Professional Documents
Culture Documents
2003-11-3
Endometriosis
2003-11-3
Definition:
Abnormal growth of endometrial tissue outside the uterine cavity.
2003-11-3
2003-11-3
Pathogenesis:
Implantation Theory Retrograde Menustration Theory Sampson1921 Lymphatic and Vascular Dissemination Theory Javert1952 Coelomic Theory Meyer Genetic Theory Immune System Dysfunctionimmunologic theory
2003-11-3 5
Genetic factors
Familial clustering of endometriosis is a common clinical observation. In families with endometriosisthe disease is often confined to the maternal lineand is 7 times more common in first-degree relatives than in the general population. In future studiesevaluation of DNA polymorphism may identify specific genes involved in the development of endometriosis.
2003-11-3 6
Immunologic Theory
1)
Lose control of immunologic balance Both cellular immunity and humoral immunity change.
Macrophage release IL1IL6TNFEGF FGF etc. stimulate TB lymphocyte proliferation and activation Activity of killer cellNK cell and T cell Produce antiendometrium antibody Abnormal expression of CAMscell adhesion molecules
7
2) 3) 4)
2003-11-3
multifactor
2003-11-3
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.
2003-11-3 10
2003-11-3
11
2003-11-3
2003-11-3
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.
2003-11-3 14
Upon closer view, these five small areas of endometriosis have a reddish-brown to bluish appearance.
2003-11-3 15
Clinical Manifestation
2003-11-3
17
Symptoms
Pain progressive dysmenorrhea dyspareunia painful defecation Menstrual disturbance infertility
2003-11-3
dysmenorrhea dyspareunia
18
Signs
Enlargement of the ovariesfixed 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.
2003-11-3 19
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
2003-11-3
20
Diagnosis
History PV examination Laparoscopygolden standard UltrasonographyBtype ultrasound CA125 200U/mlnormal value 35U/ml Antiendometrium antibody+
2003-11-3 21
Staging systems
In the AFS-r1985staging systempoints 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 disease1640 points Stage IV severe disease 40 points
2003-11-3 22
Differential diagnosis
Malignant ovary tumours
Pelvic inflammatory masses
Adenomyosis
2003-11-3
23
Treatment
2003-11-3
24
Expectant therapy
Indicationswith very limited disease
whose symptoms are minimal or nonexistent
If trying to get pregnantthe best way is to accept laparoscopic therapy as early as possible.
2003-11-3
25
Medical therapy
Indicationschronic pelvic pain severe dysmenorrhea no require to get pregnant no ovarian cyst formation
Hormoneinhibition therapy
2003-11-3
26
Drugs
Danazolpseudomenopause therapy Gestrinone GnRH amedical oophorectomy add back therapy Mifepristone RU486 Progestogenspseudopregnancy therapy
2003-11-3 27
Surgical therapy1
Indications1adnexal mass 2pelvic pain 3infertility Approaches (1) trans abdominal (2) laparoscopic
2003-11-3 28
Surgical therapy2
Methods Conservative surgery 1) preserve the fecundity 2) preserve the ovarian function Definitive surgery hysterectomy + salpingooophorectomy
2003-11-3 29
Combination
Threestep
medicalsurgical treatment
surgery
medical therapy
second looklaparoscopy
2003-11-3 30
Prognosis
With proper treatmentthe prognosis is good for relief of pain and enhancement of fertility in mild to moderate endometriosis. In most caseshormonal 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.
2003-11-3 32
Prevention
Avoid possible augmentation of menstrual reflux.
Taking oral contraceptive is recommended. Isolation and irrigation of the operative site.
2003-11-3
33
Critical points1
The pathogenesis is poorly understoodbut 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.
Critical points2
In most casessurgical therapy at the time of initial diagnosis effectively relieves pain and may enhance fertility. Alternativelymedical therapy with progestins danazolgestrinone or GnRH-a will ameliorate pelvic painbut they do not enhance fertility. Endometriosis is a recurrent diseaseand definitive treatment with removal of pelvic organs may be necessary.
2003-11-3 35
Adenomyosis
2003-11-3
36
Definition
A benign uterine condition in which endometrial glands and stroma are found deep in the myometrium.
2003-11-3
37
Etiology
Basal endometrial hyperplasia invading a hyperplastic myometrial stroma. Four primary theories Heredity Trauma Hyperestrogenemia Viral transmission
2003-11-3 38
Adenomyoma
39
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.
2003-11-3 40
Clinical features1
Symptomatic adenomyosis occurs primarily in parous women over the age of 40 . 30 50 Classic symptoms secondary dysmenorrhea abnormal uterine bleeding
2003-11-3
41
Clinical features2
Most common physical sign a diffusely enlarged uterus
(rarely exceeds 12 weeks gestation in size)
2003-11-3
42
Diagnosis
History Pelvic examinations Ultrasonography Serum markersCA-125
2003-11-3
43
Treatment
Hormone therapy Hysterectomythe only uniformly successful treatment for adenomyosis is necessary.
2003-11-3
44
2003-11-3
45