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Endometriosis ＆ Adenomyosis

Zhao aimin M.D., Ph.D., Professor

Department Of Obstetrics & Gynecology

Renji Hospital Affiliated to SJTU School of Medicine

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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 c

hange.1) Macrophage↑ release IL–1 、 IL–6 、 TNF 、 EGF 、

FGF etc. stimulate T 、 B lymphocyte proliferation and activation

2) Activity of killer cell （ NK cell and T cell ）↓ 3) Produce anti–endometrium antibody4) Abnormal expression of CAMs （ cell adhesion molecul

es ）

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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–sa

c 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 ）：• Less common sites ：1. Cervix

2. Round ligament

3. Urinary system （ bladder 、 ureter ）4. Umbilicus

5. Appendix

6. 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

• Four major components ： endometrial glands endometrial stroma fibrosis hemorrhage

Ectopic endometrium异位子宫内膜

Eutopic endometrium在位子宫内膜

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Clinical Manifestation

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Symptoms ：• Pain

progressive dysmenorrhea

dyspareunia

painful defecation

• Menstrual disturbance

• infertility

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 variableVary with the focus locationOften bear no relation to the

extent of the diseaseQuite 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 pointsStage II — mild disease ， 6～ 15 pointsStage III — moderate disease ， 16～ 40 pointsStage 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 fer

tility

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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 ini

tial 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 en

dometrial glands and stroma are found deep in the myometrium.

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Etiology ：• Basal endometrial hyperplasia invading a h

yperplastic myometrial stroma.

• Four primary theories ：Heredity

Trauma

Hyperestrogenemia

Viral transmission

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Pathology — gross appearance ：• Usually hyperemic with thickened wall

s• The foci are frequently scattered diffus

ely throughout the myometrium.• Occasionally ， may be more circumsc

ribed ， with the formation of a distinct nodule ， an adenomyoma.

Adenomyosis子宫肌腺症

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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Zhao aimin M.D., Ph.D., Professor

Department of Obstetrics & Gynecology

Renji Hospital Affiliated to SJTU School of Medicine

Thanks for Your Attention