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 population:1～ 2%
Infertile women:30～ 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.
1)
Macrophage↑ release IL–1、IL–6、TNF、EGF、
FGF etc.
stimulate T、B lymphocyte proliferation
and activation
Activity of killer cell（NK cell and T cell）↓
Produce anti–endometrium antibody
Abnormal expression of CAMs（cell adhesion
molecules）
2)
3)
4)
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• The pathogenesis
is unclear.
• multifactor
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Pathology
– macroscopic appearance（1）：
• The commonest sites：
1. Ovary（chocolate cyst）
2. Peritoneum of the recto–vaginal cul–de–
sac of the Pouch of Douglas
3. Utero–sacral ligaments
4. Sigmoid colon
5. 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）：
•
1.
2.
3.
4.
5.
6.
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
Reddish–blue 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 Ectopic endometrium
endometrium Eutopic
在位子宫内膜
异位子宫内膜
• Four major components：
endometrial glands
endometrial stroma
fibrosis
hemorrhage
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Clinical Manifestation
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Symptoms：
• Pain
progressive dysmenorrhea
dyspareunia
painful defecation
• Menstrual disturbance
• infertility
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dysmenorrhea
痛经
dyspareunia
性交痛
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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（B–type ultrasound）
CA–125↑ （＜ 200U/ml；normal value
35U/ml）
• Anti–endometrium 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， 1～5 points
Stage II — mild disease，
6～15 points
Stage III — moderate disease，16～40 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：
•
Indications：with 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：
• Indications：chronic pelvic pain
severe dysmenorrhea
no require to get pregnant
no ovarian cyst formation
• Hormone–inhibition therapy
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Drugs：
• Danazol：pseudomenopause therapy
• Gestrinone
• GnRH – a：medical oophorectomy
add – back therapy
• Mifepristone RU486
• Progestogens：pseudopregnancy 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
1) preserve the fecundity
2) preserve the ovarian function
 Definitive surgery：
hysterectomy + salpingo–oophorectomy
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Combination
medical–surgical treatment：
Three–step：
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 patient’s 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
子宫肌腺症
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Adenomyoma
子宫肌腺瘤
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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 markers：CA-125↑
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Treatment：
• Hormone therapy
• Hysterectomy，the only uniformly
successful treatment for adenomyosis，
is necessary.
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