic exam：enlargement of uterusenlargement of uterus tendernesstenderness子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜4040Clinical findingsMultiparas（4DiagnosisDiagnosis Typical symptoms and signsTypical symptoms and signsTypical symptoms and signs Histopathologic examination Histopathologic examination Histopathologic examination standard of the diagnosis standard of the diagnosis standard of the diagnosis B ultrasound would suggest the disease.B ultrasound would suggest the disease.B ultrasound would suggest the disease.子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜4141Diagnosis子宫内膜异位症Endometriosis张TreatmentTreatment1.Medication 1.Medication：GnRH-aGnRH-a2.Surgical treatment:2.Surgical treatment:total hysterectomytotal hysterectomy 子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜4242Treatment1.Medication：GnRH-aThank you!Thank you!Thank you!Thank you!子宫内膜异位症子宫内膜异位症EndometriosisEndometriosis张喜张喜4343Thank you!子宫内膜异位症Endometriosi