1. Endometriosis & Adenomyosis OB & GYN Hospital, Fudan University Lei Yuan, MD ylronda@163.com

2.  Endometriosis  Endo  Endometrium  Adenomyosis  Adeno  Adeno(ids) - OSIS

3. Key points Symptoms Diagnosis Treatment Endometriosis & Adenomyosis Case discussion Diagnosis Differential diagnosis Further examination Treatment

4.  Endometriosis  Symptoms: pains secondary dysmenorrhea; (Non Specific) dyspareunia; progressive; Infertility  Diagnosis: –Gold standard——visual inspection of the pelvis via laparoscopy –Histological confirmation——ideally ， negative one does not exclude diagnosis Basics Key pointsEndometriosis

5. Basics  Treatment: Individualized and standardized Key points Characteristic of disease Patient’s condition Surgery Laparoscopy or laparotomy Radical or conservative Non-surgical treatment (medication) First-line medication Progestins Gonadotropin-releasing hormone (GnRH) agonists Danazol (androgenic) Oral contraceptives Controlled ovarian hyperstimulation (fertility treatment) Text Endometriosis

6.  Adenomyosis Symptoms:Typical: Pain secondary dysmenorrhea progressive / severe Menorrhagia symptomless: 35 ％ 15% associated with EMs Signs: Symmetrically enlarged uterus Boggy and tender( softer than myoma) Basics Key pointsAdenomyosis

7.  Diagnosis: −Symptoms, Signs, −Ultrasonography − Pathology Basics Key pointsAdenomyosis

8.  Treatment: – Principles: patients’ age; severity of symptoms; fertility requirements –Medication: symptom relieved, none radical cure NASIDs; Ocs; Mirena( a low-dose hormonal IUD) −Surgery: no fertility desire; no respond to medical treatment Hysterectomy (ovary preservation as appropriate) www.themegallery.com

9. Case discussion

10. CASE 1

11. Case 1 History: 33-year-old female, pelvic pain during menstruation for 4 years, progressively worse over the years, with pre and postmenstrual spotting; dyspareunia and pain during defecation for 6 months, progressively worse ; no change in the color or caliber of her stool; no sexually active besides her husband; no birth control, and been trying to get pregnant for the last 3.5 years. Menstrual history: regular G0P0 Normal Pap smear 6 months ago. Case discussion

12. Case 1 Pelvic examination –Uterus: fixed, retroverted. –Tender nodularity of the uterosacral ligaments bilaterally. –Both ovaries are somewhat tender and mildly enlarged. Case discussion

13. Initial diagnosis:  Pelvic inflammation  PCOS  Endometriosis  Ovarian cancer  hydrosalpinx Next step?

14. Ultrasonography ： 1)bilateral adnexal masses; 2)a thick, viscous dark brown fluid CA125 ： 87 U/ML

15. PCOS Endometriosis What is your answer?

16. Management  Principle Principle The certainty of the diagnosis The severity of symptoms The extent of the disease The desire for future fertility The age of the patients

17. Surgical treatment  Laparoscopy  Cystectomy  Hydrotubation

18. Laparoscopic assisted cystectomy Puncture sites  Umbilicus  McBurney's point  reverse McBurney‘s point  suprapubic ventral midline

19. Video

20. From Novak Gynecology 14 th

21. Histologic features

22. Post-operative medication Status quo: Still controversial Objectives: to reduce recurrence and promote fertility Medication: GnRHa, Progestin, OCs … www.themegallery.com

23. QUESTIONS Symptoms Signs EMs Types: Staging Management

24. CASE 2

25. Case 2 History 41-year-old female, increasing colicky pain during menstruation which needs ibuprofen to relieve symptom; her volume of menstrual flow has increased steadily over the last several months, though her cycles continue to be regular; no vaginal discharge or fever. Menstrual history: regular G1P1 Normal Pap smear 2 months ago Dilation and curettage 2 months ago Case discussion

26. Case 2 Pelvic examination –Uterus: symmetrically enlarged, smooth with a boggy consistency that is somewhat tender. –No adnexal masses are appreciated. Laboratory Findings –Hemoglobin: 11g/dL Case discussion

27. Questions  Current diagnosis  Differential diagnosis  Further examination  Treatment Case discussionCase 2

28. Questions  Current diagnosis Adenomyosis?  Differential diagnosis Uterine myoma Dysfunctional uterine bleeding (DUB) Endometriosis  Further examination Radiologic imaging Ultrasound  Treatment Medication OR surgery Case discussionCase 2

29. Take home message 1. Familiarize with the causes and pathogenesis of endometriosis 2. Master the clinical features, diagnosis and differential diagnosis of endometriosis 3. Grasp the major principles behind the treatment strategy of endometriosis