Department of Obstetrics and Gynecology,CUM
Case (Part I)
Age,40 years
G2P1
Complaint:
Menstrual pain for 3 years
Present history:
Three years ago,she started to feel pain in lower abdomen
and lumbosacral (腰骶 )area during menstruation,The
pain has been worsening progressively,In addition,she
has heavy menses (月经 ).
Past history:
She gave birth to healthy male baby 15 years ago,Five
years ago she had an artificial abortion,and an IUD was
placed then.
What condition was she having?
Endometriosis
(子宫内膜异位症）
? Definition of endometriosis
? Pathology and clinical features
? Diagnosis
? Principles of treatment
Learning Objectives
What is endometriosis?
Definition:
Presence of functioning endometrial glands and
stroma (间质 ) outside their usual location in the uterine
cavity,
Pathological features:
?A benign condition with clinically ‘malignant’
biological behavior (invasion and metastasis)
? Sex hormones dependent
Introduction
?About 3%-10% in women of reproductive age
? 5%-15% women who are having an abdominal
surgery are diagnosed with the condition
? 25%-35% in women with infertility
? 20%-90% in women with chronic pelvic pain
? 40%-60% in women with menstrual pain.
Introduction
How common is the disease?
Introduction
Why does endometriosis happen?
Pathogenesis
Ectopic transplantation theory (异位种植学说）
(Direct Implantation)
? 70-90% women have retrograde menstruation (经血逆流 ).
? Viable endometrial cells exist in the peritoneal fluid in
more than 50% woman during menstruation.
? Implantation of menstrual tissue has been demonstrated
experimentally (in the monkeys) and iatrogenic (医源性的 )
implantation occurs (e.g,endometriosis in the scar of
abdominal wall after an abdominal cesarean section).
? Often pelvic deposits of endometriosis occur close to the
ends of the fallopian tubes.
Sites of endometriosis
Pathogenesis
? Endometrial tissues have been found in lymphatic nodes
and pelvic venous blood vessels.
? Presence of endometriosis in organs distal to pelvis
e.g,lung and muscle or skin of the extremities (四肢 ).
Pathogenesis
Ectopic transplantation theory (异位种植学说）
(Blood or Lymphatic Vessel Spread)
Metaplasia of Coelomic Epithelium(体腔上皮化生学说 )
Serosa (浆膜 ) and peritoneum (腹膜 ) originate from
multipotent coelomic epithelium
Predisposing factors
Genetic influences
Incidence is 6.9% in first-grade relatives of patients with
endometriosis compared with 1% in a control group.
Incidence is 75% if one of the twin sisters has endometriosis.
Immune deficiency
Monkeys with spontaneous endometriosis were found to
have lowered cell-mediated response to autologous (自体的 )
endometrial tissue.
Pathogenesis
Pathology
The basic pathological change of endometriosis is
that the ectopic endometrium periodically bleeds in
response to changes in ovarian sex hormones
resulting in growth of surrounding fibrous tissue and
formation of cysts (endometrioma/子宫内膜异位囊肿 )
and/or adhesion.
Pathology
Gross appearance
Pathology
Gross appearance
Pathology
Gross appearance
Pathology
Gross appearance
Pathology
Gross appearance
Pathology
Gross appearance
Pathology
Primary infertility
Gross appearance
Tiny lesions spots/cysts
Pathology
Gross appearance
Pathology
Gross appearance
Pathology
Gross appearance
Pathology
Gross appearance
Pathology
Gross appearance Lesions on the cervix
Pathology
Ovarian endometriosis
1,The most common site of endometriosis
2,80% lateral and 50% bilateral
3,Tiny or classic
Gross appearance
Pathology
Gross appearance
Endometrioma
(子宫内膜异位囊肿）
Chocolate cyst
(巧克力囊肿）
Pathology
Gross appearance
Endometrioma
(子宫内膜异位囊肿 )
Chocolate cyst
(巧克力囊肿）
Pathology
Microscopic appearance
Pathology
Microscopic appearance
Pathology
Microscopic appearance Siderocyte (含铁血黄 素细胞 )
Clinical Features
? Symptoms and signs vary according to site of lesions.
? 25% asymptomatic.
1,Menstrual pain or lower abdominal pain
2,Dyspareunia (性交痛 )
3,Infertility
4,Abnormal uterine bleeding
5,Pain caused by rupture of endometrioma
6,Symptoms and signs in other systems caused by
endometriosis
1,Menstrual pain or lower
abdominal pain
2,Dyspareunia (性交痛 )
3,Infertility
4,Abnormal uterine bleeding
5,Pain caused by rupture of
endometrioma
6,Symptoms and signs in other
systems caused by
endometriosis
Clinical Features
Menstrual pain or lower abdominal pain
1,Secondary dysmenorrhea that worsens over time
(继发性进行性痛经 ),
2,Lower abdominal or lumbosacral pain that occasionally
may radiate to vagina,perineum,anus and thigh,Pain
usu,starts from 1-2 days prior to menstruation,most
severe on the first day,and disappears when the period
finishes.
3,Discrepancy between severity of pain and pathological
findings.
4,27-40% of patients have no menstrual pain.
5,Persistent pain that escalates during menstruation.
6,Dyspareunia (性交痛 )
Clinical Features
1,Menstrual pain or lower
abdominal pain
2,Dyspareunia (性交痛 )
3,Infertility
4,Abnormal uterine bleeding
5,Pain caused by rupture of
endometrioma
6,Symptoms and signs in other
systems caused by
endometriosis
Clinical Features
Infertility
In patients with infertility,incidence of endometriosis
is 25%-35%.
In patients with endometriosis,infertility rate is 40%.
Causes:
1) Mechanical reason
2) Environmental change in the peritoneal cavity
Activity changes of macrophage
Autoimmune injury
Increase in prostaglandins
Clinical Features
Causes (Continued),
3) Abnormal ovarian function
Ovulation defects,17-27%
Inadequate development of corpora lutea (黄体 )
Luteinized unruptured follicle syndrome,
LUFS (未破裂卵泡黄素化综合征 ),18-79%
4) Increase in spontaneous abortion,
40% (vs,normal 15%)
Clinical Features
Infertility
1,Menstrual pain or lower
abdominal pain
2,Dyspareunia (性交痛 )
3,Infertility
4,Abnormal uterine bleeding
5,Pain caused by rupture of
endometrioma
6,Symptoms and signs in other
systems caused by
endometriosis
Clinical Features
Menstrual disorders
? 15-30%
? Heavy menses,prolonged menstruation or
premenstrual spotting.
Causes:
Damage of ovarian cortex and adhesion results in
ovarian dysfunction,anovulation and dysfunction
of corpora lutea.
Clinical Features
1,Menstrual pain or lower
abdominal pain
2,Dyspareunia (性交痛 )
3,Infertility
4,Abnormal uterine bleeding
5,Pain caused by rupture of
endometrioma
6,Symptoms and signs in other
systems caused by endometriosis
Clinical Features
Signs
? Retroverted and fixed uterus
? Tender nodules in rectouterine pouch,
uterosacral ligament,posterior wall
(lower segment) and rectovaginal septum
? Fixed mass along the side of uterus
Clinical Features
Case (Part 1)
Age,40 years
G2P1
Complaint:
Menstrual pain for 3 years
Present history:
Three years ago,she started to feel pain in lower abdomen
and lumbosacral (腰骶 ) area during menstruation,The
pain has been worsening progressively,In addition,she
has heavy menses.
Past history:
She gave birth to healthy male baby 15 years ago,Five
years ago she had an artificial abortion,and an IUD was
placed then.
How is the diagnosis made?
1,Symptoms and Signs (Presumptive diagnosis)
A history of secondary and progressive dysmenorrhea
(痛经 ) together with infertility
Tender nodules
Fixed cyst beside the uterus in
? Bimanual pelvic examination
? Rectovaginal examination
Diagnosis
Diagnosis
Useful for
discovering
lesions on
posterior wall
of uterus and
in
rectovaginal
septum,In
case of
endometriosis,
tender
nodules may
be palpated.
Rectovaginal examination
Auxiliary examinations
B ultrasound,the most often used
Laparoscopy,the most valuable
Diagnosis
Diagnosis B ultrasound
Diagnosis
Confirmed diagnosis
Laparoscopy is the first choice of diagnosis in the
following conditions:
1,Infertility with suspected endometriosis
2,Patients who have the symptoms of endometriosis,
in particular,if blood level of CA-125 is increased.
3,When clinical features and examination results
are suggestive of endometriosis,but result of B
ultrasound examination is negative,
Laparoscopy has the following added values:
? Assessing the patency of fallopian tubes
? Biopsy of the lesions
? Grading of endometriosis
Laparoscopy
Diagnosis
Diagnosis
Diagnosis
Other auxiliary examinations
CA-125
Anti-endometrium antibody
CT
MRI
Diagnosis
Clinical classification
Revised American Fertility Society (R-AFS),1985
Useful for:
?Assessment of severity
? Selection of therapeutic regimen
? Comparison
? Prognosis
Diagnosis
Differential Diagnosis
? Ovarian tumor
Ascites,solid or mixed,B ultrasound image,
CA-125>200 U/ml
? Abdominal inflammatory mass
History of infection,fever,not cyclic,
treatment with antibiotics effective.
? Adenomyosis (子宫腺肌病 )
Medial,severe pain,uterus slightly enlarged,
pain on compression,MRI
Which conditions should be differentiated from
endometriosis?
Differential Diagnosis
Differential Diagnosis
Adenomyosis
(子宫腺肌病 )
Gynecologic examination,
1,The cervix was normal.
2,The uterus was retroverted (后倾 ) and slightly enlarged,
3,A cystic mass about 5x6x6 cm3 was felt in the left
adnexa,It was relatively fixed and had hypertonia
(张力过强 ).
4,Scattered and tender nodules were palpated in the right
sacral ligament (骶韧带 ),
5,Her hemoglobin level was 12 g/L.
Case (Part II)
How is an endometriosis treated?
Treatment
Principles of treatment
Treatment should be individualized according to the
patient’s age,severity of the condition and desire for
childbearing.
? For those with mild symptom,expectant therapy
? For those who desire childbearing:
if condition is mild,medical treatment
if condition is severe,fertility preservation surgery
?For those who do not desire childbearing:
Surgical treatment,ovary preservation or radical
Expectant Therapy
Endometriosis tends to improve during pregnancy and
menopause.
Follow-up and symptoms management with prostaglandin
synthetase inhibitors (前列腺素合成酶抑制剂 )
such as:
a) Indomethacin (吲哚美辛 )/Indocin (消炎痛 )
25mg tid p.o.
b) Naproxen (萘普生 )
c) Ibuprofen (布洛芬 ) 300mg tip p.o.
d) Diclofenac potassium (双氯芬酸钾片 )/Kaflan (凯扶兰 )
25-50mg tid p.o.
Treatment
Treatment
Medical treatment
Objective,cause atrophic changes in the ectopic
endometrium
Progestins (孕激素 )
Mechanism:
Inhibition of uterine contraction
Inhibition on growth of the endometrium
1,Pseudopregnancy (假孕 ) with oral contraceptives
A tablet once daily for 6-12 days
2,Pseudopregnancy with Progestins (孕激素 )
Medical treatment
Drugs (Progestins) used
Derivatives (衍生物 ) from hydroxyprogesterone (羟孕酮 )：
(1) Medroxyprogesterone acetate/provera
(醋酸甲羟孕酮 /醋酸甲孕酮 /安宫黄体酮） 30mg daily
(2) Megestrol (甲地孕酮 /妇宁片 ) 40mg daily
(3) Long acting drugs
a) Depo-provera (醋酸甲羟孕酮避孕针 )
150mg monthly
b) Hydroxyprogesterone (羟孕酮 )
250mg once for 2 weeks
Treatment
Medical treatment
Drugs (Progestins) used
Derivatives from 19-demethyltestosterone
(1) Norethindrone (炔诺酮 )
5mg daily
(2) Gestrinone (孕三烯酮 /内美通 )
2.5mg twice a week
Treatment with progestins usually last 6 months.
Side effects:
Intermittent breakthrough bleeding,nausea,breast
tenderness,fluid retention,weight gain
Treatment
Medical treatment
Danazol （达 /丹那唑）
A very frequently used drug for endometriosis
A weak androgen
A derivative of 17-α-ethinyltestosterone
(17-α乙炔睾酮）
Mechanism:
?An antigonadotrophic agent
? Directly suppressing ovarian steroidogenesis
(甾体激素生成）
? Direct inhibiting endometrial growth
Treatment
Medical treatment
Doses:
400-800 mg/day for 6 months
Side effects:
Hypoestrogenic environment,
deceased breast size,atrophic vaginitis,hot flashes,
emotional swings.
Virilism (男性化 ),
weight gain,growth of facial hair,acne,oily skin,etc.
Treatment
Medical treatment
GnRHa (促性腺激素释放激素激动剂 )
Mechanism:
Desensitization of the pituitary
Medical hypophysectomy (药物性垂体切除 )
→ Medical oophorectomy ( 药物性卵巢切除 )
Drugs used:
Leuprorelin (亮丙瑞林 /抑那通） 3.75mg,
Triptorelin/Decapreptyl (曲谱瑞林 /达必佳 /达菲林 ) 3.75mg,
Goserelin/Zoladex （戈舍瑞林 /诺雷德） 3.6mg,
injection,once per month
Treatment
Treatment
Medical treatment
Side effects:
(1) Menopausal symptoms (绝经期症状 ),
hot flashes,dryness in vagina,loss of libido
(2) Osteoporosis (骨质疏松 )
? Expensive
Surgical treatment
Indications:
(1) Failed medical treatment
(2) Large endmetrioma (larger than 5-6 cm)
Modes of surgical operation
(1) Fertility preservation (40% recurrence)
(2) Ovarian function preservation (5%)
(3) Radical surgery (no recurrence)
Treatment
Surgical treatment,Laparoscopy
Purposes of treatment:
? Confirmed diagnosis and clinical
classification
? Removal of lesions and endometrioma
? Separation of adhesion
? Improving infertility
? Pain relief
Treatment
Treatment
Treatment
Treatment
Treatment
Treatment
Treatment
Treatment
Treatment
Case (Part I)
Age,40 years
G2P1
Complaint:
Menstrual pain for 3 years
Present history:
Three years ago,she started to feel pain in lower abdomen
and lumbosacral (腰骶 )area during menstruation,The
pain has been worsening progressively,In addition,she
has heavy menses.
Past history:
She gave birth to healthy male baby 15 years ago,Five
years ago she had an artificial abortion,and an IUD was
placed then.
Gynecologic examination,
1,Cervix was normal.
2,Uterus is retroverted,The size was normal,
3,A cystic mass about 5x6x6 cm3 was felt in the left
adnexa (附件 ),It was relatively fixed and had
hypertonic.
4,Scattered and tender nodules were palpated in the
right sacral ligament,
5,Her hemoglobin level was 12 g/L.
What treatment should be offered for this patient?
Case (Part II)
How should we prevent endometriosis?
(1) Prevent retrograde flow of menses.
Imperforate hymen (处女膜闭锁 )
Avoiding pelvic examination during menstruation
(2) Avoid implantation of the ectopic edometrium.
Iatrogenic (医源性 ) implantation
a) 3-7 days after cessation of the menses
b) Cesarean section
c) Artificial abortion
Prevention
Case (Part I)
Age,40 years
G2P1
Complaint:
Menstrual pain for 3 years
Present history:
Three years ago,she started to feel pain in lower abdomen
and lumbosacral (腰骶 )area during menstruation,The
pain has been worsening progressively,In addition,she
has heavy menses (月经 ).
Past history:
She gave birth to healthy male baby 15 years ago,Five
years ago she had an artificial abortion,and an IUD was
placed then.
What condition was she having?
Endometriosis
(子宫内膜异位症）
? Definition of endometriosis
? Pathology and clinical features
? Diagnosis
? Principles of treatment
Learning Objectives
What is endometriosis?
Definition:
Presence of functioning endometrial glands and
stroma (间质 ) outside their usual location in the uterine
cavity,
Pathological features:
?A benign condition with clinically ‘malignant’
biological behavior (invasion and metastasis)
? Sex hormones dependent
Introduction
?About 3%-10% in women of reproductive age
? 5%-15% women who are having an abdominal
surgery are diagnosed with the condition
? 25%-35% in women with infertility
? 20%-90% in women with chronic pelvic pain
? 40%-60% in women with menstrual pain.
Introduction
How common is the disease?
Introduction
Why does endometriosis happen?
Pathogenesis
Ectopic transplantation theory (异位种植学说）
(Direct Implantation)
? 70-90% women have retrograde menstruation (经血逆流 ).
? Viable endometrial cells exist in the peritoneal fluid in
more than 50% woman during menstruation.
? Implantation of menstrual tissue has been demonstrated
experimentally (in the monkeys) and iatrogenic (医源性的 )
implantation occurs (e.g,endometriosis in the scar of
abdominal wall after an abdominal cesarean section).
? Often pelvic deposits of endometriosis occur close to the
ends of the fallopian tubes.
Sites of endometriosis
Pathogenesis
? Endometrial tissues have been found in lymphatic nodes
and pelvic venous blood vessels.
? Presence of endometriosis in organs distal to pelvis
e.g,lung and muscle or skin of the extremities (四肢 ).
Pathogenesis
Ectopic transplantation theory (异位种植学说）
(Blood or Lymphatic Vessel Spread)
Metaplasia of Coelomic Epithelium(体腔上皮化生学说 )
Serosa (浆膜 ) and peritoneum (腹膜 ) originate from
multipotent coelomic epithelium
Predisposing factors
Genetic influences
Incidence is 6.9% in first-grade relatives of patients with
endometriosis compared with 1% in a control group.
Incidence is 75% if one of the twin sisters has endometriosis.
Immune deficiency
Monkeys with spontaneous endometriosis were found to
have lowered cell-mediated response to autologous (自体的 )
endometrial tissue.
Pathogenesis
Pathology
The basic pathological change of endometriosis is
that the ectopic endometrium periodically bleeds in
response to changes in ovarian sex hormones
resulting in growth of surrounding fibrous tissue and
formation of cysts (endometrioma/子宫内膜异位囊肿 )
and/or adhesion.
Pathology
Gross appearance
Pathology
Gross appearance
Pathology
Gross appearance
Pathology
Gross appearance
Pathology
Gross appearance
Pathology
Gross appearance
Pathology
Primary infertility
Gross appearance
Tiny lesions spots/cysts
Pathology
Gross appearance
Pathology
Gross appearance
Pathology
Gross appearance
Pathology
Gross appearance
Pathology
Gross appearance Lesions on the cervix
Pathology
Ovarian endometriosis
1,The most common site of endometriosis
2,80% lateral and 50% bilateral
3,Tiny or classic
Gross appearance
Pathology
Gross appearance
Endometrioma
(子宫内膜异位囊肿）
Chocolate cyst
(巧克力囊肿）
Pathology
Gross appearance
Endometrioma
(子宫内膜异位囊肿 )
Chocolate cyst
(巧克力囊肿）
Pathology
Microscopic appearance
Pathology
Microscopic appearance
Pathology
Microscopic appearance Siderocyte (含铁血黄 素细胞 )
Clinical Features
? Symptoms and signs vary according to site of lesions.
? 25% asymptomatic.
1,Menstrual pain or lower abdominal pain
2,Dyspareunia (性交痛 )
3,Infertility
4,Abnormal uterine bleeding
5,Pain caused by rupture of endometrioma
6,Symptoms and signs in other systems caused by
endometriosis
1,Menstrual pain or lower
abdominal pain
2,Dyspareunia (性交痛 )
3,Infertility
4,Abnormal uterine bleeding
5,Pain caused by rupture of
endometrioma
6,Symptoms and signs in other
systems caused by
endometriosis
Clinical Features
Menstrual pain or lower abdominal pain
1,Secondary dysmenorrhea that worsens over time
(继发性进行性痛经 ),
2,Lower abdominal or lumbosacral pain that occasionally
may radiate to vagina,perineum,anus and thigh,Pain
usu,starts from 1-2 days prior to menstruation,most
severe on the first day,and disappears when the period
finishes.
3,Discrepancy between severity of pain and pathological
findings.
4,27-40% of patients have no menstrual pain.
5,Persistent pain that escalates during menstruation.
6,Dyspareunia (性交痛 )
Clinical Features
1,Menstrual pain or lower
abdominal pain
2,Dyspareunia (性交痛 )
3,Infertility
4,Abnormal uterine bleeding
5,Pain caused by rupture of
endometrioma
6,Symptoms and signs in other
systems caused by
endometriosis
Clinical Features
Infertility
In patients with infertility,incidence of endometriosis
is 25%-35%.
In patients with endometriosis,infertility rate is 40%.
Causes:
1) Mechanical reason
2) Environmental change in the peritoneal cavity
Activity changes of macrophage
Autoimmune injury
Increase in prostaglandins
Clinical Features
Causes (Continued),
3) Abnormal ovarian function
Ovulation defects,17-27%
Inadequate development of corpora lutea (黄体 )
Luteinized unruptured follicle syndrome,
LUFS (未破裂卵泡黄素化综合征 ),18-79%
4) Increase in spontaneous abortion,
40% (vs,normal 15%)
Clinical Features
Infertility
1,Menstrual pain or lower
abdominal pain
2,Dyspareunia (性交痛 )
3,Infertility
4,Abnormal uterine bleeding
5,Pain caused by rupture of
endometrioma
6,Symptoms and signs in other
systems caused by
endometriosis
Clinical Features
Menstrual disorders
? 15-30%
? Heavy menses,prolonged menstruation or
premenstrual spotting.
Causes:
Damage of ovarian cortex and adhesion results in
ovarian dysfunction,anovulation and dysfunction
of corpora lutea.
Clinical Features
1,Menstrual pain or lower
abdominal pain
2,Dyspareunia (性交痛 )
3,Infertility
4,Abnormal uterine bleeding
5,Pain caused by rupture of
endometrioma
6,Symptoms and signs in other
systems caused by endometriosis
Clinical Features
Signs
? Retroverted and fixed uterus
? Tender nodules in rectouterine pouch,
uterosacral ligament,posterior wall
(lower segment) and rectovaginal septum
? Fixed mass along the side of uterus
Clinical Features
Case (Part 1)
Age,40 years
G2P1
Complaint:
Menstrual pain for 3 years
Present history:
Three years ago,she started to feel pain in lower abdomen
and lumbosacral (腰骶 ) area during menstruation,The
pain has been worsening progressively,In addition,she
has heavy menses.
Past history:
She gave birth to healthy male baby 15 years ago,Five
years ago she had an artificial abortion,and an IUD was
placed then.
How is the diagnosis made?
1,Symptoms and Signs (Presumptive diagnosis)
A history of secondary and progressive dysmenorrhea
(痛经 ) together with infertility
Tender nodules
Fixed cyst beside the uterus in
? Bimanual pelvic examination
? Rectovaginal examination
Diagnosis
Diagnosis
Useful for
discovering
lesions on
posterior wall
of uterus and
in
rectovaginal
septum,In
case of
endometriosis,
tender
nodules may
be palpated.
Rectovaginal examination
Auxiliary examinations
B ultrasound,the most often used
Laparoscopy,the most valuable
Diagnosis
Diagnosis B ultrasound
Diagnosis
Confirmed diagnosis
Laparoscopy is the first choice of diagnosis in the
following conditions:
1,Infertility with suspected endometriosis
2,Patients who have the symptoms of endometriosis,
in particular,if blood level of CA-125 is increased.
3,When clinical features and examination results
are suggestive of endometriosis,but result of B
ultrasound examination is negative,
Laparoscopy has the following added values:
? Assessing the patency of fallopian tubes
? Biopsy of the lesions
? Grading of endometriosis
Laparoscopy
Diagnosis
Diagnosis
Diagnosis
Other auxiliary examinations
CA-125
Anti-endometrium antibody
CT
MRI
Diagnosis
Clinical classification
Revised American Fertility Society (R-AFS),1985
Useful for:
?Assessment of severity
? Selection of therapeutic regimen
? Comparison
? Prognosis
Diagnosis
Differential Diagnosis
? Ovarian tumor
Ascites,solid or mixed,B ultrasound image,
CA-125>200 U/ml
? Abdominal inflammatory mass
History of infection,fever,not cyclic,
treatment with antibiotics effective.
? Adenomyosis (子宫腺肌病 )
Medial,severe pain,uterus slightly enlarged,
pain on compression,MRI
Which conditions should be differentiated from
endometriosis?
Differential Diagnosis
Differential Diagnosis
Adenomyosis
(子宫腺肌病 )
Gynecologic examination,
1,The cervix was normal.
2,The uterus was retroverted (后倾 ) and slightly enlarged,
3,A cystic mass about 5x6x6 cm3 was felt in the left
adnexa,It was relatively fixed and had hypertonia
(张力过强 ).
4,Scattered and tender nodules were palpated in the right
sacral ligament (骶韧带 ),
5,Her hemoglobin level was 12 g/L.
Case (Part II)
How is an endometriosis treated?
Treatment
Principles of treatment
Treatment should be individualized according to the
patient’s age,severity of the condition and desire for
childbearing.
? For those with mild symptom,expectant therapy
? For those who desire childbearing:
if condition is mild,medical treatment
if condition is severe,fertility preservation surgery
?For those who do not desire childbearing:
Surgical treatment,ovary preservation or radical
Expectant Therapy
Endometriosis tends to improve during pregnancy and
menopause.
Follow-up and symptoms management with prostaglandin
synthetase inhibitors (前列腺素合成酶抑制剂 )
such as:
a) Indomethacin (吲哚美辛 )/Indocin (消炎痛 )
25mg tid p.o.
b) Naproxen (萘普生 )
c) Ibuprofen (布洛芬 ) 300mg tip p.o.
d) Diclofenac potassium (双氯芬酸钾片 )/Kaflan (凯扶兰 )
25-50mg tid p.o.
Treatment
Treatment
Medical treatment
Objective,cause atrophic changes in the ectopic
endometrium
Progestins (孕激素 )
Mechanism:
Inhibition of uterine contraction
Inhibition on growth of the endometrium
1,Pseudopregnancy (假孕 ) with oral contraceptives
A tablet once daily for 6-12 days
2,Pseudopregnancy with Progestins (孕激素 )
Medical treatment
Drugs (Progestins) used
Derivatives (衍生物 ) from hydroxyprogesterone (羟孕酮 )：
(1) Medroxyprogesterone acetate/provera
(醋酸甲羟孕酮 /醋酸甲孕酮 /安宫黄体酮） 30mg daily
(2) Megestrol (甲地孕酮 /妇宁片 ) 40mg daily
(3) Long acting drugs
a) Depo-provera (醋酸甲羟孕酮避孕针 )
150mg monthly
b) Hydroxyprogesterone (羟孕酮 )
250mg once for 2 weeks
Treatment
Medical treatment
Drugs (Progestins) used
Derivatives from 19-demethyltestosterone
(1) Norethindrone (炔诺酮 )
5mg daily
(2) Gestrinone (孕三烯酮 /内美通 )
2.5mg twice a week
Treatment with progestins usually last 6 months.
Side effects:
Intermittent breakthrough bleeding,nausea,breast
tenderness,fluid retention,weight gain
Treatment
Medical treatment
Danazol （达 /丹那唑）
A very frequently used drug for endometriosis
A weak androgen
A derivative of 17-α-ethinyltestosterone
(17-α乙炔睾酮）
Mechanism:
?An antigonadotrophic agent
? Directly suppressing ovarian steroidogenesis
(甾体激素生成）
? Direct inhibiting endometrial growth
Treatment
Medical treatment
Doses:
400-800 mg/day for 6 months
Side effects:
Hypoestrogenic environment,
deceased breast size,atrophic vaginitis,hot flashes,
emotional swings.
Virilism (男性化 ),
weight gain,growth of facial hair,acne,oily skin,etc.
Treatment
Medical treatment
GnRHa (促性腺激素释放激素激动剂 )
Mechanism:
Desensitization of the pituitary
Medical hypophysectomy (药物性垂体切除 )
→ Medical oophorectomy ( 药物性卵巢切除 )
Drugs used:
Leuprorelin (亮丙瑞林 /抑那通） 3.75mg,
Triptorelin/Decapreptyl (曲谱瑞林 /达必佳 /达菲林 ) 3.75mg,
Goserelin/Zoladex （戈舍瑞林 /诺雷德） 3.6mg,
injection,once per month
Treatment
Treatment
Medical treatment
Side effects:
(1) Menopausal symptoms (绝经期症状 ),
hot flashes,dryness in vagina,loss of libido
(2) Osteoporosis (骨质疏松 )
? Expensive
Surgical treatment
Indications:
(1) Failed medical treatment
(2) Large endmetrioma (larger than 5-6 cm)
Modes of surgical operation
(1) Fertility preservation (40% recurrence)
(2) Ovarian function preservation (5%)
(3) Radical surgery (no recurrence)
Treatment
Surgical treatment,Laparoscopy
Purposes of treatment:
? Confirmed diagnosis and clinical
classification
? Removal of lesions and endometrioma
? Separation of adhesion
? Improving infertility
? Pain relief
Treatment
Treatment
Treatment
Treatment
Treatment
Treatment
Treatment
Treatment
Treatment
Case (Part I)
Age,40 years
G2P1
Complaint:
Menstrual pain for 3 years
Present history:
Three years ago,she started to feel pain in lower abdomen
and lumbosacral (腰骶 )area during menstruation,The
pain has been worsening progressively,In addition,she
has heavy menses.
Past history:
She gave birth to healthy male baby 15 years ago,Five
years ago she had an artificial abortion,and an IUD was
placed then.
Gynecologic examination,
1,Cervix was normal.
2,Uterus is retroverted,The size was normal,
3,A cystic mass about 5x6x6 cm3 was felt in the left
adnexa (附件 ),It was relatively fixed and had
hypertonic.
4,Scattered and tender nodules were palpated in the
right sacral ligament,
5,Her hemoglobin level was 12 g/L.
What treatment should be offered for this patient?
Case (Part II)
How should we prevent endometriosis?
(1) Prevent retrograde flow of menses.
Imperforate hymen (处女膜闭锁 )
Avoiding pelvic examination during menstruation
(2) Avoid implantation of the ectopic edometrium.
Iatrogenic (医源性 ) implantation
a) 3-7 days after cessation of the menses
b) Cesarean section
c) Artificial abortion
Prevention
