Endometriosis Women’s Hospital, School of Medicine Zhejiang University Prof. Lin Jun

Definition Endometriosis is usually defined as the presence of endometrial-like tissue, that is, glands and stroma, outside the endometrium in uterine cavity and myometrium.

Common sites of endometriosis The most common sites： uterosacral ligament rectouterine pouch ovary Others： uterine serosa fallopian tube sigmoid colon outside of the pelvis : Umbilicus , bladder, kidney

Prevalence present in 10%-15% of women in reproductive age group, especially from age 25 to 45 normally not seen before age 15 or after menopause less and late childbearing latest study: more frequent menses (cycle length ≤ 27 days ) and prolonged menstrual flow (≥ 1 week) 2 times risk

Pathogenesis Theories of sources of ectopic endometrium Implantation theory ——Sampson 1921 endometrium transfer → implant →grow ⒈retrograde menstruation theory ⒉iatrogenic implantation ⒊ transport by lymph and vein

Pathogenesis Theories of source of ectopic endometrium metaplasia theory of coelomic epithelium induction theory

Pathogenesis Factors related with endometriosis Genetic Factors ：high risk in first-degree relatives Immunologic Factors Inflammation Character of uterine eutopic endometrium

Pathology ectopic endometrium ↓ hemorrhage proliferation of fibrous tissue ＆ adhesions dark blue or dark brown spots scarring nodules or cysts

Pathology Ovarian endometriosis Peritoneal endometriosis Deep infiltrating endometriosis others

Gross appearance : ovarian endometriosis red, blue, or brown spots endometriomas —— chocolate cysts

Gross appearance : peritoneal endometriosis common sites： uterosacral ligament、rectouterine pouch purple spots dark brown spots red lesions white lesions peritoneum lack

peritoneal endometriosis

peritoneal endometriosis

cervix umbilicus

The microscopic findings ： endometrial glands endometrial stroma fibrin red blood cells and hemosiderin ≥2 findings to be diagnosed

Clinical Findings symptoms： dysmenorrhoea and chronic pelvic pain the most typical symptom：secondary dysmenorrhea that worsens over time dyspareunia abnormal uterine bleeding heavy menses, prolonged menstruation or premenstrual spotting infertility：50% of patients acute abdomen: inter-cyst hemorrhage, or rupture

Clinical Findings symptoms： others： diarrhoea constipation bloody stool painful urination bloody urine backache

Causes of infertility 1) Mechanical reason 2) Environmental change in the peritoneal cavity 3) Abnormal immune function 4) Abnormal ovarian function (anovulation,LPD, LUFS) 5) Increase in spontaneous abortion

Clinical Findings Pelvic Examination： fixed retroverted uterine tender nodules on uterosacral ligament or rectouterine pouch tender and fixed adnexal masses

Diagnosis history pelvic examination laparoscopy —— golden diagnosis standard diagnosis, classification ＆treatment ultrasound, (CT and MRI, expensive) serum CA125 ↑but usually ＜100IU/ml anti-endometrium antibody

Diagnosis Clinical classification Revised American Fertility Society (r-AFS), 1985 Useful for: Assessment of severity Selection of therapeutic regimen Comparison Prognosis

r-AFS

Differential Diagnosis Ovarian tumor ascites, solid or mixed, B ultrasound image, CA-125>100 IU/ml Abdominal inflammatory mass history of infection, fever, not cyclic, treatment with antibiotics effectively Adenomyosis medial, severe pain, uterus slightly enlarged

Treatment Principles of treatment： Treatment should be individualized according to the age, severity of the condition and desire for childbearing. With mild symptom: expectant therapy With childbearing desire: mild-condition: medication severe-condition: fertility preservation surgery No childbearing desire : Surgical treatment: ovary preservation or radical surgery

Treatment Expectant Therapy Follow-up symptoms management：NSAIDs

Treatment Medication Objective: cause atrophic changes in the ectopic endometrium

Medication Pseudopregnancy therapy ⒈ oral contraceptives：a pill once daily for 6-12 m ⒉ progestins： medroxyprogesterone 30mg daily megestrol 40mg daily norethindrone 5mg daily Side effects: Intermittent breakthrough bleeding, nausea, breast tenderness, fluid retention, weight gain

Medication Pseudomenopause therapy ⒈GnRH-a m / H, 1 inj/q28d, start d1 Mechanism: Medical hypophysectomy / Medical oophorectomy leuprorelin 3.75mg goserelin 3.6mg tryptorelin 3.75mg m / H, 1 inj/q28d, start d1

Medication ⒈GnRH-a Side effects: (1) Menopausal symptoms : hot flashes, dryness in vagina, loss of libido (2) Osteoporosis

Medication Pseudomenopause therapy ⒉ Danazol A derivative of 17-α-ethinyltestosterone Mechanism: Directly suppressing ovarian steroidogenesis Direct inhibiting the growth of endometrium 400-600 mg/d for 6 months

Medication ⒉ Danazol Side effects: acne, deepening of the voice, oily skin, headache, hot flashes, loss of libido, weight gain

Medication others： gestrinone mifepristone

Surgical treatment Purposes： ⑴ diagnosis and classification ⑵ excise or destroy all endometriotic tissue ⑶ remove all adhesions, restore pelvic anatomy ⑷ enhance fecundity ⑸ relieve pain

Surgical treatment laparoscopy + medicine golden standard of treatment

Surgical treatment Modes of surgical operation: (1) Fertility preservation (2) Ovarian function preservation (3) Radical surgery (4) Surgery for pain relief

Treatment Combination of medication and surgery surgery + medication medication + surgery + medication Treatment for patients with infertility

Prevention Prevent retrograde flow of menses Contraception with medicine Avoid iatrogenic implantation of the ectopic endometrium

Adenomyosis

Definition Adenomyosis is defined by the presence of endometrial glands and stroma within the myometrium. It is associated with myometrial hypertrophy and proliferation.

Endometriosis ＆ Adenomyosis Adenomyosis is thought to be unrelated to endometriosis. Pathogenesis ＆ histological confirmation Sites of lesions Clinical findings

Clinical findings Symptoms： prolonged and heavy menses Multiparas（＞40 y） were most commonly affected. Symptoms： prolonged and heavy menses Dysmenorrhea that worsens over time Pelvic exam： enlargement of uterus tenderness

Diagnosis Typical symptoms and signs Histopathologic examination —— standard of the diagnosis B ultrasound would suggest the disease.

Treatment 1. Medication ：GnRH-a 2. Surgical treatment : total hysterectomy

Thank you !