1. Department of Obstetrics and Gynecology
Endometriosis Disease
Xiaoli Chen
Department of Obstetrics and Gynecology

2. Endometriosis
Adenomyosis

3. What is...?
Endometriosis
A condition in which the tissue that normally lines the uterus grows in other areas of the body, causing pain, irregular bleeding, and frequently infertility.

6. Characteristics Common in reproductive-age women Estrogen dependence
Genetic disease
Immunologic disease
Inflammatory disease
Benign diseases, malignant behavior
5-10% of reproductive-age women
25-35% of patients with infertility
Usually regresses following menopause and not usually found prior to menarche
No differences among ethnic groups or socioeconomic status
Genetic predisposition - 6-7% increased risk with history of first degree relative

7. Pathogenesis

8. Pathogenesis Not clear. 4 theories proposed:
- Retrograde menstruation theory
- Coelomic metaplasia theory
- Lymphatic or vascular dissemination theory
- Immunology theory
No single theory can account for the location of endometriosis in all cases.

9. Pathology

10. Pathology: Classification of Common Pelvic Endometriosis
Ovarian endometriosis
Minimal: superficial minimal
Classic: cyst
Peritoneal endometriosis
Pigmentation: classic indigo or brown ectopic tubercles。
Non-pigmentation ：early focus

11. Pathology: Microscopic Examination
Endometrial tissue (glands and stroma)
Fibrin and red cell
Hemosiderin

13. Clinical presentation
Symptoms
Dysmenorrhea (progressive)
Chronic pelvic pain
Dyspareunia
Pain caused by rupture of endometrioma
Infertility
Menstrual disturbance
Painful defecation

14. Clinical presentation
Signs
Fixed,retroverted uterus
Enlargement of the ovaries
Tender nodular uterosacral ligament

15. Diagnosis

16. Diagnosis Medical history Gynecological examination
Auxiliary examination
laparoscopy
Imaging
laboratory

17. Diagnosis: Medical History
Menstruation
Reproduction
Family history
Operation history
Relationship of dysmenorrhea and gynecological operation

18. Diagnosis: Gynecological Examination
Bimanual or trimanual examination
Uterus
Mass
Tenderness nodes

19. Diagnosis: Laparoscopy
The best method for diagnosis
Diagnosis by direct inspect
Pathological confirmation needed
Treatment at the same time

20. Diagnosis: Imaging B-mode sonography Sensitivity 97％, specificity 96％.
Mass: location, size, content, blood supply, etc.

21. Diagnosis: Imaging CT or MRI
Provide additional and confirmatory information
More costly

22. Diagnosis: Laboratory
CA125
Slightly elevated in moderate or severe patients.
Limited on sensitivity and specificity.
No single use for diagnosis.

23. Diagnosis: Laboratory
Anti-endometrium antibody
Negative in most of normal women.
Positive rate over 60％ in endometriosis patients.
Positive means active ectopic endometrium.
Not popular used in clinic.

24. Differential Diagnosis

25. Differential Diagnosis
Diseases
Malignant tumor of ovary
Pelvic inflammatory mass
Adenomyosis
Aspects
History
Gyn Examintion
B-mode ultrasonography
Lab research

26. Treatment Expectant therapy Medical treatment Surgical treatment
- Pseudomenopause therapy
- Danazol
- GnRH agonists
- Pseudopregnancy therapy
Surgical treatment
All treatment options are suppressive rather than curative
Very helpful for dysmenorrhea, chronic pelvic pain, but not very effective for infertility

27. Medical Oophorectomy - GnRH agonists
Mechanism:
- Desensitization of the pituitary
- Medical hypophysectomy →medical oophrectomy
Drugs used:
- Leuprorelin 3.75mg/28 Days D5
- Goserelin/Zoladex 3.6mg/28 Days D5
- Triptorelin/Decapreptyl 3.75mg/28 Days D5
Side dffects:
- (1)Menopausal symptoms:
hot flashes, dryness in vagina, loss of libido
- (2)Osteoporosis
Add-Back Therapy

28. Pseudomenopause therapy- Danazol
Synthetic steroid
- 17α-ethinyltestosterone Derivative
Mechanism:
- Directly suppressing ovarian steroidogenesis
- Direct inhibiting endometrial growth
Doses:
mg/day for 6 months
Side effects:
- Hypoestrogenic environment: decreased breast
size, atrophic vaginitis, hot flashes, emotional swings
- Virilism

29. Pseudopregnancy therapy- Progestogen
Mechanism:
Inhibition of uterine contraction
Inhibition on growth of the endometrium
Doses:
Medroxyprogesterone 20-50mg/day
6 months
Side effects : weight, fluid retention, breakthrough bleeding, depression

30. Surgery Diagnostic surgery Very conservative surgery
no attempt to treat any of the endometriosis
Very conservative surgery
treatment of a very large, obvious, or treatable area of endometriosis
Aggressive surgery
removes all the endo while preserving the organs
maintains fertility
Radical surgery
removal of the reproductive organs
hysterectomy

31. Treatment -- infertility
Minimal disease - pregnancy rate without
treatment after 5 years is 90%
severe disease - proceed to laparoscopy
woman over 35 yrs old - proceed with
treatment
Medical therapy is of limited value
Assisted reproduction

32. Lifestyle Exercise Eating well and getting enough rest
Practicing relaxation techniques such as yoga and meditation
Exercise often helps to relieve or lessen pelvic pain and menstrual cramps.
Eating well and getting enough rest also helps the body to manage pain.
Practicing relaxation techniques such as yoga and meditation help to ease pain too.

33. Recurrences May recur with medical therapy or surgical therapy
GnRH agonists or Danazol
- Minimal disease – 37%,
- severe disease – 74%
Surgery – 40% after 5 years
56% of all patients after 7 years

34. Adenomyosis

35. Basic Concepts
Definition of Adenomyosis:
Presence of functioning endometrial glands and stroma in the myometrium.
Myometrial cells around become hypertrophy and hyperplasia compensatively

36. Pathogenesis

37. Pathogenesis The pathogenesis is not known.
Propose by Cullen in 1908, the theory of direct growth of the basal layer of endometrium into the myometrium is widely accepted.

38. Pathogenesis
Estrogen has been implicated as a stimulus to the development of adenomyosis.
The symptomatic improvement that occurs with the onset of menopause supports this concept.

39. Pathogenesis Induction Factors Inheritance
Trauma (curettage / cesarean section )
Hyperestrogenemia
Virus infection
经血逆流：背景：70％-90％的妇女有经血返流。

40. Pathology

41. Pathology Macroanatomy Uterus enlarges uniformly, like a ball.
Usually not bigger than 12 weeks of gestation.
Thick muscle fiber and micro vesicle seen in myomerium.
Some grew like myoma, called adenomyoma.

42. Pathology Microscopic examination
Endometrial glands and stroma in the myometrium, scattered like islands.
Ectopic glands usually in proliferate phase.
Local secretory changes seen occasionally.

43. Symptoms and Signs Hypermenorrhea 50% Dysmenorrhea 30%
Symmetrically enlarged uterus
- Improved ultrasound: preoperative diagnosis
- MRI: negative/equivocal sonogram
presence of leiomyomas

44. Diagnosis Primary diagnosis Classic symptoms and signs.
B-mode ultrasonography and CT is helpful in diagnosis.
Confirmative diagnosis
Pathological examination.

45. Diagnosis Differ from Pregnancy: pregnancy test, ultrasound
Submucous leiomyomas: hysteroscopy
Endometrial cancer: endometrial biopsy
Myoma: ultrasound
Endometriosis:ultrasound
premenstrual and intramenstrual dysmenorrhea, adherent adnexal masses, and “shotty” cul-de-sac/uterosacral ligament nodulations

46. Complications and Prevention
Chronic severe anemia
Primary adenocarcinoma
★Adenomyosis can’t be prevented.

47. Treatment

48. Treatment: Medication
No medication is radical
Mild symptoms
NSAID
Oral contraceptive pills
Young, pregnancy-desiring, close to menopause
Try GnRHa

49. Treatment: Surgery Suitable for patients with： Severe symptoms
Relatively old age
No desire for pregnancy
No effect by medication

50. Treatment: Surgery Methods Total hysterectomy Adenomyoma resection
Young with pregnancy desiring
Prone to recurrence
Laparoscopic uterosacral nerve ablation / Presacral neurectomy
Pain relief rate: 80％

51. Thank you