1. Endometriosis Women’s Hospital, School of Medicine Zhejiang University Prof. Lin Jun

2. Definition
Endometriosis is usually defined as the presence of endometrial-like tissue, that is, glands and stroma, outside the endometrium
in uterine cavity and myometrium.

3. Common sites of endometriosis
The most common sites：
uterosacral ligament
rectouterine pouch
ovary
Others：
uterine serosa
fallopian tube
sigmoid colon
outside of the pelvis :
Umbilicus , bladder, kidney

4. Prevalence
present in 10%-15% of women in reproductive age group, especially from age 25 to 45
normally not seen before age 15 or after menopause
less and late childbearing
latest study: more frequent menses (cycle length ≤ 27 days ) and prolonged menstrual flow (≥ 1 week) 2 times risk

5. Pathogenesis Theories of sources of ectopic endometrium
Implantation theory ——Sampson 1921
endometrium transfer → implant →grow
⒈retrograde menstruation theory
⒉iatrogenic implantation
⒊ transport by lymph and vein

6. Pathogenesis Theories of source of ectopic endometrium
metaplasia theory of coelomic epithelium
induction theory

7. Pathogenesis Factors related with endometriosis
Genetic Factors ：high risk in first-degree relatives
Immunologic Factors
Inflammation
Character of uterine eutopic endometrium

8. Pathology ectopic endometrium ↓ hemorrhage
proliferation of fibrous tissue ＆ adhesions
dark blue or dark brown spots
scarring nodules or cysts

9. Pathology Ovarian endometriosis Peritoneal endometriosis
Deep infiltrating endometriosis
others

10. Gross appearance : ovarian endometriosis red, blue, or brown spots
endometriomas —— chocolate cysts

11. Gross appearance : peritoneal endometriosis common sites：
uterosacral ligament、rectouterine pouch
purple spots
dark brown spots
red lesions
white lesions
peritoneum lack

12. peritoneal endometriosis

13. peritoneal endometriosis

14. cervix
umbilicus

15. The microscopic findings ：
endometrial glands
endometrial stroma
fibrin
red blood cells and hemosiderin
≥2 findings to be diagnosed

16. Clinical Findings symptoms： dysmenorrhoea and chronic pelvic pain
the most typical symptom：secondary dysmenorrhea that worsens over time
dyspareunia
abnormal uterine bleeding
heavy menses, prolonged menstruation or premenstrual spotting
infertility：50% of patients
acute abdomen: inter-cyst hemorrhage, or rupture

17. Clinical Findings symptoms： others： diarrhoea constipation
bloody stool
painful urination
bloody urine
backache

18. Causes of infertility 1) Mechanical reason
2) Environmental change in the peritoneal cavity
3) Abnormal immune function
4) Abnormal ovarian function (anovulation,LPD, LUFS)
5) Increase in spontaneous abortion

19. Clinical Findings Pelvic Examination： fixed retroverted uterine
tender nodules on uterosacral ligament or rectouterine pouch
tender and fixed adnexal masses

20. Diagnosis history pelvic examination
laparoscopy —— golden diagnosis standard
diagnosis, classification ＆treatment
ultrasound, (CT and MRI, expensive)
serum CA125 ↑but usually ＜100IU/ml
anti-endometrium antibody

21. Diagnosis Clinical classification
Revised American Fertility Society (r-AFS), 1985
Useful for:
Assessment of severity
Selection of therapeutic regimen
Comparison
Prognosis

22. r-AFS

23. Differential Diagnosis
Ovarian tumor
ascites, solid or mixed, B ultrasound image, CA-125>100 IU/ml
Abdominal inflammatory mass
history of infection, fever, not cyclic, treatment with antibiotics effectively
Adenomyosis
medial, severe pain, uterus slightly enlarged

24. Treatment Principles of treatment：
Treatment should be individualized according to the age, severity of the condition and desire for childbearing.
With mild symptom: expectant therapy
With childbearing desire:
mild-condition: medication
severe-condition: fertility preservation surgery
No childbearing desire :
Surgical treatment: ovary preservation or radical surgery

25. Treatment
Expectant Therapy
Follow-up
symptoms management：NSAIDs

26. Treatment Medication Objective:
cause atrophic changes in the ectopic endometrium

27. Medication Pseudopregnancy therapy
⒈ oral contraceptives：a pill once daily for 6-12 m
⒉ progestins：
medroxyprogesterone 30mg daily
megestrol 40mg daily
norethindrone 5mg daily
Side effects:
Intermittent breakthrough bleeding, nausea, breast tenderness, fluid retention, weight gain

28. Medication Pseudomenopause therapy ⒈GnRH-a m / H, 1 inj/q28d, start d1
Mechanism: Medical hypophysectomy
/ Medical oophorectomy
leuprorelin 3.75mg
goserelin 3.6mg
tryptorelin 3.75mg
m / H, 1 inj/q28d, start d1

29. Medication ⒈GnRH-a Side effects: (1) Menopausal symptoms :
hot flashes, dryness in vagina, loss of libido
(2) Osteoporosis

30. Medication Pseudomenopause therapy ⒉ Danazol
A derivative of 17-α-ethinyltestosterone
Mechanism:
Directly suppressing ovarian steroidogenesis
Direct inhibiting the growth of endometrium
mg/d for 6 months

31. Medication ⒉ Danazol Side effects:
acne, deepening of the voice, oily skin, headache, hot flashes, loss of libido, weight gain

32. Medication
others：
gestrinone
mifepristone

33. Surgical treatment Purposes： ⑴ diagnosis and classification
⑵ excise or destroy all endometriotic tissue
⑶ remove all adhesions, restore pelvic anatomy
⑷ enhance fecundity
⑸ relieve pain

34. Surgical treatment
laparoscopy + medicine
golden standard of treatment

35. Surgical treatment Modes of surgical operation:
(1) Fertility preservation
(2) Ovarian function preservation
(3) Radical surgery
(4) Surgery for pain relief

36. Treatment Combination of medication and surgery surgery + medication
medication + surgery + medication
Treatment for patients with infertility

37. Prevention Prevent retrograde flow of menses
Contraception with medicine
Avoid iatrogenic implantation of the ectopic endometrium

38. Adenomyosis

39. Definition
Adenomyosis is defined by the presence of endometrial glands and stroma within the myometrium. It is associated with myometrial hypertrophy and proliferation.

40. Endometriosis ＆ Adenomyosis
Adenomyosis is thought to be unrelated to endometriosis.
Pathogenesis ＆ histological confirmation
Sites of lesions
Clinical findings

41. Clinical findings Symptoms： prolonged and heavy menses
Multiparas（＞40 y） were most commonly affected.
Symptoms：
prolonged and heavy menses
Dysmenorrhea that worsens over time
Pelvic exam：
enlargement of uterus
tenderness

42. Diagnosis Typical symptoms and signs Histopathologic examination
—— standard of the diagnosis
B ultrasound would suggest the disease.

43. Treatment 1. Medication ：GnRH-a
2. Surgical treatment : total hysterectomy

44. Thank you !