Endometriosis Disease

2009.5.5

Xiaoli ChenDepartment of Obstetrics and

Gynecology

EndometriosisEndometriosisEndometriosisEndometriosis

AdenomyosisAdenomyosis

Endometriosis

• A condition in which the tissue that normally lines the uterus grows in other areas of the body, causing pain, irregular bleeding, and frequently infertility.

Characteristics

• Common in reproductive-age women

• Estrogen dependence• Genetic disease• Immunologic disease• Inflammatory disease• Benign diseases, malignant

behavior

PathogenesisPathogenesisPathogenesisPathogenesis

Pathogenesis

• Not clear.

• 4 theories proposed: - Retrograde menstruation theory - Coelomic metaplasia theory - Lymphatic or vascular dissemination theory - Immunology theory

• No single theory can account for the location of endometriosis in all cases.

Pathology

Pathology: Classification of Common

Pelvic Endometriosis• Ovarian endometriosis

– Minimal: superficial minimal

– Classic: cyst

• Peritoneal endometriosis

– Pigmentation: classic indigo or brown ectopic tubercles 。

– Non-pigmentation ： early focus

Pathology: Microscopic Examination

• Endometrial tissue (glands and

stroma)

• Fibrin and red cell

• Hemosiderin

Clinical presentation• Symptoms

• Dysmenorrhea (progressive)• Chronic pelvic pain• Dyspareunia• Pain caused by rupture of endometrioma• Infertility• Menstrual disturbance• Painful defecation

Clinical presentation

•Signs

• Fixed,retroverted uterus• Enlargement of the ovaries• Tender nodular uterosacral

ligament

Diagnosis

Diagnosis

• Medical history

• Gynecological examination

• Auxiliary examination

– laparoscopy

– Imaging

– laboratory

Diagnosis: Medical History

• Menstruation

• Reproduction

• Family history

• Operation history

• Relationship of dysmenorrhea and

gynecological operation

Diagnosis: Gynecological Examination

• Bimanual or trimanual examination

– Uterus

– Mass

– Tenderness nodes

Diagnosis: Laparoscopy

• The best method for diagnosis

• Diagnosis by direct inspect

• Pathological confirmation needed

• Treatment at the same time

Diagnosis: Imaging

• B-mode sonography

– Sensitivity 97 ％ , specificity 96 ％ .

– Mass: location, size, content, blood

supply, etc.

Diagnosis: Imaging

• CT or MRI

– Provide additional and

confirmatory information

– More costly

Diagnosis: Laboratory

• CA125

– Slightly elevated in moderate or

severe patients.

– Limited on sensitivity and specificity.

– No single use for diagnosis.

Diagnosis: Laboratory

• Anti-endometrium antibody

– Negative in most of normal women.

– Positive rate over 60 ％ in endometriosis

patients.

– Positive means active ectopic endometrium.

– Not popular used in clinic.

Differential

Diagnosis

Differential Diagnosis

• Diseases

– Malignant tumor of

ovary

– Pelvic

inflammatory mass

– Adenomyosis

Aspects History

Gyn Examintion

B-mode

ultrasonography

Lab research

Treatment

• Expectant therapy• Medical treatment - Pseudomenopause therapy

- Danazol - GnRH agonists - Pseudopregnancy therapy

• Surgical treatment

Medical Oophorectomy - GnRH agonists

• Mechanism: - Desensitization of the pituitary - Medical hypophysectomy →medical oophrectomy

• Drugs used: - Leuprorelin 3.75mg/28 Days D5 - Goserelin/Zoladex 3.6mg/28 Days D5 - Triptorelin/Decapreptyl 3.75mg/28 Days D5

• Side dffects: - (1)Menopausal symptoms: hot flashes, dryness in vagina, loss of libido - (2)Osteoporosis

• Add-Back Therapy

Pseudomenopause therapy- Danazol

• Synthetic steroid - 17α-ethinyltestosterone Derivative• Mechanism: - Directly suppressing ovarian steroidogenesis - Direct inhibiting endometrial growth

• Doses: - 400-800 mg/day for 6 months

• Side effects: - Hypoestrogenic environment: decreased breast size, atrophic vaginitis, hot flashes, emotional

swings - Virilism

Pseudopregnancy therapy- Progestogen

• Mechanism:– Inhibition of uterine contraction– Inhibition on growth of the endometrium

• Doses: Medroxyprogesterone 20-50mg/day 6 months• Side effects : weight, fluid retention,

breakthrough bleeding, depression

Surgery· Diagnostic surgery

· no attempt to treat any of the endometriosis

· Very conservative surgery· treatment of a very large, obvious, or treatable

area of endometriosis

· Aggressive surgery· removes all the endo while preserving the organs· maintains fertility

· Radical surgery· removal of the reproductive organs· hysterectomy

Treatment -- infertility

• Minimal disease - pregnancy rate without treatment after 5 years is 90% • severe disease - proceed to laparoscopy• woman over 35 yrs old - proceed with treatment• Medical therapy is of limited value• Assisted reproduction

Lifestyle• Exercise • Eating well and getting enough

rest• Practicing relaxation techniques

such as yoga and meditation

Recurrences• May recur with medical therapy or

surgical therapy• GnRH agonists or Danazol - Minimal disease – 37%, - severe disease – 74% • Surgery – 40% after 5 years • 56% of all patients after 7 years

Adenomyosis

• Definition of Adenomyosis:

– Presence of functioning endometrial glands and stroma in the myometrium.

• Myometrial cells around become hypertrophy and hyperplasia compensatively

Basic Concepts

Pathogenesis

Pathogenesis

• The pathogenesis is not known.

• Propose by Cullen in 1908, the

theory of direct growth of the basal

layer of endometrium into the

myometrium is widely accepted.

Pathogenesis

• Estrogen has been implicated as a

stimulus to the development of

adenomyosis.

• The symptomatic improvement that

occurs with the onset of menopause

supports this concept.

Pathogenesis

• Induction Factors

– Inheritance

– Trauma (curettage / cesarean section )

– Hyperestrogenemia

– Virus infection

Pathology

Pathology• Macroanatomy

– Uterus enlarges uniformly, like a ball.

– Usually not bigger than 12 weeks of gestation.

– Thick muscle fiber and micro vesicle seen in myomerium.

– Some grew like myoma, called adenomyoma.

Pathology

• Microscopic examination– Endometrial glands and stroma in

the myometrium, scattered like islands.

– Ectopic glands usually in proliferate phase.

– Local secretory changes seen

occasionally.

Symptoms and Signs

• Hypermenorrhea 50%• Dysmenorrhea 30%• Symmetrically enlarged uterus - Improved ultrasound: preoperative

diagnosis

- MRI: negative/equivocal sonogram presence of leiomyomas

Diagnosis

• Primary diagnosis– Classic symptoms and signs.– B-mode ultrasonography and CT

is helpful in diagnosis.• Confirmative diagnosis

– Pathological examination.

DiagnosisDiffer from• Pregnancy: pregnancy test, ultrasound• Submucous leiomyomas: hysteroscopy• Endometrial cancer: endometrial

biopsy• Myoma: ultrasound• Endometriosis:ultrasound

Complications and Prevention

• Chronic severe anemia• Primary adenocarcinoma

★Adenomyosis can’t be prevented.

Treatment

Treatment: Medication

• No medication is radical

• Mild symptoms

– NSAID

– Oral contraceptive pills

• Young, pregnancy-desiring, close to menopause

– Try GnRHa

Treatment: Surgery

• Suitable for patients with ：– Severe symptoms

– Relatively old age

– No desire for pregnancy

– No effect by medication

Treatment: Surgery

• Methods– Total hysterectomy– Adenomyoma resection

•Young with pregnancy desiring•Prone to recurrence

– Laparoscopic uterosacral nerve ablation / Presacral neurectomy•Pain relief rate: 80 ％