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Endometrioza-dijagnostika i liječenje
D.Barišić
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Endometrioza
žarišta po peritoneju endometriom adenomioza duboka zdjelična endometrioza1. retrocervikalni čvor2. endometrioza u septumu rektovaginale3. čvor na rektumu4. čvor na sigmi5. infiltracija uretera +-parametrija
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Biokemijski markeri - istraživanja
Übersicht der Studien zu Biomarkern als diagnostische Tests für EndometrioseStudie Sensitivität (%) Spezifität (%) PPV (%) NPV (%)
Somigliana et al. [14] CA 125 im Serum 27 97 - -Somigliana et al. [14] CA 125, CA 19-9 und IL-6 im Serum 42 71 - -
Somigliana et al. [15] CA 125 und ICAM-1 im Serum 28 92 - -
Gagne et al. 2003 [16] Endometriale Leukozytenmarker in Kombination mit CA-125-Werten im Serum, der Länge des Menstruationszyklus, histologischen Daten und Gravidität 61 95 -
-Zachariah et al. [22] Frei zirkulierende DNA 70 87 - -Mihalyi et al. [23] Plasmakonzentrationen von IL-6, IL-8, TNF-α, hsCRP, CA 125 und CA 19-9 – mittelschwere bis schwere Endometriose 100 84 - -Mihalyi et al. [23] Plasmakonzentrationen von IL-6, IL-8, TNF-α, hsCRP, CA 125 und CA 19-9 – minimale bis leichte Endometriose 87 71 - -Tokushiga et al. [26] CYFRA 21-1 im Urin 94 98,2 95,6 97,5
CCR-1 in Leukozyten des peripheren Blutes 90 7485 82Agic et al. [28] CCR-1 in Leukozyten des peripheren Blutes, MCP-1 und CA 125 im Serum92,2 81,6 92,3 83,2PPV positiver prädiktiver Wert, NPV negativer prädiktiver Wert, CA „cancer antigen“, ICAM „intercellular adhesion molecule“, IL Interleukin, TNF Tumor-Nekrose-Faktor, hsCRP hochsensitives C-reaktives Protein, CYFRA 21-1 lösliches Fragment von Zytokeratin 19, CCR-1 G-Protein-gekoppelter Chemokinrezeptor, MCP-1 „monocyte
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Endometrioza peritoneja zdjelice
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Endometriotična cista jajnika
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Endometrioza III i IV stupnja po rAFS smanjuje ovarijsku rezervu,mjerenu razinom antimullerovskog hormonaShebl O., i sur. Gynecol Endocrinol, 2009.
Ekscizija endometrioma značajno smanjuje ovarijsku rezervu, mjerenu brojem antralnih folikula u slijedećim ciklusima i razinom AMHĆorić M., i sur. Arch Gynecol 2010.
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The Cochrane Database of Systematic Reviews – “Pre and post operative medical therapy for endometriosis surgery”, Review 2005.,
conclusions - implications for practice
Pre-operacijska medik. terapija pokazala je sniženje AFS skora ali bez boljeg ishoda liječenja po pacijentice.
Poslijeoperacijska terapija niskodozažnim monofaznim kontraceptivima značajno ne utječe na dugotrajni ishod tj. učestalost recidiva nakon kirurškog liječenja endometrioze. Odgoda recidiva je evidentna u life-table analizi
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Adenomioza
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Postotak žena s adenomiozom u korelaciji s životnom dobi
0
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30 YRS 35 YRS 40 YRS
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UZV slike adenomioze
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stražnji forniks
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Kirurške th opcije
histerektomija kirurška resekcija (lpsc?) selektivna embolizacija art. uterine - nema
reprodukcijskih rezultata u lit. budućnost - fokusirani uzv visokog
intenziteta (HIFU) transvaginalno?
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Hormonska th adenomioze
LNG IUD gestageni GnRH analozi
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rASRM 1996.
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rASRM klasifikacija
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Enzian score DZE
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Zašto boli duboka zdjelična endometrioza? kompresija okolnih struktura u zdjelici?
nervna vlakna nađena su u endometriju i u ektopičnim
žarištima u žena s endometriozom Anaf V., i sur.Fertil Steril 2006.
endometrioza ima neuromodularna svojstva
invazija nervnih vlakana u endometriotične lezije mogući je
uzrok boli
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a Darstellung eines mit Endometriose assoziierten Nervs in einer peritonealen EM-Läsion. b Dreifachfärbung zur Darstellung von Nervenfasern (grün) in Kolokalisation zu unreifen Gefäßen (rot). L Lumen, E Epithel, S Stromazellen. c Durch Douglas-Flüssigkeit einer Patientin mit EM induzierte Nervenfaseraussprossung aus einem sensiblen Hinterwurzelganglion
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DZE
blok u zdjelištu reduciran Douglasov prostor sa ili bez endometrioma fibroza peritoneja infiltracija sakrouterinih ligamenata uterus s adenomiozom, “prelomljen”
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DZE – retroperitonealna bolest!
retrocervikalni čvor čvor u stražnjem forniksu rodnice čvor u septumu rektovaginale infiltracija rektuma infiltracija sigme stenoza uretera
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< rodnica
rektum
čvor
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stenoza uretera
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Prosječno trajanje simptoma do dg endometrioze: 9 godina
Zašto?
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Preporuka
dismenoreja u adolescentnoj dobi: NSAID kroz 3-6 mjeseci
bez poboljšanja – M.O.K. kroz 3-6 mj. bez poboljšanja – dg. lpsc.
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Preporuka
detaljna anamneza pažljiv gin.pregled u klasičnim spekulima, palpacija forniksa rodnice, procjena fibroze
sakrout.ligamenata i peritoneja zdjelice, te gibljivosti adneksa i uterusa
fiksirani uterus i rv = endometrioza? bolnost pregleda= endometrioza? svakako digitorektalni pregled
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UZV tek nakon palpacijskog pregleda!
kod sumnje na DZE: i.v.urografija ili barem uzv bubrega,
pogotovo kod recidivirajućih uroinfekata irigografija?!
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Zaključak endometrioza je kompleksna proliferativna bolest i značajan je
javnozdravstveni problem razdoblje od početka tegoba do dg mora biti što kraće, pa će
bolest biti otkrivena u ranoj fazi za dg je potrebna detaljna anamneza i pažljiv ginekološki pregled nužno je detaljno objasniti pacijentici što je endometrioza terapijske opcije ovise o:
1. težini simptoma 2. životnoj dobi žene3. lokalizaciji žarišta4. uznapredovalosti bolesti5. reprodukcijskom planu