Endometriosis

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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– sac of the Pouch of Douglas 3. Utero–sacral ligaments 4. Sigmoid colon 5. Broad ligament
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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
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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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Differential diagnosis：
• Malignant ovary tumours • Pelvic inflammatory masses • Adenomyosis
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Treatment
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Expectant therapy：
• 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:
• • 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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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.
Endometriosis ＆ Adenomyosis
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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:
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Immunologic Theory：
• •
1)
2) 3) 4)
Lose control of immunologic balance Both cellular immunity and humoral immunity change.
Macrophage↑ release IL–1、IL–6、TNF、EGF、 FGF etc. stimulate T、B lymphocyte proliferation and activation Activity of killer cell（NK cell and T cell）↓ Produce anti–endometrium antibody Abnormal expression of CAMs（cell adhesion molecules）
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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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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
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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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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 osis：
• • • • • 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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Pathology – macroscopic appearance （2）：
• 1. 2. 3. 4. 5. 6. Less common sites： Cervix Round ligament Urinary system（bladder、ureter） Umbilicus Appendix Laparotomy scars
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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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Clinical Manifestation
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Symptoms：
• Pain progressive dysmenorrhea dyspareunia painful defecation • Menstrual disturbance • infertility
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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 points Stage II — mild disease， 6～15 points Stage III — moderate disease，16～40 points Stage IV — severe disease， ≥ 40 points