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Endometriosis

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Endometriosis & Adenomyosis Omar Al Omari, MRCOG Obstetrician & Gynaecologist Jordan Hospital Medical Center * * Critical points 1 The pathogenesis is poorly ... – PowerPoint PPT presentation

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Title: Endometriosis


1
Endometriosis Adenomyosis
  • Omar Al Omari, MRCOG
  • Obstetrician Gynaecologist
  • Jordan Hospital Medical Center

2
Endometriosis
3
  • Definition
  • Abnormal growth of endometrial
  • tissue outside the uterine cavity.

4
Incidence and Prevalence
  • Increased significantly
  • Range from 1 50
  • General population1 2
  • Infertile women30 50
  • Occurs primarily in women in 25 45s

5
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)

6
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.

7
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)

8
  • The pathogenesis is unclear.
  • multifactorial

9
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

10
  • 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.

11
(No Transcript)
12
Pathology macroscopic appearance (2)
  • Less common sites
  • Cervix
  • Round ligament
  • Urinary system(bladder?ureter)
  • Umbilicus
  • Appendix
  • Laparotomy scars

13
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

14
  • 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.

15
  • Upon closer view, these five small areas of
    endometriosis have a reddish-brown to bluish
    appearance.

16
Pathology microscopic appearance
  • Histomorphologically similar to eutopic
    endometrium
  • Four major components
  • endometrial glands
  • endometrial stroma
  • fibrosis
  • hemorrhage


17
Clinical Manifestation
18
Symptoms
  • Pain
  • progressive dysmenorrhea
  • dyspareunia
  • painful defecation
  • Menstrual disturbance
  • infertility

19
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.

20
  • 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)

21
Diagnosis
  • History
  • PV examination
  • Laparoscopy(golden standard)
  • Ultrasonography(Btype ultrasound)
  • CA125? (lt 200U/mlnormal value 35U/ml)
  • Antiendometrium antibody()

22
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

23
Differential diagnosis
  • Malignant ovary tumours
  • Pelvic inflammatory masses
  • Adenomyosis

24
Treatment
25
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.

26
Medical therapy
  • Indicationschronic pelvic pain
  • severe dysmenorrhea
  • no require to get
    pregnant
  • no ovarian cyst
    formation
  • Hormoneinhibition therapy

27
Drugs
  • Danazolpseudomenopause therapy
  • Gestrinone
  • GnRH amedical oophorectomy
  • add back therapy
  • Mifepristone RU486
  • Progestogenspseudopregnancy therapy

28
Surgical therapy(1)
  • Indications(1)adnexal mass
  • (2)pelvic pain
  • (3)infertility
  • Approaches
  • (1) trans abdominal
  • (2) laparoscopic

29
Surgical therapy(2)
  • Methods
  • Conservative surgery
  • preserve the fecundity
  • preserve the ovarian function
  • Definitive surgery
  • hysterectomy salpingooophorectomy

30
Combination medicalsurgical treatment
  • Threestep

surgery
medical therapy
second look(laparoscopy)
31
  • 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

32
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.

33
Prevention
  • Avoid possible augmentation of menstrual reflux.
  • Taking oral contraceptive is recommended.
  • Isolation and irrigation of the operative site.

34
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.

35
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.

36
Adenomyosis
37
Definition
  • A benign uterine condition in which
    endometrial glands and stroma are found deep in
    the myometrium.

38
Etiology
  • Basal endometrial hyperplasia invading a
    hyperplastic myometrial stroma.
  • Four primary theories
  • Heredity
  • Trauma
  • Hyperestrogenemia
  • Viral transmission

39
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.

40
  • 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.

41
Clinical features(1)
  • Symptomatic adenomyosis occurs primarily in
    parous women over the age of 40 .
  • (30 50)
  • Classic symptoms
  • secondary dysmenorrhea
  • abnormal uterine bleeding

42
Clinical features(2)
  • Most common physical sign
  • a diffusely enlarged uterus ,
  • (rarely exceeds 12 weeks gestation in
    size)
  • particularly tender during menstruation

43
Diagnosis
  • History
  • Pelvic examinations
  • Ultrasonography
  • Serum markersCA-125?

44
Treatment
  • Hormone therapy
  • Hysterectomy,the only uniformly successful
    treatment for adenomyosis,is necessary.

45
  • Thank You
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