I. Introduction of the disease
Adenomyosis is a common gynecological condition in which the endometrial glands and mesenchyme invade the myometrium to form diffuse or restricted lesions. It often leads to symptoms such as secondary dysmenorrhea and increased menstrual flow, thus seriously affecting women’s physical and mental health. Currently, there are many treatment options, and treatment is often individualized according to the patient’s age and fertility needs.
Causes
The cause of adenomyosis is still unknown. The current consensus is that the uterus lacks a submucosal layer, so the cells of the basal layer of the endometrium proliferate and invade the myometrium, with compensatory hypertrophy and proliferation of the surrounding myometrial cells.
There are four theories on the factors that cause cell proliferation and invasion of the basal layer of the endometrium.
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 endometriosis to the myometrium of the uterus.
III. Pathophysiology
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 invaded. However, this diagnostic criterion is still controversial.
IV. Clinical manifestations
Adenomyosis used to occur mostly in menstruating mothers over 40 years of age, but in recent years there has been a gradual trend toward younger age groups, which may be related to the increase in caesarean sections, abortions, and other procedures.
V. Symptoms
1. Menstrual disorders (40-50%): mainly manifested by prolonged periods, increased menstrual volume, and some patients may also experience spotting bleeding before and after menstruation. This is triggered by the increase in uterine volume, the increase in the lining area of the uterine cavity and the intermyometrial lesions affecting the contraction of uterine muscle fibers. In severe cases, it 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.
VI. Physical signs
The uterus is often uniformly enlarged and spherical in gynecological examination, and adenomyoma may appear as a hard nodule. The uterus usually does not exceed the size of 12 weeks of pregnancy. Near menstruation, the uterus is painful to the touch; during menstruation, the uterus increases in size, becomes softer in texture, and the 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.
VII. Diagnosis
The 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 objectively understand the location and scope of the lesion before surgery, which is more helpful for deciding the treatment method.
Some patients with adenomyosis have elevated serum CA125 levels, which are of value in monitoring the efficacy of treatment.
Differential diagnosis
Adenomyosis and uterine fibroids have the same pathogenic group and similar clinical manifestations, so it is easy to misdiagnose adenomyosis as uterine fibroids, with a misdiagnosis rate of up to 32%. In addition, uterine adenomyosis is often combined with uterine fibroids, so ultrasound and other imaging methods often report only uterine fibroids and neglect the diagnosis of uterine adenomyosis, and the rate of missed diagnosis can be 33.9%.
The key points of differentiation between the two are as follows.
Uterine adenomyosis fibroids secondary to dysmenorrhea are common and rare Uterine morphology is more homogeneous enlargement more nodular enlargement with menstruation relationship with menstruation does not change with menstruation ultrasound uterine wall thickening, dark shadow of cords inside, different from normal tissue no echogenicity or hypoechoic nodules within the myometrial wall blood CA125 partially elevated normal
Uterine adenomyosis also needs to be differentiated from malignant tumors such as uterine smooth muscle sarcoma, but histopathological evidence is needed for final clarification.
Disease treatment
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. And often combined with surgery, drugs and other comprehensive treatment plan.
1.Pharmaceutical treatment
(1) Symptomatic treatment.
For those patients with mild symptoms who only require relief of dysmenorrhea, especially those who are near menopause, symptomatic treatment with non-steroidal anti-inflammatory drugs can be chosen during dysmenorrhea. Because the ectopic endometrium will gradually shrink after menopause, such patients will be relieved of the pain after menopause without surgical treatment.
(2) Pseudo-menopause therapy.
GnRHa injection can make the hormone level in the body reach the state of menopause, thus causing the ectopic endometrium to gradually shrink and play a therapeutic role. This method is also called “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.
(3) False pregnancy therapy.
Some scholars believe that oral contraceptive drugs or progestin can control the development of adenomyosis by causing ectopic endometrium to metastasize and atrophy. 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.
(4) Traditional Chinese medicine (TCM) treatment.
According to the understanding of TCM, adenomyosis is related to internal stasis of blood, and the formation of blood stasis is related to pathogenic factors such as cold condensation, qi stagnation, phlegm and dampness. Therefore, the treatment should be based on the principle of activating blood stasis, but should also take into account the causes of blood stasis formation and the degree of weakness.
2.Surgical treatment
Surgical treatment includes radical surgery and conservative surgery. Radical surgery is hysterectomy, while conservative surgery includes adenomyosis (adenomyoma) excision, endometrial and myomectomy, myometrial electrocoagulation, uterine artery blocking, anterior sacral neurectomy and sacral neurectomy.
Hysterectomy.
It is suitable for patients who have no fertility requirements 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.
Focal hysterectomy for adenomyosis.
It is indicated for patients with fertility requirements or who are young. 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 advancement 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 that cause endometriosis and reducing the recurrence rate.
(4) Decreased local estrogen levels and receptor numbers.
(5) Establishment of collateral circulation of the in situ endometrium, which can gradually migrate and grow back to function from the basal lamina.
Ravina et al. reported that uterine artery embolization for adenomyosis resulted in approximately 50% reduction in menstrual flow and over 90% relief of dysmenorrhea. Wang Yitang et al. reported that among 128 patients with adenomyosis treated with uterine artery embolization, dysmenorrhea disappeared completely in 80 cases (62.5%), significantly relieved in 42 cases (32.8%), and partially relieved in 6 cases (5%) after surgery. Twenty-one cases had normal pregnancies and delivered healthy babies 9–36 months after surgery.
However, some scholars believe that uterine artery embolization affects the blood flow to the uterus and ovaries and thus has a negative effect on pregnancy. It may lead to infertility, miscarriage, preterm delivery and increase the rate of cesarean delivery.
X. Disease prognosis
Adenomyosis has a high recurrence rate, but the disease can be cured after hysterectomy and menopause. The malignancy rate is low. The malignancy rate of endometriosis, a disease similar to adenomyosis, is reported to be 1.5% in China and 0.7% – 1.0% abroad. In contrast, the occurrence of malignancy in adenomyosis is much less common.