EndometriosisEndometriosis

Women’s Hospital, School of Medicine Zhejiang Women’s Hospital, School of Medicine Zhejiang UniversityUniversity

Prof. Lin JunProf. Lin Jun

EndometriosisEndometriosis

Women’s Hospital, School of Medicine Zhejiang Women’s Hospital, School of Medicine Zhejiang UniversityUniversity

Prof. Lin JunProf. Lin Jun

DefinitionDefinition

EndometriosisEndometriosis is usually defined as the is usually defined as the

presence of endometrial-like tissue, that presence of endometrial-like tissue, that

is, glands and stroma, outside the is, glands and stroma, outside the

endometrium endometrium

in uterine cavity and myometrium. in uterine cavity and myometrium.

EndometriosisEndometriosis is usually defined as the is usually defined as the

presence of endometrial-like tissue, that presence of endometrial-like tissue, that

is, glands and stroma, outside the is, glands and stroma, outside the

endometrium endometrium

in uterine cavity and myometrium. in uterine cavity and myometrium.

Common sites of endometriosisCommon 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

The most common sites ：• uterosacral ligament• rectouterine pouch • ovary

Others ：• uterine serosa• fallopian tube• sigmoid colon

outside of the pelvis :• Umbilicus , bladder, kidney

PrevalencePrevalence• 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

• 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

PathogenesisPathogenesis PathogenesisPathogenesis 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

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

PathogenesisPathogenesisPathogenesisPathogenesis

Theories of source of ectopic endometrium

• metaplasia theory of coelomic epithelium

• induction theory

Theories of source of ectopic endometrium

• metaplasia theory of coelomic epithelium

• induction theory

PathogenesisPathogenesis PathogenesisPathogenesis Factors related with endometriosis

• Genetic Factors ： high risk in first-degree

relatives

• Immunologic Factors

• Inflammation

• Character of uterine eutopic endometrium

Factors related with endometriosis

• Genetic Factors ： high risk in first-degree

relatives

• Immunologic Factors

• Inflammation

• Character of uterine eutopic endometrium

Pathology Pathology

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

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

PathologyPathology

• Ovarian endometriosis

• Peritoneal endometriosis

• Deep infiltrating endometriosis

• others

• Ovarian endometriosis

• Peritoneal endometriosis

• Deep infiltrating endometriosis

• others

Gross appearance :Gross appearance :

ovarian endometriosis • red, blue, or brown spots • endometriomas —— chocolate cysts

ovarian endometriosis • red, blue, or brown spots • endometriomas —— chocolate cysts

Gross appearance :Gross appearance :

peritoneal endometriosiscommon sites ： uterosacral ligament 、 rectouterine

pouch

peritoneal endometriosiscommon sites ： uterosacral ligament 、 rectouterine

pouch

purple spotsdark brown spotsred lesionswhite lesionsperitoneum lack

purple spotsdark brown spotsred lesionswhite lesionsperitoneum lack

peritoneal endometriosisperitoneal endometriosis

peritoneal endometriosisperitoneal endometriosis

cervix cervix umbilicus

umbilicus

The microscopic findingsThe microscopic findings ：The microscopic findingsThe microscopic findings ：

• endometrial glands • endometrial stroma • fibrin• red blood cells and hemosiderin

≥2 findings to be diagnosed

• endometrial glands • endometrial stroma • fibrin• red blood cells and hemosiderin

≥2 findings to be diagnosed

Clinical FindingsClinical Findings Clinical FindingsClinical 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

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 FindingsClinical FindingsClinical FindingsClinical Findings

symptoms ：

others ：

symptoms ：

others ：diarrhoea

constipation

bloody stool

painful urination

bloody urine

backache

diarrhoea

constipation

bloody stool

painful urination

bloody urine

backache

Causes of infertilityCauses 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

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 FindingsClinical FindingsClinical FindingsClinical Findings

Pelvic Examination ：• fixed retroverted uterine

• tender nodules on uterosacral ligament or rectouterine pouch

• tender and fixed adnexal masses

Pelvic Examination ：• fixed retroverted uterine

• tender nodules on uterosacral ligament or rectouterine pouch

• tender and fixed adnexal masses

Diagnosis 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

• history

• pelvic examination

• laparoscopy —— golden diagnosis standard

diagnosis, classification ＆ treatment

• ultrasound, (CT and MRI, expensive)

• serum CA125 ↑but usually ＜ 100IU/ml

• anti-endometrium antibody

DiagnosisDiagnosis

Clinical classification

Revised American Fertility Society (r-AFS), 1985

Useful for:• Assessment of severity• Selection of therapeutic regimen• Comparison• Prognosis

Clinical classification

Revised American Fertility Society (r-AFS), 1985

Useful for:• Assessment of severity• Selection of therapeutic regimen• Comparison• Prognosis

r-AFSr-AFS

Differential DiagnosisDifferential 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

• 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 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

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

TreatmentTreatment

Expectant Therapy

• Follow-up

• symptoms management ： NSAIDs

Expectant Therapy

• Follow-up

• symptoms management ： NSAIDs

TreatmentTreatment

Medication

Objective:

cause atrophic changes in the ectopic

endometrium

Medication

Objective:

cause atrophic changes in the ectopic

endometrium

MedicationMedication

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

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

MedicationMedication

Pseudomenopause therapy

⒈GnRH-a

Mechanism: Medical hypophysectomy / Medical oophorectomy

• leuprorelin 3.75mg• goserelin 3.6mg• tryptorelin 3.75mg m / H, 1 inj/q28d, start d1

Pseudomenopause therapy

⒈GnRH-a

Mechanism: Medical hypophysectomy / Medical oophorectomy

• leuprorelin 3.75mg• goserelin 3.6mg• tryptorelin 3.75mg m / H, 1 inj/q28d, start d1

MedicationMedication

⒈GnRH-a

Side effects:

(1) Menopausal symptoms :

hot flashes, dryness in vagina, loss of libido

(2) Osteoporosis

⒈GnRH-a

Side effects:

(1) Menopausal symptoms :

hot flashes, dryness in vagina, loss of libido

(2) Osteoporosis

MedicationMedication

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

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

MedicationMedication

⒉ Danazol

Side effects:

acne, deepening of the voice, oily skin,

headache, hot flashes, loss of libido,

weight gain

⒉ Danazol

Side effects:

acne, deepening of the voice, oily skin,

headache, hot flashes, loss of libido,

weight gain

MedicationMedication

others ：

• gestrinone• mifepristone

others ：

• gestrinone• mifepristone

Surgical treatmentSurgical 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

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 treatmentSurgical treatment

laparoscopy + medicine

golden standard of treatment

laparoscopy + medicine

golden standard of treatment

Surgical treatmentSurgical treatment

Modes of surgical operation:

(1) Fertility preservation

(2) Ovarian function preservation

(3) Radical surgery

(4) Surgery for pain relief

Modes of surgical operation:

(1) Fertility preservation

(2) Ovarian function preservation

(3) Radical surgery

(4) Surgery for pain relief

TreatmentTreatment

Combination of medication and surgery

• surgery + medication surgery + medication

• medication + surgery + medicationmedication + surgery + medication

Treatment for patients with infertility

Combination of medication and surgery

• surgery + medication surgery + medication

• medication + surgery + medicationmedication + surgery + medication

Treatment for patients with infertility

PreventionPrevention

• Prevent retrograde flow of menses

• Contraception with medicine

• Avoid iatrogenic implantation of the

ectopic endometrium

• Prevent retrograde flow of menses

• Contraception with medicine

• Avoid iatrogenic implantation of the

ectopic endometrium

Adenomyosis

Adenomyosis

DefinitionDefinitionDefinitionDefinition

• Adenomyosis is defined by the presence

of endometrial glands and stroma within

the myometrium. It is associated with

myometrial hypertrophy and proliferation.

• Adenomyosis is defined by the presence

of endometrial glands and stroma within

the myometrium. It is associated with

myometrial hypertrophy and proliferation.

Endometriosis Endometriosis ＆＆ AdenomyosisAdenomyosisEndometriosis Endometriosis ＆＆ AdenomyosisAdenomyosis

• Pathogenesis ＆ histological confirmation

• Sites of lesions• Clinical

findings

• Pathogenesis ＆ histological confirmation

• Sites of lesions• Clinical

findings

Adenomyosis is thought to be unrelated to Adenomyosis is thought to be unrelated to endometriosisendometriosis..

Adenomyosis is thought to be unrelated to Adenomyosis is thought to be unrelated to endometriosisendometriosis..

Clinical findingsClinical findings

Multiparas （＞ 40 y ） were most commonly affected.

Symptoms ：• prolonged and heavy menses • Dysmenorrhea that worsens over time

Pelvic exam ：• enlargement of uterus• tenderness

Multiparas （＞ 40 y ） were most commonly affected.

Symptoms ：• prolonged and heavy menses • Dysmenorrhea that worsens over time

Pelvic exam ：• enlargement of uterus• tenderness

DiagnosisDiagnosisDiagnosisDiagnosis

• Typical symptoms and signsTypical symptoms and signs

• Histopathologic examination Histopathologic examination

—— —— standard of the diagnosisstandard of the diagnosis

• B ultrasound would suggest the disease.B ultrasound would suggest the disease.

• Typical symptoms and signsTypical symptoms and signs

• Histopathologic examination Histopathologic examination

—— —— standard of the diagnosisstandard of the diagnosis

• B ultrasound would suggest the disease.B ultrasound would suggest the disease.

TreatmentTreatmentTreatmentTreatment

1. Medication ： GnRH-a

2. Surgical treatment : total hysterectomy

1. Medication ： GnRH-a

2. Surgical treatment : total hysterectomy

Thank you !Thank you !