Adenomyosis is a common gynecological condition in which the endometrial glands and mesenchyme invade the myometrium to form a diffuse or confined lesion. It often leads to symptoms such as secondary dysmenorrhea and increased menstrual flow, which seriously affects women’s physical and mental health. Adenomyosis used to occur in menstruating women over 40 years of age, but in recent years there has been a trend toward a younger age group. There are many treatment options for this disease, and clinical decisions need to be individualized to take into account the patient’s age, symptoms and fertility requirements.
Etiology.
The etiology of adenomyosis is still unknown. The current consensus is that due to the lack of a submucosal layer in the uterus, the cells of the basal layer of the endometrium proliferate and invade the myometrium, and the surrounding cells of the myometrium become compensatory hypertrophic and proliferate and form a lesion. There are four theories on the factors of endometrial basal lamina cell proliferation and invasion.
1, genetic related ;
2, uterine injury, such as curettage and cesarean delivery can increase the occurrence of adenomyosis;
3, hyperestrogenemia and hyperprolactinemia;
4, viral infections.
5, obstruction of the reproductive tract, which increases the pressure in the uterine cavity during menstruation and leads to ectopic endometriosis to the myometrium of the uterus.
Pathology.
Macroscopic examination: the uterus is mostly uniformly enlarged, spherical, and often occurs in the posterior wall of the uterus. There are two types of myometrial lesions: diffuse and limited, the former being called adenomyosis and the latter adenomyoma. The uterine wall is dissected to reveal a marked thickening and hardening of the myometrium, with thick bundles of muscle fibers and microcystic cavities seen in the myometrium, with occasional old blood in the cavity, often poorly defined from normal smooth muscle tissue. The clinical description is often described as “towel-like changes”.
Microscopic examination: endometrial glands and interstitium in an island-like distribution within the myometrium are the microscopic features of this disease. Because endometrial tissue is found in the myometrium in 10-30% of uterine specimens from other diseases, the diagnosis of adenomyosis requires that the depth of endometrial glandular cell invasion be greater than 3 mm or that the next low magnification field of view of cells in the basal layer of the endometrium be satisfied. However, this diagnostic criterion is still controversial.
Clinical manifestations.
Symptoms.
1. Menstrual disorders (40-50%): The main manifestations are prolonged menstruation, increased menstrual volume, and some patients may also have spotting bleeding before and after menstruation. This is triggered by an increase in the size of the uterus, an increase in the area of the endometrium of the uterine cavity and an intermyometrial lesion affecting the contraction of the uterine muscle fibers. Severe cases can lead to anemia.
2. Dysmenorrhea (25%): characterized by secondary progressive aggravation of dysmenorrhea. It often starts to appear a week before the onset of menstruation and is relieved when the period is over. This is due to congestion and swelling of the ectopic endometrium in the myometrium during menstruation under the influence of ovarian hormones as well as bleeding. It also increases the blood volume in the blood vessels of the myometrium, causing the expansion of the firm and thick myometrium and causing severe dysmenorrhea.
3. About 35% of patients have no obvious symptoms.
Physical signs.
The uterus is often uniformly enlarged and spherical on gynecological examination, and adenomyoma may appear as a hard nodule. The uterus usually does not exceed the size of 12 weeks of gestation. Near menstruation, the uterus is painful to the touch; during menstruation, the uterus increases in size, becomes softer in texture, and pressure pain is more pronounced than usual; after menstruation, the uterus shrinks. This cyclically occurring change in signs is one of the important bases for the diagnosis of the disease. The uterus is often poorly mobile due to adhesions to the surrounding, especially posterior, rectum. Endometriosis is combined with endometriosis in about 15-40% of patients, and fibroids in about half of patients.
Diagnosis.
A preliminary diagnosis can be made based on the typical history and signs, and histopathological examination is required to confirm the diagnosis. Imaging is the most effective means of preoperative diagnosis of this disease. The sensitivity of vaginal ultrasonography is 80% and the specificity is 74%, which is more accurate than the abdominal probe. MRI can provide an objective understanding of the location and extent of the lesion before surgery, which is more helpful in deciding the treatment method. Some patients with adenomyosis have elevated serum CA125 levels, which are of value in monitoring the outcome.
Differential diagnosis.
Adenomyosis and uterine fibroids have the same pathogenic group and similar clinical presentation, so it is easy to misdiagnose adenomyosis as uterine fibroids, with a misdiagnosis rate of up to 32%. In addition, adenomyosis is often combined with uterine fibroids, so ultrasound and other imaging methods often report only uterine fibroids and ignore the diagnosis of adenomyosis, and the rate of missed diagnosis can be 33.9%. Adenomyosis also needs to be differentiated from malignant tumors such as uterine smooth muscle sarcoma, but histopathological evidence is needed for final clarification.
1. Disease treatment.
There are many treatment options for this disease, and clinical decision making needs to be individualized with the patient’s age, symptoms and fertility requirements. A combination of surgery and medications is often used as a comprehensive treatment plan.
Pharmacological treatment, symptomatic treatment: For those patients with mild symptoms who only require relief of dysmenorrhea, especially near menopause, they can choose to be treated symptomatically with non-steroidal anti-inflammatory drugs during dysmenorrhea. Since the ectopic endometrium will gradually shrink after menopause, such patients will be relieved of their pain after menopause without surgical treatment.
Pseudo-menopausal therapy: GnRHa injections can bring the hormone level in the body to the state of menopause, thus causing the ectopic endometrium to gradually shrink and play a therapeutic role. This method is also known as “pharmacological oophorectomy” or “pharmacological pituitary gland removal”. Usually, the serum estrogen level in the body reaches the depot level within 3-6 weeks after the drug is administered, and the dysmenorrhea can be relieved. Moreover, GnRHa can make the uterus shrink significantly after application, so it can be used as a preoperative drug for some patients with large lesions and difficult surgery. Waiting for the uterus to become smaller before surgery, the risk and difficulty will be significantly reduced. However, long-term application of GnRHa can lead to menopausal symptoms and even serious cardiovascular and cerebrovascular complications and osteoporosis, so it is recommended to add estrogen in reverse after 3 months of GnRHa application to alleviate the complications. In addition, GnRHa is expensive, costing about RMB 1000-2000 per month, so it is not currently used as a long-term treatment option, and once the drug is stopped, the resumption of menstruation may lead to the re-progression of the lesion. Therefore, GnRHa is currently often used as the drug of choice for preoperative lesion reduction and postoperative recurrence reduction.
Pseudopregnancy therapy: Some scholars believe that oral contraceptive drugs or progestins can control the development of adenomyosis by methylation and atrophy of the ectopic endometrium. Some patients choose to go on Manometrium to release highly effective progestin locally and continuously in the uterus to control the endometriotic lesions between the myometrial walls. However, some scholars believe that most of the endometrium in adenomyosis ectopic is the basal endometrium and they are not sensitive to progestin. Therefore, the effectiveness of progestin (oral contraceptive pills and Mannitol) in treating adenomyosis is still controversial.
TCM treatment: According to the understanding of TCM, adenomyosis is related to internal obstruction of blood stasis, which in turn is related to pathogenic factors such as cold clotting, qi stagnation, phlegm and dampness. Therefore, in terms of treatment, the principle of activating blood stasis should be taken into account, but also the causes of blood stasis formation and the degree of weakness.
2.Surgical treatment.
Surgical treatment includes radical surgery and conservative surgery. The radical surgery is hysterectomy, and the conservative surgery includes adenomyosis lesion (adenomyoma) excision, endometrial and myomectomy, myometrial electrocoagulation, uterine artery blocking, presacral neurectomy and sacral neurectomy, etc.
Hysterectomy: It is suitable for patients who have no requirement for childbirth and have extensive lesions with severe symptoms and ineffective conservative treatment. Moreover, in order to avoid residual lesions, total hysterectomy is preferred and partial hysterectomy is generally not advocated.
Excision of adenomyosis lesions: for patients with fertility requirements or young patients. Because adenomyosis is often diffuse and poorly defined from the normal muscle tissue of the uterus, the choice of excision to reduce bleeding, residual and facilitate postoperative pregnancy is a very confusing issue. Takeuchi et al. reported that a laparoscopic transverse H-shaped incision of the uterine lesion could reduce the risk of penetration of the uterine cavity during resection of the lesion, and the muscle layer surrounding the lesion was folded and sutured. Masato Nishida chose a central longitudinal excision of the uterine body without postoperative adjuvant therapy, and pregnancy was possible 3 months after surgery.
3. Interventional treatment.
In recent years, with the continuous progress of interventional treatment techniques. Selective uterine artery embolization can also be used as one of the treatment options for adenomyosis. The mechanisms of action are.
1, necrosis of ectopic endometrium, reduction of prostaglandin secretion and relief of dysmenorrhea.
2. softening of the uterine body after embolization, reduction in volume and endometrial area, and reduction in menstrual flow
3. continuous reduction in uterine volume and smooth muscle contraction, blocking the tiny channels causing endometriosis and reducing the recurrence rate.
4. a decrease in local estrogen levels and receptor numbers
5. the establishment of collateral circulation of the in situ endometrium, which can gradually migrate and grow back to function from the basal layer. ravina et al. reported that uterine artery embolization for adenomyosis resulted in about 50% reduction in menstrual volume and over 90% relief of dysmenorrhea.