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Comprehensive Guide to Endometriosis: Symptoms, Diagnosis, and Treatment Options

Learn about endometriosis, its common sites, prevalence, pathogenesis theories, clinical findings, diagnosis methods, and treatment options including expectant therapy, medication, and surgery.

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Comprehensive Guide to Endometriosis: Symptoms, Diagnosis, and Treatment Options

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  1. Endometriosis

  2. Definition Endometriosisis 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 (乙状结肠) outside of the pelvis : • Umbilicus(脐) , 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 (种植学说)——Sampson 1921 endometrium transfer → implant →grow ⒈retrograde menstruation (经血逆流) theory ⒉iatrogenic (医源性的) implantation ⒊ transport by lymph and vein

  6. Pathogenesis Theories of source of ectopic endometrium • metaplasia theory of coelomic epithelium(体腔上皮化生学说) • induction theory（诱导学说）

  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(脐)

  15. The microscopic findings： • endometrial glands • endometrial stroma • fibrin • red blood cells and hemosiderin（含铁血黄素） ≥2 findings to be diagnosed

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

  17. Clinical Findings symptoms： others： diarrhoea（腹泻） constipation（便秘） 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（腹水）, 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（非甾体类抗炎药）

  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 （醋酸甲孕酮）30mg daily • megestrol （甲地孕酮） 40mg daily • norethindrone （炔诺酮） 5mg daily Side effects: Intermittent breakthrough bleeding, nausea, breast tenderness, fluid retention, weight gain

  28. Medication Pseudomenopause therapy ⒈GnRH-a Mechanism: Medical hypophysectomy (药物性垂体切除) / Medical oophorectomy (药物性卵巢切除) • leuprorelin （亮丙瑞林，抑那通）3.75mg • goserelin （戈舍瑞林，诺雷德）3.6mg • tryptorelin （曲普瑞林，达菲林） 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(性欲) (2) Osteoporosis

  30. Medication Pseudomenopause therapy ⒉ Danazol A derivative of 17-α-ethinyltestosterone （17-α乙炔睾酮衍生物） Mechanism: • Directly suppressing ovarian steroidogenesis （甾体激素生成） • Direct inhibiting the growth of endometrium 400-600 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 （孕三烯酮） • 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 (医源性) 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 • Pathogenesis ＆ histological confirmation • Sites of lesions • Clinical findings Adenomyosis is thought to be unrelated to endometriosis.

  41. Clinical findings Multiparas（＞40y） were most commonly affected. Symptoms： • prolonged and heavy menses • Dysmenorrheathat 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 !

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