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Endometriosis

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Endometriosis Disease. 2009.5.5. Xiaoli Chen. Department of Obstetrics and Gynecology ... A condition in which the tissue that normally lines the uterus grows ... – PowerPoint PPT presentation

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Title: Endometriosis


1
Endometriosis Disease
Xiaoli Chen Department of Obstetrics and
Gynecology
2009.5.5
2
Endometriosis
  • Adenomyosis

3
Endometriosis
What is...?
  • 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.

4
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5
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6
Characteristics
  • Common in reproductive-age women
  • Estrogen dependence
  • Genetic disease
  • Immunologic disease
  • Inflammatory disease
  • Benign diseases, malignant behavior

7
Pathogenesis
8
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.

9
  • Pathology

10
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

11
Pathology Microscopic Examination
  • Endometrial tissue (glands and stroma)
  • Fibrin and red cell
  • Hemosiderin

12
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13
Clinical presentation
  • Symptoms
  • Dysmenorrhea (progressive)
  • Chronic pelvic pain
  • Dyspareunia
  • Pain caused by rupture of endometrioma
  • Infertility
  • Menstrual disturbance
  • Painful defecation

14
Clinical presentation
  • Signs
  • Fixed,retroverted uterus
  • Enlargement of the ovaries
  • Tender nodular uterosacral ligament

15
  • Diagnosis

16
Diagnosis
  • Medical history
  • Gynecological examination
  • Auxiliary examination
  • laparoscopy
  • Imaging
  • laboratory

17
Diagnosis Medical History
  • Menstruation
  • Reproduction
  • Family history
  • Operation history
  • Relationship of dysmenorrhea and gynecological
    operation

18
Diagnosis Gynecological Examination
  • Bimanual or trimanual examination
  • Uterus
  • Mass
  • Tenderness nodes

19
Diagnosis Laparoscopy
  • The best method for diagnosis
  • Diagnosis by direct inspect
  • Pathological confirmation needed
  • Treatment at the same time

20
Diagnosis Imaging
  • B-mode sonography
  • Sensitivity 97, specificity 96.
  • Mass location, size, content, blood supply, etc.

21
Diagnosis Imaging
  • CT or MRI
  • Provide additional and confirmatory information
  • More costly

22
Diagnosis Laboratory
  • CA125
  • Slightly elevated in moderate or severe patients.
  • Limited on sensitivity and specificity.
  • No single use for diagnosis.

23
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.

24
  • Differential Diagnosis

25
Differential Diagnosis
  • Diseases
  • Malignant tumor of ovary
  • Pelvic inflammatory mass
  • Adenomyosis
  • Aspects
  • History
  • Gyn Examintion
  • B-mode ultrasonography
  • Lab research

26
Treatment
  • Expectant therapy
  • Medical treatment
  • - Pseudomenopause therapy
  • - Danazol
  • - GnRH agonists
  • - Pseudopregnancy therapy
  • Surgical treatment

27
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

28
Pseudomenopause therapy- Danazol
  • Synthetic steroid
  • - 17a-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

29
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

30
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

31
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

32
Lifestyle
  • Exercise
  • Eating well and getting enough rest
  • Practicing relaxation techniques such as yoga and
    meditation

33
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

34
Adenomyosis
35
Basic Concepts
  • Definition of Adenomyosis
  • Presence of functioning endometrial glands and
    stroma in the myometrium.
  • Myometrial cells around become hypertrophy and
    hyperplasia compensatively

36
  • Pathogenesis

37
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.

38
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.

39
Pathogenesis
  • Induction Factors
  • Inheritance
  • Trauma (curettage / cesarean section )
  • Hyperestrogenemia
  • Virus infection

40
  • Pathology

41
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.

42
Pathology
  • Microscopic examination
  • Endometrial glands and stroma in the myometrium,
    scattered like islands.
  • Ectopic glands usually in proliferate phase.
  • Local secretory changes seen occasionally.

43
Symptoms and Signs
  • Hypermenorrhea 50
  • Dysmenorrhea 30
  • Symmetrically enlarged uterus
  • - Improved ultrasound preoperative diagnosis
  • - MRI negative/equivocal sonogram
  • presence of leiomyomas

44
Diagnosis
  • Primary diagnosis
  • Classic symptoms and signs.
  • B-mode ultrasonography and CT is helpful in
    diagnosis.
  • Confirmative diagnosis
  • Pathological examination.

45
Diagnosis
  • Differ from
  • Pregnancy pregnancy test, ultrasound
  • Submucous leiomyomas hysteroscopy
  • Endometrial cancer endometrial biopsy
  • Myoma ultrasound
  • Endometriosisultrasound

46
Complications and Prevention
  • Chronic severe anemia
  • Primary adenocarcinoma
  • ?Adenomyosis cant be prevented.

47
  • Treatment

48
Treatment Medication
  • No medication is radical
  • Mild symptoms
  • NSAID
  • Oral contraceptive pills
  • Young, pregnancy-desiring, close to menopause
  • Try GnRHa

49
Treatment Surgery
  • Suitable for patients with
  • Severe symptoms
  • Relatively old age
  • No desire for pregnancy
  • No effect by medication

50
Treatment Surgery
  • Methods
  • Total hysterectomy
  • Adenomyoma resection
  • Young with pregnancy desiring
  • Prone to recurrence
  • Laparoscopic uterosacral nerve ablation /
    Presacral neurectomy
  • Pain relief rate 80

51
Thank you
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