子宮內(nèi)膜異位癥和子宮腺肌病

（endometriosisandadenomyosis）

第1頁Objectives（教學(xué)目標(biāo)）1. Familiarizetheprevailingtheoriesonpossiblecausesandpathogenesisofendometriosis。（熟悉子宮內(nèi)膜異位癥也許病因和發(fā)病機制）2. Mastertheclinicalfeatures,diagnosisanddifferentialdiagnosisofendometriosis（掌握子宮內(nèi)膜異位癥臨床特點、診斷及鑒別診斷）第2頁Objectives（教學(xué)目標(biāo)）3. Understandtheprinciplesofthetreatmentstrategyofendometriosis。（理解子宮內(nèi)膜異位癥治療策略標(biāo)準(zhǔn)）第3頁主要內(nèi)容Maincontent

Pathogenesis病因和發(fā)病機制

Pathologicalfeatures病理特點

Clinicalfindings臨床體現(xiàn)

Diagnosis診斷

Differentialdiagnosis鑒別診斷

Treatment治療第4頁第5頁子宮內(nèi)膜異位性疾?。?/p>

子宮內(nèi)膜異位癥（endometriosis，EM）子宮腺肌病(adenomyosis)

第6頁

定義：DefinitionAgynecologicalconditioninwhichendometrialcellsappearandgrowoutsidetheuterinecavity。

（endometriosis,EM）具有生長功能子宮內(nèi)膜出現(xiàn)在子宮體以外身體其他部位，生長、侵蝕、周期性出血稱子宮內(nèi)膜異位癥，簡稱內(nèi)異癥第7頁發(fā)生部位

ovarian（卵巢）peritonea（腹膜）deepinfiltratingendometriosis(DIE)異位子宮內(nèi)膜能夠侵犯全身任何部位，絕大多數(shù)位于盆腔臟器和腹膜。最常見被侵犯部位是子宮骶韌帶及卵巢第8頁

IncidencerateTheendometriosisincidenceofFertilewomenis76%，Hormonedependentdisease，生育年紀(jì)婦女是內(nèi)異癥高發(fā)人群約占76%，是一種激素依賴性疾病。第9頁Incidencerate1.Recurringpelvicpain，20%-90%

慢性盆腔疼痛及痛經(jīng)，2.Infertility，40%，不孕3.dyspareunia，pain，性交不適，疼痛4.Menstrualdisturbances，月經(jīng)紊亂15%-30%第10頁Thecharacteristicsofendometriosis

子宮內(nèi)膜異位癥特點Diverseclinicalmanifestations臨床體現(xiàn)多樣Histologicallybenign組織學(xué)上良性Buthyperplasia,infiltration,metastasisandrecurrenceof"malignant"behavior,causingextensiveadhesion但有增生、浸潤、轉(zhuǎn)移及復(fù)發(fā)等“惡性”行為，引發(fā)廣泛粘連Growthishormonallydependent生長激素依賴性11第11頁

Etiologyandpathogenesis

一、病因和發(fā)病機制

Nosingletheoryexplainsallcasesofendometriosis.發(fā)病機制不清，提出了多種學(xué)說第12頁Mechanismsummory

EndometrialimplantationtheoryhasbeenrecognizedSampson'stheoryofhemorhedraltransplantingandtranscoelomicmetaplasiaistheleadingtheory以sampson經(jīng)血逆流種植及體腔上皮化生學(xué)說為主導(dǎo)理論.Endomyelitisdeterminism在位內(nèi)膜決定論.第13頁

EMRetrogrademenstruation種植學(xué)說Coelomicmetaplasia體腔上皮化生Inductiontheory誘導(dǎo)學(xué)說Geneticfactors遺傳原因Immuneandinflammatory免疫與炎癥原因Endomyelitisdeterminism在位內(nèi)膜決定論Etiology:theories

第14頁Etiologicalstudy病因?qū)W研究種植學(xué)說：Sampsonfirstputforwardthetheoryofmenstrualbloodrefluflowin19211923年Sampson最早提出經(jīng)血逆流學(xué)說Endometrialimplantationtheoryhasbeenrecognized種植學(xué)說內(nèi)膜種植學(xué)說已為人們所公認(rèn)第15頁Etiologicalstudy病因?qū)W研究1.Endometrialglandularepitheliumandstromalcellsmayreverseflowduringmenstruation2.Throughthetubalintothepelviccavity,implantedintheovaryandadjacentpelvicperitoneumandcontinuetogrow,spread,theformationofpelvicdysplasia經(jīng)期時子宮內(nèi)膜腺上皮和間質(zhì)細(xì)胞可隨經(jīng)血逆流，經(jīng)輸卵管進入盆腔，種植于卵巢和鄰近盆腔腹膜并在該處繼續(xù)生長、蔓延，形成盆腔內(nèi)異癥第16頁TheBasicpathologicalchangesofendometriosis

基本病理變化Implantationofendometrialcellstotheperitonealsurfacecanleadtoaspectrumofdiseaseseveritywiththemostseverecausingextensivepelvicadhesionsandanatomicdistortion.將子宮內(nèi)膜細(xì)胞移植到腹膜表面也許造成一系列嚴(yán)重疾病，其中最嚴(yán)重是廣泛盆腔粘連和解剖變形Eightypercentinvolvedoneovaryandfiftypercentinvolvedbothovaries80％累及一側(cè)卵巢，50％累及雙側(cè)卵巢17第17頁TheClassificationofendometriosis

常見盆腔內(nèi)異癥分類Ectopicendometriumwiththechangeofovarianhormoneperiodicbleeding,resultingintheproliferationofsurroundingfibroustissueandcysts,adhesionformation,purplebrownspotsorvesiclesinthelesionarea,eventuallydevelopintodifferentsizeofpurplebrownsolidnodulesormass.異位子宮內(nèi)膜隨卵巢激素變化發(fā)生周期性出血，造成周圍纖維組織增生和囊腫、粘連形成，在病變區(qū)出現(xiàn)紫褐色斑點或小泡，最后發(fā)展為大小不等紫褐色實質(zhì)性結(jié)節(jié)或包塊.

18第18頁TheClassificationofendometriosisFormationofasingleormultiplecysts,thecapsulefortheoldbleedinglikechocolatecalledovarianchocolatecyst,thesurfacewasgreyishblue

卵巢Microlesiontype:red,purple,blue,orbrownspotsorvesiclesonthesuperficialsurfaceoftheovary微小病灶型：卵巢淺表皮層紅色、紫藍(lán)色或褐色斑點或小泡典型病灶型：形成單個或多種囊腫，囊內(nèi)為陳舊出血呈巧克力樣稱卵巢巧克力囊腫，表面呈灰藍(lán)色；第19頁第20頁Uterinesacralligament,rectumuterinedepression,uterineposteriorwalllowersegmentoftheheterotopic,lowposition,easytooccur宮骶韌帶、直腸子宮陷凹、子宮后壁下段異位癥，位置低，好發(fā)部位第21頁Earlylesion:localscatteredpurple-brownhemorrhagicspotsorgranularnodules.Thelesiondeveloped：Theposteriorwalloftheuterusadheredtotheanteriorwalloftherectum病變早期：局部散在紫褐色出血點或顆粒狀結(jié)節(jié)病變發(fā)展：子宮后壁與直腸前壁粘連，直腸子宮陷凹變淺、消失、表面有紫藍(lán)色結(jié)節(jié)第22頁典型或微小腹膜子宮內(nèi)膜異位病灶A(yù)：典型黑色皺縮病變伴有血管增生及橘紅色囊泡B：紅色息肉樣病灶伴血管增生A:thetypicalblackwrinkledlesionisaccompaniedbyvascularhyperplasiaandorangevesiclesB:redpolypoidlesionwithvascularhyperplasia第23頁卵巢子宮內(nèi)膜異位癥24A：淺表卵巢子宮內(nèi)膜異位癥B：淺表卵巢子宮內(nèi)膜異位癥及子宮內(nèi)膜異位囊腫在粘連分解術(shù)前腹腔鏡下所見C：腹腔鏡下子宮及右卵巢黑紅色子宮內(nèi)膜異位囊腫D、E：卵巢子宮內(nèi)膜異位囊腫剔除術(shù)A:superficialovarianendometriosisB:superficialovarianendometriosisandendometriosiscystwereseenunderlaparoscopebeforeadhesolysisC:blackandredendometriosiscystofuterusandrightovaryunderlaparoscopeD,E:removalofovarianendometriosiscyst第24頁

鏡檢：microscopicpathologicfeatures異位病灶中可見：Endometrialglandinterstitialcellulosebleeding

子宮內(nèi)膜腺體間質(zhì)纖維素出血

第25頁Malignanttransformationofectopicintimaisrare,andtheincidenceislessthan1%Characteristicsofbiologicalbehavior-invasivegrowth,damagetosurroundingtissues,distantmetastasisandrecurrenceThecauseofthemalignantchangeisnotclearDiagnosticcriteriaformalignanttransformationClearcellcarcinomaandendometrioidcarcinomaEvilchange惡變異位內(nèi)膜很少發(fā)生惡變，發(fā)生率低于1%生物學(xué)行為特點-浸潤性種植生長、對周圍組織破壞、遠(yuǎn)處轉(zhuǎn)移和易復(fù)發(fā)惡變病因不明確惡變診斷標(biāo)準(zhǔn)透明細(xì)胞癌和子宮內(nèi)膜樣癌第26頁Clinicalfindings臨床體現(xiàn)Pain：疼痛Infertility：不孕Dyspareunia：性交不適Paramenia：月經(jīng)異常Othersymptom其他癥狀個別無癥狀第27頁

paincharacter

1.Painfulcharacteristic:sendsubsequentlydysmenorrhea,pelvicpain,sexualintercourseispainful2.Thepainfulpart;Moreinthemiddleofthelowerabdomenandlumbosacraldepartmentorradiationtoperineum,anus,thigh.3.Thedegreeofpain:andlesionsizeisnotnecessarilyproportional,andthesitehasacertainrelationship第28頁

Infertility：不孕

PelvicanatomyisabnormalChangeofmicroenvironmentinpelviccavityMenstrualdisorderOvariandysfunction盆腔解剖構(gòu)造異常盆腔內(nèi)微環(huán)境變化月經(jīng)失調(diào)卵巢功能異常第29頁Dyspareunia:性交不適Paincausedbyabumporuterinecontractionduringintercourse,Itisdeepsexcommonlypainful,menstruationcomesbeforemenstruationsexualintercourseispainfulthemostapparent30第30頁Paramenia月經(jīng)異常Incidence:15%~30%increaseinmenstrualvolume,prolongedmenstrualperiodormenstrualdrippingnotfullorearlymenstrualspotting發(fā)生率：15%～30%經(jīng)量增多、經(jīng)期延長或月經(jīng)淋漓不盡或經(jīng)前期點滴出血31第31頁Othersymptoms其他癥狀腸道內(nèi)異病灶膀胱內(nèi)異病灶輸尿管異位病灶手術(shù)瘢痕異位病灶32DifferentlesionsinintestinaltractAdifferentlesioninthebladderEctopicureterallesionSurgicalscarectopiclesion第32頁Examination體征1.Pelvicmass:chocolatecystofovary2.Uterineposteriorfixation,severelylimitedmovement3.Palacralligament,posterioruterinewallnodulestenderness4.Purplebluenodulesandspotsonvulva,vaginaandcervix1．

盆腔包塊：卵巢巧克力囊腫2．

子宮后位固定，活動嚴(yán)重受限3．

宮骶韌帶、子宮后壁結(jié)節(jié)觸痛4.外陰、陰道、宮頸紫藍(lán)色結(jié)節(jié)，斑點第33頁診斷DiagnosisLaparoscopyandlaparotomyaretheaccuratemethodsofdiagnosis.Basisisfocalmorphology,notbeprovedcompletelybypathology。(Goldstandard)腹腔鏡檢查及開腹探查術(shù)是診斷精確辦法。根據(jù)是病灶形態(tài)，不一定所有經(jīng)病理證明Non-surgicaldiagnosticcriteriaincluded:pain,infertility,pelvicexamination,b-ultrasound,CA125,Positivepredictivevalue.非手術(shù)診斷標(biāo)準(zhǔn)包括：疼痛、不育、盆腔檢查、B超、CA125.5項中有3項陽性都有很高陽性預(yù)測值.第34頁B超顯示卵巢巧克力囊腫第35頁Differentialdiagnosis

鑒別診斷OvarianmalignancyPelvicinflammatorymassadenomyosis卵巢惡性腫瘤盆腔炎性包塊子宮腺肌病36第36頁子宮內(nèi)膜異位癥分期（修正AFS分期法第37頁1.若輸卵管所有包入應(yīng)改為16分2.Ⅰ期（微型）1～5分；Ⅱ期（輕型）6～15分；Ⅲ期（中型）16～40分；Ⅳ期（重型）>40分第38頁治療TreatmentObjective：ReduceandremovelesionsPainreliefandcontrolTreatmentandfertilitypromotionPreventandreducerecurrence

縮減和清除病灶減輕和控制疼痛治療和促進生育預(yù)防和減少復(fù)發(fā)第39頁ageFertilityrequirementsSymptomseverityDegreeofthelesionAlwaystreatPatientswillThedoctorisAmedicalinstitutionIndividualizedtreatmentThepaininfertilityEndometriosiscystFundamentalconsiderationsforthetreatmentofendosarphyExpectationmanagementmedicalmanagementsurgicalmanagementconjointmanagement第40頁藥品治療

medicalmanagement1）Non-steroidalanti-inflammatorydrugshavemanyeffectsinrelievingfeverandpainandanti-inflammatory。非甾體類抗炎藥2）pseudopregnancytherapy假孕療法Combinationoralcontraceptivesworkbysuppressingovulationandpossiblybycausingcervicalandendometrialchangesthatreducethelikelihoodofimplantation.口服避孕藥減少垂體促性腺激素水平，并造成類似妊娠人工閉經(jīng)。第41頁

pseudopregnancytherapy假孕療法

progestin

Byinhibitingthesecretionofpituitarygonadotropin,falsepregnancyiscaused.Medroxyprogesterone30mg/dayfor6months孕激素通過抑制垂體促性腺激素分泌，造成假孕。甲羥孕酮30mg/日，連用6個月。第42頁Gonadotropin-releasinghormoneagonist

（

(（GnRH-a）

ThesyntheticdecapeptidecompoundhasthesameeffectastheinternalGnRHandpromotesthereleaseofpituitaryLHandFSH,butitsaffinitytoGnRHreceptorishundredsoftimeshigherthanthenaturalone,inhibitsthesecretionofgonadotropinbythepituitary,leadingtoasignificantdecreaseinthelevelofovarianhormoneandtemporaryamenorrhea.Leuprin3.75mg,1time/28days,3-6timesGoserelin3.6mg,1time/28days,3-6times人工合成十肽類化合物，其作用與體內(nèi)GnRH相同，促進垂體LH和FSH釋放，但其對GnRH受體親和力較天然高百倍，抑制垂體分泌促性腺激素，造成卵巢激素水平顯著下降，出現(xiàn)臨時性閉經(jīng)。第43頁5）促性腺激素釋放激素激動劑（GnRH-a）

人工合成十肽類化合物，其作用與體內(nèi)GnRH相同，促進垂體LH和FSH釋放，但其對GnRH受體親和力較天然高百倍，抑制垂體分泌促性腺激素，造成卵巢激素水平顯著下降，出現(xiàn)臨時性閉經(jīng)。亮丙瑞林3.75mg，1次/28天，3-6次戈舍瑞林3.6mg，1次/28天，3-6次第44頁surgicalmanagement手術(shù)治療Indicationofoperation:PainaccessorymassinfertileOperationmethod:transabdominalsurgerylaparoscopicsurgeryOperativeprocedure:operationtopreservereproductivefunctionOvarianpreservationsurgeryRadicalsurgery第45頁Laparoscopicchocolatecystremovalofovary腹腔鏡下卵巢巧克力囊腫剝除術(shù)第46頁Provention1.Preventmenstrualbloodflow2.Drugcontraception3.AvoidiatrogenicplantingIatrogenicendometrium1.避免經(jīng)血倒流2.藥品避孕3.避免醫(yī)源性引發(fā)種植醫(yī)源性異位內(nèi)膜第47頁EMKnowledgePointSummaryEndometriosisisabenignandinvasivediseasethatoftenoccursinwomenduringchildbearingyearsCommonsymptomsarepain,infertility,menstrualdisorders,abdominaldiscomfortTypicalsignsarepelvictendernessnodulesorchocolatecystsoftheovariesLaparoscopyorlaparotomyisthegoldstandardforEMdiagnosisEndometriosisisrelatedtoovarianhormoneandishormone-dependentdisease,easytorelapse.第48頁二、子宮腺肌?。╝denomyosis）Adenomyosisoccurswhentheendometriuminvadesthemyometrium.Mostofthemareaged30to50.About15%werecomplicatedwithendometriosis,andabouthalfwerecomplicatedwithuterinefibroids.當(dāng)子宮內(nèi)膜侵入子宮肌層時稱為子宮腺肌病。多發(fā)生于30歲~50歲經(jīng)產(chǎn)婦。約15%合并內(nèi)異癥，約半數(shù)合并子宮肌瘤。第49頁Etiologyandpathogenesis

病因和機制Etiology：Multiplepregnancy，delivery,inducedabortion，chronicendometritisTheendometrialbasallayerwasdamagedPathogenesis：Theunderlyinglayeroftheendometriumlackssubmucosa,whichisindirectcontactwiththemusclelayerandlackstheprotectiveeffectofthesubmucosa.Asaresult,theendometriumiseasytoinvadethemusclelayerinanatomicalstructure基底層子宮內(nèi)膜侵入肌層生長造成，數(shù)次妊娠及分娩、人工流產(chǎn)、慢性子宮內(nèi)膜炎等造成子宮內(nèi)膜基底層損傷。內(nèi)膜基底層缺乏黏膜下層，內(nèi)膜直接與肌層接觸，缺乏黏膜下層保護作用，使得在解剖構(gòu)造上子宮內(nèi)膜易于侵入肌層第50頁