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
Sampson1921
Lymphatic and Vascular Dissemination Theory
Javert1952
Coelomic Theory
Meyer
Genetic Theory
Immune System Dysfunctionimmunologic theory
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Genetic factors
Familial clustering of endometriosis is a common
clinical observation.
In families with endometriosisthe disease is
often confined to the maternal lineand is 7 times
more common in first-degree relatives than in the
general population.
In future studiesevaluation 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
change.
1) Macrophage release IL1IL6TNFEGF
FGF etc. stimulate TB lymphocyte proliferation
and activation
2) Activity of killer cellNK cell and T cell
3) Produce antiendometrium antibody
4) Abnormal expression of CAMscell adhesion
molecules

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 The pathogenesis
is unclear.
multifactor

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Pathology
macroscopic appearance1
The commonest sites
1. Ovarychocolate cyst
2. Peritoneum of the rectovaginal culde
sac of the Pouch of Douglas
3. Uterosacral 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 systembladderureter
4. Umbilicus
5. Appendix
6. Laparotomy scars
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Multiple appearances of
endometriosis implants
Brownishdiscolored peritoneum
Superficial peritoneal ecchymosis
Raisedreddishsuperficial nodules
Reddishblue invasive nodules
Fibroticwhitish nodules
Raisedglossytranslucent blobs
Patchywhite 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 Eutopic endometrium Ectopic endometrium

Four major components

endometrial glands
endometrial stroma
fibrosis
hemorrhage
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Clinical Manifestation

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Symptoms
Pain
dysmenorrhea
progressive dysmenorrhea

dyspareunia dyspareunia

painful defecation
Menstrual disturbance
infertility

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Signs
Enlargement of the ovariesfixed
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 variable
Vary with the focus location
Often bear no relation to the
extent of the disease
Quite often deposits are found
incidentally in women who
have no symptoms.
25% have no symptoms

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Diagnosis
History
PV examination
Laparoscopygolden standard
UltrasonographyBtype ultrasound
CA125 200U/mlnormal value
35U/ml
Antiendometrium antibody+
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Staging systems
In the AFS-r1985staging systempoints 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 15 points
Stage II mild disease 615 points
Stage III moderate disease1640 points
Stage 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

Indicationswith very limited disease

whose symptoms are minimal or nonexistent

If trying to get pregnantthe best way is

to accept laparoscopic therapy as early as
possible.

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Medical therapy
Indicationschronic pelvic pain
severe dysmenorrhea
no require to get pregnant
no ovarian cyst formation
Hormoneinhibition therapy

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Drugs
Danazolpseudomenopause therapy
Gestrinone
GnRH amedical oophorectomy
add back therapy
Mifepristone RU486
Progestogenspseudopregnancy therapy

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Surgical therapy1
Indications1adnexal mass
2pelvic pain
3infertility
Approaches
(1) trans abdominal
(2) laparoscopic

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Surgical therapy2
Methods
Conservative surgery
1) preserve the fecundity
2) preserve the ovarian function
Definitive surgery
hysterectomy + salpingooophorectomy

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Combination
medicalsurgical treatment
Threestep surgery

medical therapy

second looklaparoscopy

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 It is important to
individualize the
choice of therapy.
Therapy must be
tailored to
the degree of
symptomatology
the patients age
her desire to
maintain fertility
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Prognosis
With proper treatmentthe prognosis is good for
relief of pain and enhancement of fertility in mild
to moderate endometriosis.
In most caseshormonal 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 points1
The pathogenesis is poorly understoodbut
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 points2
In most casessurgical therapy at the time of
initial diagnosis effectively relieves pain and may
enhance fertility.
Alternativelymedical therapy with progestins
danazolgestrinone or GnRH-a will ameliorate
pelvic painbut they do not enhance fertility.
Endometriosis is a recurrent diseaseand
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
endometrial glands and stroma are
found deep in the myometrium.

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Etiology
Basal endometrial hyperplasia invading a
hyperplastic myometrial stroma.
Four primary theories
Heredity
Trauma
Hyperestrogenemia
Viral transmission
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Pathology
gross appearance
Usually hyperemic with thickened
walls
The foci are frequently scattered
diffusely throughout the myometrium.
Occasionallymay be more
circumscribedwith the formation of
a distinct nodulean adenomyoma.
Adenomyosis Adenomyoma

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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 features1
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 features2
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 markersCA-125

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Treatment
Hormone therapy
Hysterectomythe only uniformly
successful treatment for adenomyosis
is necessary.

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Thanks for Your Attention

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

Department of Obstetrics & Gynecology
Renji Hospital Affiliated to SJTU School of Medicine
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