子宫内膜异位症英语课件市公开课一等奖省课获奖课件

子宫内膜异位症和子宫腺肌病

（endometriosisandadenomyosis）

第1页Objectives（教学目标）1. Familiarizetheprevailingtheoriesonpossiblecausesandpathogenesisofendometriosis。（熟悉子宫内膜异位症也许病因和发病机制）2. Mastertheclinicalfeatures,diagnosisanddifferentialdiagnosisofendometriosis（掌握子宫内膜异位症临床特点、诊断及鉴别诊断）第2页Objectives（教学目标）3. Understandtheprinciplesofthetreatmentstrategyofendometriosis。（理解子宫内膜异位症治疗策略标准）第3页主要内容Maincontent

Pathogenesis病因和发病机制

Pathologicalfeatures病理特点

Clinicalfindings临床体现

Diagnosis诊断

Differentialdiagnosis鉴别诊断

Treatment治疗第4页第5页子宫内膜异位性疾病：

子宫内膜异位症（endometriosis，EM）子宫腺肌病(adenomyosis)

第6页

定义：DefinitionAgynecologicalconditioninwhichendometrialcellsappearandgrowoutsidetheuterinecavity。

（endometriosis,EM）具有生长功能子宫内膜出现在子宫体以外身体其他部位，生长、侵蚀、周期性出血称子宫内膜异位症，简称内异症第7页发生部位

ovarian（卵巢）peritonea（腹膜）deepinfiltratingendometriosis(DIE)异位子宫内膜能够侵犯全身任何部位，绝大多数位于盆腔脏器和腹膜。最常见被侵犯部位是子宫骶韧带及卵巢第8页

IncidencerateTheendometriosisincidenceofFertilewomenis76%，Hormonedependentdisease，生育年纪妇女是内异症高发人群约占76%，是一种激素依赖性疾病。第9页Incidencerate1.Recurringpelvicpain，20%-90%

慢性盆腔疼痛及痛经，2.Infertility，40%，不孕3.dyspareunia，pain，性交不适，疼痛4.Menstrualdisturbances，月经紊乱15%-30%第10页Thecharacteristicsofendometriosis

子宫内膜异位症特点Diverseclinicalmanifestations临床体现多样Histologicallybenign组织学上良性Buthyperplasia,infiltration,metastasisandrecurrenceof"malignant"behavior,causingextensiveadhesion但有增生、浸润、转移及复发等“恶性”行为，引发广泛粘连Growthishormonallydependent生长激素依赖性11第11页

Etiologyandpathogenesis

一、病因和发病机制

Nosingletheoryexplainsallcasesofendometriosis.发病机制不清，提出了多种学说第12页Mechanismsummory

EndometrialimplantationtheoryhasbeenrecognizedSampson'stheoryofhemorhedraltransplantingandtranscoelomicmetaplasiaistheleadingtheory以sampson经血逆流种植及体腔上皮化生学说为主导理论.Endomyelitisdeterminism在位内膜决定论.第13页

EMRetrogrademenstruation种植学说Coelomicmetaplasia体腔上皮化生Inductiontheory诱导学说Geneticfactors遗传原因Immuneandinflammatory免疫与炎症原因Endomyelitisdeterminism在位内膜决定论Etiology:theories

第14页Etiologicalstudy病因学研究种植学说：Sampsonfirstputforwardthetheoryofmenstrualbloodrefluflowin19211923年Sampson最早提出经血逆流学说Endometrialimplantationtheoryhasbeenrecognized种植学说内膜种植学说已为人们所公认第15页Etiologicalstudy病因学研究1.Endometrialglandularepitheliumandstromalcellsmayreverseflowduringmenstruation2.Throughthetubalintothepelviccavity,implantedintheovaryandadjacentpelvicperitoneumandcontinuetogrow,spread,theformationofpelvicdysplasia经期时子宫内膜腺上皮和间质细胞可随经血逆流，经输卵管进入盆腔，种植于卵巢和邻近盆腔腹膜并在该处继续生长、蔓延，形成盆腔内异症第16页TheBasicpathologicalchangesofendometriosis

基本病理变化Implantationofendometrialcellstotheperitonealsurfacecanleadtoaspectrumofdiseaseseveritywiththemostseverecausingextensivepelvicadhesionsandanatomicdistortion.将子宫内膜细胞移植到腹膜表面也许造成一系列严重疾病，其中最严重是广泛盆腔粘连和解剖变形Eightypercentinvolvedoneovaryandfiftypercentinvolvedbothovaries80％累及一侧卵巢，50％累及双侧卵巢17第17页TheClassificationofendometriosis

常见盆腔内异症分类Ectopicendometriumwiththechangeofovarianhormoneperiodicbleeding,resultingintheproliferationofsurroundingfibroustissueandcysts,adhesionformation,purplebrownspotsorvesiclesinthelesionarea,eventuallydevelopintodifferentsizeofpurplebrownsolidnodulesormass.异位子宫内膜随卵巢激素变化发生周期性出血，造成周围纤维组织增生和囊肿、粘连形成，在病变区出现紫褐色斑点或小泡，最后发展为大小不等紫褐色实质性结节或包块.

18第18页TheClassificationofendometriosisFormationofasingleormultiplecysts,thecapsulefortheoldbleedinglikechocolatecalledovarianchocolatecyst,thesurfacewasgreyishblue

卵巢Microlesiontype:red,purple,blue,orbrownspotsorvesiclesonthesuperficialsurfaceoftheovary微小病灶型：卵巢浅表皮层红色、紫蓝色或褐色斑点或小泡典型病灶型：形成单个或多种囊肿，囊内为陈旧出血呈巧克力样称卵巢巧克力囊肿，表面呈灰蓝色；第19页第20页Uterinesacralligament,rectumuterinedepression,uterineposteriorwalllowersegmentoftheheterotopic,lowposition,easytooccur宫骶韧带、直肠子宫陷凹、子宫后壁下段异位症，位置低，好发部位第21页Earlylesion:localscatteredpurple-brownhemorrhagicspotsorgranularnodules.Thelesiondeveloped：Theposteriorwalloftheuterusadheredtotheanteriorwalloftherectum病变早期：局部散在紫褐色出血点或颗粒状结节病变发展：子宫后壁与直肠前壁粘连，直肠子宫陷凹变浅、消失、表面有紫蓝色结节第22页典型或微小腹膜子宫内膜异位病灶A：典型黑色皱缩病变伴有血管增生及橘红色囊泡B：红色息肉样病灶伴血管增生A:thetypicalblackwrinkledlesionisaccompaniedbyvascularhyperplasiaandorangevesiclesB:redpolypoidlesionwithvascularhyperplasia第23页卵巢子宫内膜异位症24A：浅表卵巢子宫内膜异位症B：浅表卵巢子宫内膜异位症及子宫内膜异位囊肿在粘连分解术前腹腔镜下所见C：腹腔镜下子宫及右卵巢黑红色子宫内膜异位囊肿D、E：卵巢子宫内膜异位囊肿剔除术A:superficialovarianendometriosisB:superficialovarianendometriosisandendometriosiscystwereseenunderlaparoscopebeforeadhesolysisC:blackandredendometriosiscystofuterusandrightovaryunderlaparoscopeD,E:removalofovarianendometriosiscyst第24页

镜检：microscopicpathologicfeatures异位病灶中可见：Endometrialglandinterstitialcellulosebleeding

子宫内膜腺体间质纤维素出血

第25页Malignanttransformationofectopicintimaisrare,andtheincidenceislessthan1%Characteristicsofbiologicalbehavior-invasivegrowth,damagetosurroundingtissues,distantmetastasisandrecurrenceThecauseofthemalignantchangeisnotclearDiagnosticcriteriaformalignanttransformationClearcellcarcinomaandendometrioidcarcinomaEvilchange恶变异位内膜很少发生恶变，发生率低于1%生物学行为特点-浸润性种植生长、对周围组织破坏、远处转移和易复发恶变病因不明确恶变诊断标准透明细胞癌和子宫内膜样癌第26页Clinicalfindings临床体现Pain：疼痛Infertility：不孕Dyspareunia：性交不适Paramenia：月经异常Othersymptom其他症状个别无症状第27页

paincharacter

1.Painfulcharacteristic:sendsubsequentlydysmenorrhea,pelvicpain,sexualintercourseispainful2.Thepainfulpart;Moreinthemiddleofthelowerabdomenandlumbosacraldepartmentorradiationtoperineum,anus,thigh.3.Thedegreeofpain:andlesionsizeisnotnecessarilyproportional,andthesitehasacertainrelationship第28页

Infertility：不孕

PelvicanatomyisabnormalChangeofmicroenvironmentinpelviccavityMenstrualdisorderOvariandysfunction盆腔解剖构造异常盆腔内微环境变化月经失调卵巢功能异常第29页Dyspareunia:性交不适Paincausedbyabumporuterinecontractionduringintercourse,Itisdeepsexcommonlypainful,menstruationcomesbeforemenstruationsexualintercourseispainfulthemostapparent30第30页Paramenia月经异常Incidence:15%~30%increaseinmenstrualvolume,prolongedmenstrualperiodormenstrualdrippingnotfullorearlymenstrualspotting发生率：15%～30%经量增多、经期延长或月经淋漓不尽或经前期点滴出血31第31页Othersymptoms其他症状肠道内异病灶膀胱内异病灶输尿管异位病灶手术瘢痕异位病灶32DifferentlesionsinintestinaltractAdifferentlesioninthebladderEctopicureterallesionSurgicalscarectopiclesion第32页Examination体征1.Pelvicmass:chocolatecystofovary2.Uterineposteriorfixation,severelylimitedmovement3.Palacralligament,posterioruterinewallnodulestenderness4.Purplebluenodulesandspotsonvulva,vaginaandcervix1．

盆腔包块：卵巢巧克力囊肿2．

子宫后位固定，活动严重受限3．

宫骶韧带、子宫后壁结节触痛4.外阴、阴道、宫颈紫蓝色结节，斑点第33页诊断DiagnosisLaparoscopyandlaparotomyaretheaccuratemethodsofdiagnosis.Basisisfocalmorphology,notbeprovedcompletelybypathology。(Goldstandard)腹腔镜检查及开腹探查术是诊断精确办法。根据是病灶形态，不一定所有经病理证明Non-surgicaldiagnosticcriteriaincluded:pain,infertility,pelvicexamination,b-ultrasound,CA125,Positivepredictivevalue.非手术诊断标准包括：疼痛、不育、盆腔检查、B超、CA125.5项中有3项阳性都有很高阳性预测值.第34页B超显示卵巢巧克力囊肿第35页Differentialdiagnosis

鉴别诊断OvarianmalignancyPelvicinflammatorymassadenomyosis卵巢恶性肿瘤盆腔炎性包块子宫腺肌病36第36页子宫内膜异位症分期（修正AFS分期法第37页1.若输卵管所有包入应改为16分2.Ⅰ期（微型）1～5分；Ⅱ期（轻型）6～15分；Ⅲ期（中型）16～40分；Ⅳ期（重型）>40分第38页治疗TreatmentObjective：ReduceandremovelesionsPainreliefandcontrolTreatmentandfertilitypromotionPreventandreducerecurrence

缩减和清除病灶减轻和控制疼痛治疗和促进生育预防和减少复发第39页ageFertilityrequirementsSymptomseverityDegreeofthelesionAlwaystreatPatientswillThedoctorisAmedicalinstitutionIndividualizedtreatmentThepaininfertilityEndometriosiscystFundamentalconsiderationsforthetreatmentofendosarphyExpectationmanagementmedicalmanagementsurgicalmanagementconjointmanagement第40页药品治疗

medicalmanagement1）Non-steroidalanti-inflammatorydrugshavemanyeffectsinrelievingfeverandpainandanti-inflammatory。非甾体类抗炎药2）pseudopregnancytherapy假孕疗法Combinationoralcontraceptivesworkbysuppressingovulationandpossiblybycausingcervicalandendometrialchangesthatreducethelikelihoodofimplantation.口服避孕药减少垂体促性腺激素水平，并造成类似妊娠人工闭经。第41页

pseudopregnancytherapy假孕疗法

progestin

Byinhibitingthesecretionofpituitarygonadotropin,falsepregnancyiscaused.Medroxyprogesterone30mg/dayfor6months孕激素通过抑制垂体促性腺激素分泌，造成假孕。甲羟孕酮30mg/日，连用6个月。第42页Gonadotropin-releasinghormoneagonist

（

(（GnRH-a）

ThesyntheticdecapeptidecompoundhasthesameeffectastheinternalGnRHandpromotesthereleaseofpituitaryLHandFSH,butitsaffinitytoGnRHreceptorishundredsoftimeshigherthanthenaturalone,inhibitsthesecretionofgonadotropinbythepituitary,leadingtoasignificantdecreaseinthelevelofovarianhormoneandtemporaryamenorrhea.Leuprin3.75mg,1time/28days,3-6timesGoserelin3.6mg,1time/28days,3-6times人工合成十肽类化合物，其作用与体内GnRH相同，促进垂体LH和FSH释放，但其对GnRH受体亲和力较天然高百倍，抑制垂体分泌促性腺激素，造成卵巢激素水平显著下降，出现临时性闭经。第43页5）促性腺激素释放激素激动剂（GnRH-a）

人工合成十肽类化合物，其作用与体内GnRH相同，促进垂体LH和FSH释放，但其对GnRH受体亲和力较天然高百倍，抑制垂体分泌促性腺激素，造成卵巢激素水平显著下降，出现临时性闭经。亮丙瑞林3.75mg，1次/28天，3-6次戈舍瑞林3.6mg，1次/28天，3-6次第44页surgicalmanagement手术治疗Indicationofoperation:PainaccessorymassinfertileOperationmethod:transabdominalsurgerylaparoscopicsurgeryOperativeprocedure:operationtopreservereproductivefunctionOvarianpreservationsurgeryRadicalsurgery第45页Laparoscopicchocolatecystremovalofovary腹腔镜下卵巢巧克力囊肿剥除术第46页Provention1.Preventmenstrualbloodflow2.Drugcontraception3.AvoidiatrogenicplantingIatrogenicendometrium1.避免经血倒流2.药品避孕3.避免医源性引发种植医源性异位内膜第47页EMKnowledgePointSummaryEndometriosisisabenignandinvasivediseasethatoftenoccursinwomenduringchildbearingyearsCommonsymptomsarepain,infertility,menstrualdisorders,abdominaldiscomfortTypicalsignsarepelvictendernessnodulesorchocolatecystsoftheovariesLaparoscopyorlaparotomyisthegoldstandardforEMdiagnosisEndometriosisisrelatedtoovarianhormoneandishormone-dependentdisease,easytorelapse.第48页二、子宫腺肌病（adenomyosis）Adenomyosisoccurswhentheendometriuminvadesthemyometrium.Mostofthemareaged30to50.About15%werecomplicatedwithendometriosis,andabouthalfwerecomplicatedwithuterinefibroids.当子宫内膜侵入子宫肌层时称为子宫腺肌病。多发生于30岁~50岁经产妇。约15%合并内异症，约半数合并子宫肌瘤。第49页Etiologyandpathogenesis

病因和机制Etiology：Multiplepregnancy，delivery,inducedabortion，chronicendometritisTheendometrialbasallayerwasdamagedPathogenesis：Theunderlyinglayeroftheendometriumlackssubmucosa,whichisindirectcontactwiththemusclelayerandlackstheprotectiveeffectofthesubmucosa.Asaresult,theendometriumiseasytoinvadethemusclelayerinanatomicalstructure基底层子宫内膜侵入肌层生长造成，数次妊娠及分娩、人工流产、慢性子宫内膜炎等造成子宫内膜基底层损伤。内膜基底层缺乏黏膜下层，内膜直接与肌层接触，缺乏黏膜下层保护作用，使得在解剖构造上子宫内膜易于侵入肌层第50页