Endometriosis & Adenomyosis

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Endometriosis Adenomyosis
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Endometriosis
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• Definition
• Abnormal growth of endometrial
• tissue outside the uterine cavity.

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Incidence and Prevalence

• Increase significantly
• Range from 1 50
• General population1 2
• Infertile women30 50
• Occurs primarily in women in 25 45s

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Pathogenesis

• Implantation Theory
• Retrograde Menustration Theory
• Sampson,1921
• Lymphatic and Vascular Dissemination Theory
• Javert,1952
• Coelomic Theory
• Meyer
• Genetic Theory
• Immune System Dysfunction(immunologic theory)

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Genetic factors

• Familial clustering of endometriosis is a common
  clinical observation.
• In families with endometriosis,the disease is
  often confined to the maternal line,and is 7
  times more common in first-degree relatives than
  in the general population.
• In future studies,evaluation of DNA polymorphism
  may identify specific genes involved in the
  development of endometriosis.

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Immunologic Theory

• Lose control of immunologic balance
• Both cellular immunity and humoral immunity
  change.
• Macrophage? release IL1?IL6?TNF?EGF?FGF
  etc. stimulate T?B lymphocyte proliferation
  and activation
• Activity of killer cell(NK cell and T cell)?
• Produce antiendometrium antibody
• Abnormal expression of CAMs(cell adhesion
  molecules)

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• The pathogenesis is unclear.
• multifactor

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Pathology macroscopic appearance(1)

• The commonest sites
• Ovary(chocolate cyst)
• Peritoneum of the rectovaginal culdesac of the
  Pouch of Douglas
• Uterosacral ligaments
• Sigmoid colon
• Broad ligament

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• This is a section through an enlarnged
  12 cm ovary to demonstrate a cystic cavity
  filled with old blood typical for endometriosis
  with formation of an endometriotic, or
  "chocolate", cyst.

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Pathology macroscopic appearance (2)

• Less common sites
• Cervix
• Round ligament
• Urinary system(bladder?ureter)
• Umbilicus
• Appendix
• Laparotomy scars

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Multiple appearances of endometriosis implants

• Brownish,discolored peritoneum
• Superficial peritoneal ecchymosis
• Raised,reddish,superficial nodules
• Reddishblue invasive nodules
• Fibrotic,whitish nodules
• Raised,glossy,translucent blobs
• Patchy,white opacified peritoneum
• Reddish or bluish ovarian cysts

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• Grossly, in areas of endometriosis the blood
  is darker and gives the small foci of
  endometriosis the gross appearance of "powder
  burns". Small foci are seen here just under the
  serosa of the posterior uterus in the pouch of
  Douglas. Such areas of endometriosis can be seen
  and obliterated by cauterization via laparoscopy.

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• Upon closer view, these five small areas of
  endometriosis have a reddish-brown to bluish
  appearance.

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Pathology microscopic appearance

• Histomorphologically similar to eutopic
  endometrium
• Four major components
• endometrial glands
• endometrial stroma
• fibrosis
• hemorrhage

Ectopic endometrium ??????
Eutopic endometrium ??????
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Clinical Manifestation
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Symptoms

• Pain
• progressive dysmenorrhea
• dyspareunia
• painful defecation
• Menstrual disturbance
• infertility

dysmenorrhea ??
dyspareunia ???
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Signs

• Enlargement of the ovaries,fixed
• Fixed retroversion of the uterus
• Tender nodules within the pelvis
• Cannot be diagnosed by PV alone.
• Should always be considered when patients have
  symptoms referable to the pelvic cavity.

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• Very variable
• Vary with the focus location
• Often bear no relation to the extent of the
  disease
• Quite often deposits are found incidentally in
  women who have no symptoms.
• (25 have no symptoms)

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Diagnosis

• History
• PV examination
• Laparoscopy(golden standard)
• Ultrasonography(Btype ultrasound)
• CA125? (lt 200U/mlnormal value 35U/ml)
• Antiendometrium antibody()

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Staging systems

• In the AFS-r(1985)staging system,points are
  assigned for severity of endometriosis based on
  the size and depth of the implant and for the
  severity of adhesions.
• The points are summed and the patients are
  assigned to one to four stages
• Stage I minimal disease, 15 points
• Stage II mild disease, 615 points
• Stage III moderate disease,1640 points
• Stage IV severe disease, 40 points

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Differential diagnosis

• Malignant ovary tumours
• Pelvic inflammatory masses
• Adenomyosis

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Treatment
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Expectant therapy

• Indicationswith very limited disease
• (whose symptoms are minimal or nonexistent)
• If trying to get pregnant,the best way is to
  accept laparoscopic therapy as early as possible.

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Medical therapy

• Indicationschronic pelvic pain
• severe dysmenorrhea
• no require to get
  pregnant
• no ovarian cyst
  formation
• Hormoneinhibition therapy

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Drugs

• Danazolpseudomenopause therapy
• Gestrinone
• GnRH amedical oophorectomy
• add back therapy
• Mifepristone RU486
• Progestogenspseudopregnancy therapy

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Surgical therapy(1)

• Indications(1)adnexal mass
• (2)pelvic pain
• (3)infertility
• Approaches
• (1) trans abdominal
• (2) laparoscopic

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Surgical therapy(2)

• Methods
• Conservative surgery
• preserve the fecundity
• preserve the ovarian function
• Definitive surgery
• hysterectomy salpingooophorectomy

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Combination medicalsurgical treatment

• Threestep

surgery
medical therapy
second look(laparoscopy)
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• It is important to individualize the choice of
  therapy.
• Therapy must be tailored to
• the degree of symptomatology
• the patients age
• her desire to maintain fertility

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Prognosis

• With proper treatment,the prognosis is good for
  relief of pain and enhancement of fertility in
  mild to moderate endometriosis.
• In most cases,hormonal therapy is temporarily
  effective in controlling symptoms and arresting
  growth but is generally less effective than
  surgery in increasing fertility.
• The recurrent rate is very high.

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Prevention

• Avoid possible augmentation of menstrual reflux.
• Taking oral contraceptive is recommended.
• Isolation and irrigation of the operative site.

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Critical points(1)

• The pathogenesis is poorly understood,but
  emerging evidence supports the causative role of
  retrograde menstruation and implantation of
  endometrial tissue.
• Endometriosis is a common in women with pelvic
  pain or infertility.
• Laparoscopy is the optimal technique to diagnose
  pelvic endometriosis.

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Critical points(2)

• In most cases,surgical therapy at the time of
  initial diagnosis effectively relieves pain and
  may enhance fertility.
• Alternatively,medical therapy with
  progestins?danazol?gestrinone or GnRH-a will
  ameliorate pelvic pain,but they do not enhance
  fertility.
• Endometriosis is a recurrent disease,and
  definitive treatment with removal of pelvic
  organs may be necessary.

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Adenomyosis
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Definition

• A benign uterine condition in which
  endometrial glands and stroma are found deep in
  the myometrium.

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Etiology

• Basal endometrial hyperplasia invading a
  hyperplastic myometrial stroma.
• Four primary theories
• Heredity
• Trauma
• Hyperestrogenemia
• Viral transmission

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Pathology gross appearance

• Usually hyperemic with thickened walls
• The foci are frequently scattered diffusely
  throughout the myometrium.
• Occasionally,may be more circumscribed,with the
  formation of a distinct nodule,an adenomyoma.

Adenomyosis ?????
Adenomyoma ?????
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• The thickened and spongy appearing
  myometrial wall of this sectioned uterus is
  typical of adenomyosis. There is also a small
  white leiomyoma at the lower left.

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Clinical features(1)

• Symptomatic adenomyosis occurs primarily in
  parous women over the age of 40 .
• (30 50)
• Classic symptoms
• secondary dysmenorrhea
• abnormal uterine bleeding

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Clinical features(2)

• Most common physical sign
• a diffusely enlarged uterus ,
• (rarely exceeds 12 weeks gestation in
  size)
• particularly tender during menstruation

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Diagnosis

• History
• Pelvic examinations
• Ultrasonography
• Serum markersCA-125?

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Treatment

• Hormone therapy
• Hysterectomy,the only uniformly successful
  treatment for adenomyosis,is necessary.

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