Transcript of Endometriosis & Adenomyosis Omar Al Omari, MRCOG Obstetrician & Gynaecologist Jordan Hospital...
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- Endometriosis & Adenomyosis Omar Al Omari, MRCOG
Obstetrician & Gynaecologist Jordan Hospital Medical Center
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- 2 Endometriosis
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- 3 Definition : Abnormal growth of endometrial tissue outside
the uterine cavity.
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- 4 Incidence and Prevalence : Increased significantly Range from
1 50% General population : 1 2% Infertile women : 30 50% Occurs
primarily in women in 25 45s
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- 5 Pathogenesis : Implantation Theory Retrograde Menustration
Theory Sampson 1921 Lymphatic and Vascular Dissemination Theory
Javert 1952 Coelomic Theory Meyer Genetic Theory Immune System
Dysfunction immunologic theory
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- 6 Genetic factors Familial clustering of endometriosis is a
common clinical observation. In families with endometriosis the
disease is often confined to the maternal line and is 7 times more
common in first-degree relatives than in the general population. In
future studies evaluation of DNA polymorphism may identify specific
genes involved in the development of endometriosis.
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- 7 Immunologic Theory Lose control of immunologic balance Both
cellular immunity and humoral immunity change. 1)Macrophage release
IL1 IL6 TNF EGF FGF etc. stimulate T B lymphocyte proliferation and
activation 2)Activity of killer cell NK cell and T cell 3)Produce
antiendometrium antibody 4)Abnormal expression of CAMs cell
adhesion molecules
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- 8 The pathogenesis is unclear. multifactorial
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- 9 Pathology macroscopic appearance 1 The commonest sites
1.Ovary chocolate cyst 2.Peritoneum of the rectovaginal culde sac
of the Pouch of Douglas 3.Utero sacral ligaments 4.Sigmoid colon
5.Broad ligament
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- 10 This is a section through an enlarnged 12 cm ovary to
demonstrate a cystic cavity filled with old blood typical for
endometriosis with formation of an endometriotic, or "chocolate",
cyst.
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- 12 Pathology macroscopic appearance 2 Less common sites
1.Cervix 2.Round ligament 3.Urinary system bladder ureter
4.Umbilicus 5.Appendix 6.Laparotomy scars
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- 13 Multiple appearances of endometriosis implants Brownish
discolored peritoneum Superficial peritoneal ecchymosis Raised
reddish superficial nodules Reddishblue invasive nodules Fibrotic
whitish nodules Raised glossy translucent blobs Patchy white
opacified peritoneum Reddish or bluish ovarian cysts
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- 14 Grossly, in areas of endometriosis the blood is darker and
gives the small foci of endometriosis the gross appearance of
"powder burns". Small foci are seen here just under the serosa of
the posterior uterus in the pouch of Douglas. Such areas of
endometriosis can be seen and obliterated by cauterization via
laparoscopy.
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- 15 Upon closer view, these five small areas of endometriosis
have a reddish-brown to bluish appearance.
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- 16 Pathology microscopic appearance Histomorphologically
similar to eutopic endometrium Four major components endometrial
glands endometrial stroma fibrosis hemorrhage
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- 17 Clinical Manifestation
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- 18 Symptoms Pain progressive dysmenorrhea dyspareunia painful
defecation Menstrual disturbance infertility
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- 19 Signs Enlargement of the ovaries fixed Fixed retroversion of
the uterus Tender nodules within the pelvis Cannot be diagnosed by
PV alone. Should always be considered when patients have symptoms
referable to the pelvic cavity.
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- 20 Very variable Vary with the focus location Often bear no
relation to the extent of the disease Quite often deposits are
found incidentally in women who have no symptoms. 25% have no
symptoms
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- 21 Diagnosis History PV examination Laparoscopy golden standard
Ultrasonography Btype ultrasound CA125 200U/ml normal value 35U/ml
Antiendometrium antibody +
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- 22 Staging systems In the AFS-r 1985 staging system points are
assigned for severity of endometriosis based on the size and depth
of the implant and for the severity of adhesions. The points are
summed and the patients are assigned to one to four stages Stage I
minimal disease 1 5 points Stage II mild disease 6 15 points Stage
III moderate disease 16 40 points Stage IV severe disease 40
points
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- 23 Differential diagnosis Malignant ovary tumours Pelvic
inflammatory masses Adenomyosis
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- 24 Treatment
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- 25 Expectant therapy Indications with very limited disease
whose symptoms are minimal or nonexistent If trying to get pregnant
the best way is to accept laparoscopic therapy as early as
possible.
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- 26 Medical therapy Indications chronic pelvic pain severe
dysmenorrhea no require to get pregnant no ovarian cyst formation
Hormoneinhibition therapy
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- 27 Drugs Danazol pseudomenopause therapy Gestrinone GnRH a
medical oophorectomy add back therapy Mifepristone RU486
Progestogens pseudopregnancy therapy
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- 28 Surgical therapy 1 Indications 1 adnexal mass 2 pelvic pain
3 infertility Approaches (1) trans abdominal (2) laparoscopic
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- 29 Surgical therapy 2 Methods Conservative surgery 1)preserve
the fecundity 2)preserve the ovarian function Definitive surgery
hysterectomy + salpingooophorectomy
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- 30 Combination medicalsurgical treatment Threestep surgery
medical therapy second look laparoscopy
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- 31 It is important to individualize the choice of therapy.
Therapy must be tailored to the degree of symptomatology the
patients age her desire to maintain fertility
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- 32 Prognosis With proper treatment the prognosis is good for
relief of pain and enhancement of fertility in mild to moderate
endometriosis. In most cases hormonal therapy is temporarily
effective in controlling symptoms and arresting growth but is
generally less effective than surgery in increasing fertility. The
recurrent rate is very high.
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- 33 Prevention Avoid possible augmentation of menstrual reflux.
Taking oral contraceptive is recommended. Isolation and irrigation
of the operative site.
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- 34 Critical points 1 The pathogenesis is poorly understood but
emerging evidence supports the causative role of retrograde
menstruation and implantation of endometrial tissue. Endometriosis
is a common in women with pelvic pain or infertility. Laparoscopy
is the optimal technique to diagnose pelvic endometriosis.
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- 35 Critical points 2 In most cases surgical therapy at the time
of initial diagnosis effectively relieves pain and may enhance
fertility. Alternatively medical therapy with progestins danazol
gestrinone or GnRH-a will ameliorate pelvic pain but they do not
enhance fertility. Endometriosis is a recurrent disease and
definitive treatment with removal of pelvic organs may be
necessary.
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- 36 Adenomyosis
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- 37 Definition A benign uterine condition in which endometrial
glands and stroma are found deep in the myometrium.
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- 38 Etiology Basal endometrial hyperplasia invading a
hyperplastic myometrial stroma. Four primary theories Heredity
Trauma Hyperestrogenemia Viral transmission
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- 39 Pathology gross appearance Usually hyperemic with thickened
walls The foci are frequently scattered diffusely throughout the
myometrium. Occasionally may be more circumscribed with the
formation of a distinct nodule an adenomyoma.
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- 40 The thickened and spongy appearing myometrial wall of this
sectioned uterus is typical of adenomyosis. There is also a small
white leiomyoma at the lower left.
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- 41 Clinical features 1 Symptomatic adenomyosis occurs primarily
in parous women over the age of 40. 30 50 Classic symptoms
secondary dysmenorrhea abnormal uterine bleeding
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- 42 Clinical features 2 Most common physical sign a diffusely
enlarged uterus (rarely exceeds 12 weeks gestation in size)
particularly tender during menstruation
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- 43 Diagnosis History Pelvic examinations Ultrasonography Serum
markers CA-125
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- 44 Treatment Hormone therapy Hysterectomy the only uniformly
successful treatment for adenomyosis is necessary.
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- Thank You 45