Endometriosis

Li qi ling
 Learning Objectives

• Definition of endometriosis
• Pathology and clinical features
• Diagnosis
• Principles of treatment
 Introduction

What is endometriosis?
Definition:
Presence of functioning endometrial glands and
stroma 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

How common is the disease?

• 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.
 Pathogenesis
1.Ectopic transplantation theory(Direct Implantation)
*70-90% women have retrograde menstruation .

*Viable endometrial cells exist in the peritoneal fluid in

more than 50% woman during menstruation.

*Implantation of menstrual tissue has been demonstrated

experimentally and iatrogenic implantation occurs .

*Often pelvic deposits of endometriosis occur close to the

ends of the fallopian tubes.
 Pathogenesis
Sites of endometriosis
 Pathogenesis
Ectopic transplantation theory
(Blood or Lymphatic Vessel Spread)
• 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 .
 Pathogenesis
2.Metaplasia of Coelomic Epithelium
Serosa and peritoneum originate from
multipotent coelomic epithelium
Predisposing factors
3.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.
4.Immune deficiency
Monkeys with spontaneous endometriosis were found to
have lowered cell-mediated response to autologous
endometrial tissue.
 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 ） and/or
adhesion.
 Pathology
Gross appearance
Pathology
Gross appearance
Pathology
Gross appearance
Pathology
Gross appearance
 Pathology
Gross appearance
Pathology
Gross appearance
Pathology
Gross appearance

Tiny lesions spots/cysts

Primary infertility
Pathology
Gross appearance
 Pathology
Gross appearance
Pathology
Gross appearance
Pathology
Gross appearance
 Pathology
Gross appearance Lesions on the cervix
 Pathology
Gross appearance
Ovarian endometriosis
1. The most common site of endometriosis
2. 80% lateral and 50% bilateral
3. Tiny or classic
 Pathology
Gross appearance
Endometrioma

Chocolate cyst
 Pathology
Gross appearance
Endometrioma
Chocolate cyst
 Pathology
Microscopic appearance
 Pathology
Microscopic appearance
 Pathology
Microscopic appearance Siderocyte
 Clinical Features

• Symptoms and signs vary according to site of lesions.

• 25% asymptomatic.
1. Menstrual pain or lower abdominal pain
2. Dyspareunia
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 .
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
 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
Infertility
Causes (Continued) :

3) Abnormal ovarian function

Ovulation defects: 17-27%
Inadequate development of corpora lutea
Luteinized unruptured follicle syndrome,
LUFS : 18-79%
4) Increase in spontaneous abortion:
40% (vs. normal 15%)
 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

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
 Diagnosis

1. Symptoms and Signs (Presumptive diagnosis)

A history of secondary and progressive dysmenorrhea
together with infertility
Tender nodules
Fixed cyst beside the uterus in

• Bimanual pelvic examination

• Rectovaginal examination
 Diagnosis

Rectovaginal examination
Useful for
discovering
lesions on
posterior wall
of uterus and
in
rectovaginal
septum. In
case of
endometriosis
, tender
nodules may
be palpated.
 Diagnosis

Auxiliary examinations
B ultrasound: the most often used
Laparoscopy: the most valuable
Diagnosis B ultrasound
 Diagnosis Laparoscopy

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
Diagnosis
Diagnosis
Diagnosis
 Diagnosis

Other auxiliary examinations

CA-125
Anti-endometrium antibody
CT
MRI
 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
Medial, severe pain, uterus slightly enlarged,
pain on compression, MRI
Differential Diagnosis

Adenomyosis
 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
 Treatment
Expectant Therapy
Endometriosis tends to improve during pregnancy and
menopause.
Follow-up and symptoms management with prostaglandin
synthetase inhibitors)
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

Medical treatment
Objective: cause atrophic changes in the ectopic
endometrium
Progestins
Mechanism:
Inhibition of uterine contraction
Inhibition on growth of the endometrium
1. Pseudopregnancy with oral contraceptives
A tablet once daily for 6-12 days
2. Pseudopregnancy with Progestins
 Treatment
Medical treatment
Drugs (Progestins) used
Derivatives 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 :
weight gain, growth of facial hair, acne, oily skin, etc.
 Treatment

Medical treatment
GnRHa
Mechanism:
Desensitization of the pituitary
Medical hypophysectomy
→ Medical oophorectomy
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

Medical treatment
Side effects:
(1) Menopausal symptoms:
hot flashes, dryness in vagina, loss of libido
(2) Osteoporosis
• Expensive
 Treatment

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
 Prevention

(1) Prevent retrograde flow of menses.

Imperforate hymen
Avoiding pelvic examination during menstruation
(2) Avoid implantation of the ectopic edometrium.
Iatrogenic implantation
a) 3-7 days after cessation of the menses
b) Cesarean section
c) Artificial abortion
Thank you for your attention