Endometriosis

Definition:

Abnormal growth of endometrial tissue outside the uterine cavity.

Incidence and Prevalence:

Increase significantly
Range from 1～ 50%
General population:1～ 2%
Infertile women:30～ 50%
Occurs primarily in women in 25～ 45s

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）

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.


Immunologic Theory：

Lose control of immunologic balance
Both cellular immunity and humoral immunity change.
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）

The pathogenesis is unclear.

multifactor

Pathology :

1- macroscopic appearance :

The commonest sites：
Ovary（chocolate cyst）
Peritoneum of the recto–vaginal cul–de–sac of the Pouch of Douglas
Utero–sacral ligaments
Sigmoid colon
Broad ligament


2- macroscopic appearance :

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


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


Pathology – microscopic appearance :

Histomorphologically similar to eutopic endometrium

Four major components：
endometrial glands
endometrial stroma
fibrosis
hemorrhage
Clinical Manifestation :

Symptoms：

Pain
progressive dysmenorrhea
dyspareunia
painful defecation
Menstrual disturbance
infertility

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.
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）

Diagnosis：

History
PV examination
Laparoscopy（golden standard）
Ultrasonography（B–type ultrasound）
CA–125↑ （＜ 200U/ml；normal value 35U/ml）
Anti–endometrium antibody（+）

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


Differential diagnosis：

Malignant ovary tumours

Pelvic inflammatory masses

Adenomyosis


Treatment :

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.

Medical therapy：

Indications：chronic pelvic pain
severe dysmenorrhea
no require to get pregnant
no ovarian cyst formation

Hormone–inhibition therapy

Drugs：

Danazol：pseudomenopause therapy
Gestrinone
GnRH – a：medical oophorectomy
add – back therapy
Mifepristone RU486
Progestogens：pseudopregnancy therapy

Surgical therapy（1）：

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


Surgical therapy（2）：

Methods：
Conservative surgery
preserve the fecundity
preserve the ovarian function
Definitive surgery：
hysterectomy + salpingo–oophorectomy

Combination medical–surgical treatment：

Three–step：

surgery - medical therapy - second look（laparoscopy）

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


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.


Prevention：

Avoid possible augmentation of menstrual reflux.

Taking oral contraceptive is recommended.

Isolation and irrigation of the operative site.


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.


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.


Adenomyosis :

Definition：

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


Etiology：

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


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.


Clinical features（1）：

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


Clinical features（2）：

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

Diagnosis：

History
Pelvic examinations
Ultrasonography
Serum markers：CA-125↑

Treatment：

Hormone therapy
Hysterectomy，the only uniformly successful treatment for adenomyosis，is necessary.Lenovo G560 Series 067999U Laptop (Black)

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