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.
Immunologic Theory ：
Lose control of immunologic balance
Both cellular immunity and humoral immunity change.
Macrophage ↑ release IL–1 、 IL–6 、 TNF 、 EGF 、 FGF etc. stimulate T 、 B lymphocyte proliferation and activation
Activity of killer cell （ NK cell and T cell ） ↓
Produce anti–endometrium antibody
Abnormal expression of CAMs （ cell adhesion molecules ）
The pathogenesis is unclear.
Pathology – macroscopic appearance （ 1 ） ：
The commonest sites ：
Ovary （ chocolate cyst ）
Peritoneum of the recto–vaginal cul–de–sac of the Pouch of Douglas
Utero – sacral ligaments
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.
Pathology – macroscopic appearance （ 2 ） ：
Less common sites ：
Urinary system （ bladder 、 ureter ）
Multiple appearances of endometriosis implants ：
Brownish ， discolored peritoneum
Superficial peritoneal ecchymosis
Raised ， reddish ， superficial nodules
Reddish–blue invasive nodules
Fibrotic ， whitish nodules
Raised ， glossy ， translucent blobs
Patchy ， white opacified peritoneum
Reddish or bluish ovarian cysts
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.
Upon closer view, these five small areas of endometriosis have a reddish-brown to bluish appearance.
Pathology – microscopic appearance
Histomorphologically similar to eutopic endometrium
Four major components ：
Clinical Manifestation www.freelivedoctor.com
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.
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 ）
Laparoscopy （ golden standard ）
Ultrasonography （ B–type ultrasound ）
CA–125 ↑ （ ＜ 200U/ml ； normal value 35U/ml ）
Anti–endometrium antibody （ + ）
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
Differential diagnosis ：
Malignant ovary tumours
Pelvic inflammatory masses
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.
Medical therapy ：
Indications ： chronic pelvic pain
no require to get pregnant
no ovarian cyst formation
Danazol ： pseudomenopause therapy
GnRH – a ： medical oophorectomy
add – back therapy
Progestogens ： pseudopregnancy therapy
Surgical therapy （ 1 ）：
Indications （ 1 ） adnexal mass
（ 2 ） pelvic pain
（ 3 ） infertility
(1) trans – abdominal
Surgical therapy （ 2 ）：
preserve the fecundity
preserve the ovarian function
Definitive surgery ：
hysterectomy + salpingo–oophorectomy
Combination medical–surgical treatment ：
surgery medical therapy second look （ laparoscopy ） www.freelivedoctor.com
It is important to individualize the choice of therapy.
Therapy must be tailored to
the degree of symptomatology
the patient’s age
her desire to maintain fertility
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 .
Avoid possible augmentation of menstrual reflux.
Taking oral contraceptive is recommended.
Isolation and irrigation of the operative site.
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.
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.
A benign uterine condition in which endometrial glands and stroma are found deep in the myometrium.
Basal endometrial hyperplasia invading a hyperplastic myometrial stroma .
Four primary theories ：
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 .
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.
Clinical features （ 1 ）：
Symptomatic adenomyosis occurs primarily in parous women over the age of 40 .
（ 30 ～ 50 ）
Classic symptoms ：
abnormal uterine bleeding
Clinical features （ 2 ）：
Most common physical sign ：
a diffusely enlarged uterus ，
(rarely exceeds 12 weeks’ gestation in size)
particularly tender during menstruation
Serum markers ： CA-125 ↑
Hysterectomy ， the only uniformly successful treatment for adenomyosis ， is necessary.