Endometriosis

子宮內(nèi)膜異位癥子宮內(nèi)膜異位癥-21.定義[Definition]

Activeendometrium(具有活性的子宮內(nèi)膜)isfoundinlocationsotherthantheliningoftheuterinecavity.(出現(xiàn)在子宮體以外部位)

Cyclicbleeding(周期性的出血)mayoccurintheislets(島,病灶)ofendometriosisaswellasinthenormalendometrium,formingendometrioticleisions(內(nèi)膜異位病灶)anddevelopingsomesymptomssuchaspainanddisfunctionoforgansinvolved.(病變發(fā)展可出現(xiàn)疼痛及器官的功能異常)子宮內(nèi)膜異位癥-2Figure7.1showsthesitesatwhichendometriosismayoccur.

子宮內(nèi)膜異位癥-22.病因及發(fā)病機(jī)理[Etiologyandpathogenesis]1)Retrogrademenstruationorimplantation(經(jīng)血逆流/種植學(xué)說(shuō))minutefragmentsofendometrium(子宮內(nèi)膜碎屑)passalongthefallopiantubes(輸卵管)duringmenstruationandspillintothepelvicpartoftheperitonealcavity(盆腹腔),becomingimplantedonthesurfaceoftheovary,intherectovaginalpouch(子宮直腸陷凹)orinsomeothersituations,anddevelopingintoendometriosis.子宮內(nèi)膜異位癥-2

Endometriosisinabdominalscar(腹部傷口andumbilical(臍部的）endometriosisarethecasesinpointofimplantationtheory(種植學(xué)說(shuō)).Thesemayfollowanopera-tionforendometriosis,myomectomy(肌瘤摘除術(shù),iftheuterinecavityisopened).子宮內(nèi)膜異位癥-22)Serosalmetaplasia（體腔上皮化生學(xué)說(shuō)）TheMullerinducts(苗勒氏管)areoriginallyDerived(起源)fromaninfoldingofthe

embryoniccoelom(胚胎體腔的內(nèi)折).Asweknow,theMullerinductswilllaterformthefallopiantubes(輸卵管),uterusanduppervagina(陰道).anditissuggestedthatendometriosismayresultfrommataplasiaoftheperitoneal

endothelialcells(腹膜間皮細(xì)胞,alsooriginatedfromembryoniccoelom)inthepelviccavity.子宮內(nèi)膜異位癥-23.(病理)[Pathology]Thepathologicappearanceofendome-triosisvariesgreatlydependingonthelocationandextentofthedisease.(病變的程度和部位)

Thetwobasicfeatures:(兩個(gè)基本特征))Cyclicbleedingintheendometrioticsite(異位病灶周期性出血）,Surroundedbyazoneoffibrosisandcontractureor“puckering”

(病灶周圍組織皺縮/纖維化改變)子宮內(nèi)膜異位癥-2病理特征:

早期無(wú)色素病灶:火焰狀紅色灶腺樣息肉紫褐色斑點(diǎn)或小泡中晚期紫藍(lán)色結(jié)節(jié)巧克力囊腫子宮內(nèi)膜異位癥-2Theovaryisthemostcommonsiteofimplantation(approximately50%).Thecysts(endometrioma,內(nèi)膜異位囊腫)varyindiameterfrom1to25mm.Ovarianinvolvementisalmostalwaysbilateral.Thelargerovarianendometrioma,filledwitholddarkhemolyzedblood,areoftenreferredtoas“chocolatecysts(巧克力囊腫)’.子宮內(nèi)膜異位癥-2子宮內(nèi)膜異位癥-2子宮內(nèi)膜異位癥-2子宮內(nèi)膜異位癥-2Endometrioticfociinsitesotherthantheovaryareusuallysmallerandmorenumerous

子宮骶韌帶子宮直腸陷凹子宮后壁下段盆腔腹膜子宮內(nèi)膜異位癥-2子宮內(nèi)膜異位癥-2子宮內(nèi)膜異位癥-2

2)MicroscopicPathologicFeatures:

Theclassicmicrosocopicpictureofendometriosisconsistsofendometrialglandsendometrialstroma(內(nèi)膜間質(zhì)細(xì)胞)hemosiderin-laden(含鐵血黃素沉著)macrophagessurroundinginflammatorycellsandfibrosis(周圍纖維結(jié)締組織增生)無(wú)色素早期可見(jiàn)到典型的異位內(nèi)膜組織發(fā)生惡變機(jī)會(huì)少

子宮內(nèi)膜異位癥-2Pain

Painisthemostcommonsymptom.Itismostlycharacterizedbysecon-daryandprogressivedysmenorrhea(痛經(jīng),cyclicpaininphasewithmenses).Itcanalsocausedyspareunia(性交痛，painduringorfollowinginter-course),chronicpelvicpain(慢性盆腔痛)andlowbackpain(腰背部痛).4.[ClinicalFeatures]子宮內(nèi)膜異位癥-22)Infertility:30%~40%pelvicadhesionsmaypreventtheovumfromenteringthefallopiantube;ovarianadhesionsmaypreventreleaseoftheovumfromthefollicle;子宮內(nèi)膜異位癥-23)Pelvicexamination(體征)

輕癥無(wú)明顯體征

典型

1子宮后傾固定

2子宮骶韌帶子宮直腸陷凹子宮后壁下段可捫及大小不等的結(jié)節(jié),有觸痛

3一側(cè)或雙側(cè)捫到囊實(shí)性包塊,壁厚,不活動(dòng),有輕壓痛

4宮頸內(nèi)膜異位可見(jiàn)紫藍(lán)色小點(diǎn)子宮直腸陷凹內(nèi)膜異位可在陰道后穹窿捫及或見(jiàn)到紫藍(lán)色突起,質(zhì)地偏硬,經(jīng)期增大,觸痛明顯子宮內(nèi)膜異位癥-2D.RuptureofendometriomaSuddenruptureofanendometriomamayoccuratanytime.Ruptureshouldbesuspectedinanypatientwithknownendometriosiswhopresentsasanacuteabdominalemergency(急腹癥).Theremaybeachemicalperitonitis(腹膜炎)duetoirritationcausedbybloodproducts.子宮內(nèi)膜異位癥-25.[Diagnosis](診斷)History:secondaryandprogressivepainPhysicalsigns:implantsofnodular,firm,fixed,anddiscreteSpecialexaminations:Ultrasonagraphicscanning(超聲)Laparoscopy(腹腔鏡)CA125

子宮內(nèi)膜異位癥-26.Treatment1)Follow-upIfthepatienthasnosymptomorendometriosisisanincidentaldiscoverythereisnoneedtoinsistonanytreatment,althoughthepatientshouldbereexaminedperiodically.Forthesepatients,re-assuranceandmildanalgesics(止痛)areofteneffective.

子宮內(nèi)膜異位癥-22)localtreatmentIftherearesymptoms,adiagnosisofintraperitonealendometriosishastobeconfirmedbylaparoscopyorlaparotomy(剖腹探查).Ifthelesionsarenotextensive,localablative(病灶局部清除)treatmentwithdiathermy(電熱療法)orlasermaythenbecarriedout.子宮內(nèi)膜異位癥-23)HormonaltherapyThebasisofhormonalmethodstreatingendometriosisisthesuppressionofcyclicalovarianfunctionandhencemenstruation.Thereareseveralwaysofachievingthisandthechoiceoftreatmentmaybeinfluencedbythepatient’stolerenceofside-effects.

子宮內(nèi)膜異位癥-2A.Pseudopregnancy(假孕療法)Progestogensmaybegiveninlargedosesfor9-12monthstosuppressmenstruationandproduceastateoftenreferredtoaspseudopregnancy.Breastenlargement,abdominaldistensionandwaterretentionarecommonside-effects.子宮內(nèi)膜異位癥-2B.psudoamenorrhea(假絕經(jīng)療法)

a)Afrequentlyusedagentisdanazol.Thisisaweakandrogenwithsomeinhibitoryactionontheovary,anditcausesendometrialatrophy(內(nèi)膜萎縮).However,itisexpensiveandcancausesevereside-effectsinsomewomen,e.g.weight-gain,masculinization(男性化)anddeepeningofthevoice,whichmayevenbepermanent.子宮內(nèi)膜異位癥-2b)GnRH-a

GnRH-acancompletelysuppresstheovarianfunctionandmenstruation.Andinturnthemainside-effectsincludeflushing(潮熱)andvaginaldryness(陰道灼熱）causedbylowestrogenlevel.Whilelong-termusemayresultinbonelossfromestrogendeficiency.子宮內(nèi)膜異位癥-2

4)surgicaltreatmentConservativesurgicaltreatment

(保守手