妇产科学课件：子宫内膜异位症(英文版).ppt

1、lEndometriosis is a disorder in which abnormal growths of tissue,histologically resembling the endometrium,are present in locations other than the uterine lining.lThe lesions are usually found on the peritoneal surfaces of the reproductive organs and adjacent structures of the pelvis,but they can oc

2、cur anywhere in the body.lIts exact prevalence is unknown because surgery is required for its diagnosis,but it is estimated to be present in 10%of all reproductive age woman.Implantation theory Retrograde menstruation Iatrogenic implant Lymphatic and vascular disseminationMetaplasia theory of coelom

3、ic epithelium Induction theoryThe size of the individual lesions varies from microscopic to large invasive masses that erode into underlying organs and cause extensive adhesions formation.Ovarian endometriosisPeritoneal endometriosisDeep infiltrating endometriosisOvarian EMT bilateral ovaries involv

4、ed in 50%cases micro lesions macro lesions-chocolate cyst (endometrioma)Peritoneal EMT Uterosacral ligament,Cul-de-sac and posterial wall of the uterus Deep infiltrating EMT Uterosacral ligament,Cul-de-sac Microscopy endometrial gland endometrial stroma or hemosiderin-laden macrophagesClinical findi

5、ngs vary greatly depending on the number,size,and the extent of the lesions.Women with EMT can be completely asymptomatic or may be crippled by pelvic pain and infertility.Chronic pelvic pain and dysmenorrhea:constant pelvic pain or a low sacral backache premenstrually and subsides after menses begi

6、nsDyspareuniaInfertility Anatomic abnormality of pelvic cavityChange of the microenvironment of the pelvic cavityAbnormal immune function Ovarian dysfunctionAbnormal menstruation -Menorrhagia-premenstrual spotting Other localization urinary tract:bloody urine bowel:bloody stool scar (episiotomy and

7、cesarean section incision)Pelvic examination tender adnexal mass uterus fixed and retroverted tender nodules in uterosacral ligament,cul-de-sac and posterial wall of the uterusClinical presentationUltrasonic examinationSerum CA125 determinationlaparoscopyPelvic tumorsPelvic inflammatory diseaseAdeno

8、myosisDysmenorrhea usually this will require operative evaluationTreatment options are dictated by the patients desire for future fertility,her symptoms,the stage of her disease,and to some extent her age.It must be emphasized that therapies require operative inspection of the lesions for correct di

9、agnosis.Observation Analgesic therapyMedicine:pseudopregnancy pseudomenopause gestrinone other therapy:mifepristone surgeryIn asymptomatic patients,those with mild discomfort,or infertile women with minimal or mild endometriosis,expectant management may be appropriate.observationWhen the patient has

10、 mild premenstrual pain from minimal EMT,no abnormalities on pelvic examination,and no desire for immediate fertilityProstaglandin synthetase inhibiting drugsAnalgesic therapyPseudopregnancy Best reserved for patients with milder forms of EMT who do not desire immediate fertility and are unable to t

11、ake other treatments.Create constant high levels of progestins,as seen in pregnancy,to thin the endometrium and cause its regression with pseudodecidual changes.MedicinePseudopregnancy Oral contraception Progestin Side effect:depression,bloating,weight gain,breakthrough bleedingMedicinePseudomenopau

12、se Gn-RH(gonadotropin releasing hormone)agonists medically oophorectomySide effect:perimenopuse symdrome osteoporosis,hectic fever add-back therapyMedicinePseudomenopause Danazol:a weak androgen inhibit Gn-RH releasing sex steroids bind to androgen receptors and directly inhibit implant growthSide e

13、ffect:acne,oily skin,deepening of the voice,weight gain,edema,and adverse plasma lipoprotein changes (androgenic)MedicineOther hormonal therapiesGestrinone It is an anti-estrogen,anti-progesterone steroid with effects similar danazol.lThe dose is 2.5-5 mg orally twice weekly.lFollow up liver functio

14、n MedicineIndication medical treatment ineffective ovary endometriotic cyst larger than 5cm desire for fertilitysurgeryPreserve reproductive ability:conservative surgery,excise or destroy all endometriotic tissue,remove all adhesions,and restore pelvic anatomyPreserve ovarian function:does not desir

15、e future child-bearingStyle of operationradical surgery:total hysterectomy,bilateral salpingooophorectomy,and excision of remaining adhesions or implantation Surgery to relieve pain:presacral neurectomy or uterosacral ligamentStyle of operationPrevent retrograde of menstruationPay attention to the o

16、peration causeslEndometriosis still stand as one of the most-investigated disorders in gynecology.SO is one of the highest priorities for research.lAdenomyosis is the presence of endometrial glands and stroma within in the myometrium.l It is generally thought to be unrelated to EMT.Invagination of endometrialSymmetrically enlarged uteruslAdenomyomaMenstrual abnormalitylHypermenorrhealIncreasingly severe form of dysmenorrheaPelvic examination:symmetrically enlarged uterus