Adenomyosis is the presence of endometrial glands and mesenchyme in the myometrium, accompanied by compensatory hypertrophy and hyperplasia of the surrounding myometrial cells. It was previously referred to as intrinsic endometriosis, while non-myometrial endometriosis was referred to as extrinsic endometriosis to show the difference. The cause of pathogenesis is unclear. Typical symptoms and signs can make the initial diagnosis, and histopathological examination is required to confirm the diagnosis.
What are the clinical manifestations of adenomyosis?
Adenomyosis occurs mostly in menstruating women over 40 years of age. The main manifestations are increased menstrual flow and prolonged menstruation (40%-50%) and progressive dysmenorrhea (25%) that gradually increases. The pain often starts as early as one week before the onset of menstruation and ends at the end of the period. In addition, some patients may have unexplained midmenstrual vaginal bleeding and loss of libido. About 35% of patients do not have any clinical symptoms.
Gynecologic examination may reveal a uniformly enlarged uterus or a limited nodular bulge, which is hard and painful, especially during menstruation. 15-40% of patients have endometriosis, so the uterus is less mobile. About half of the patients are combined with uterine fibroids, which makes preoperative diagnosis difficult.
What tests can be done for uterine adenomyosis?
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, while MRI can objectively understand the location and scope of the lesion before surgery, which can help to decide the treatment method. Some patients with adenomyosis have elevated serum CA125 levels, which are valuable in monitoring the efficacy of treatment.
How is adenomyosis treated?
It depends on the patient’s age, birth requirements and symptoms.
1.Drug treatment
There is no effective drug to cure this disease. GnRHa can make pain relief or disappear, the uterus shrink, but the symptoms return after stopping the drug, the uterus enlarges again.
(1) GnRHa
GnRHa is a gonadotropin-releasing hormone agonist that acts similarly to natural GnRH, but has a strong affinity for GnRH receptors and is about 100 times more potent than GnRHa. The mechanism of action is to inhibit the secretion of pituitary gonadotropins, resulting in a decrease in the secretion of sex hormones by the ovaries, resulting in a low estrogenic state in the body and temporary menopause, which can be treated by the temporary de-escalation of the drug. Therefore, this treatment is also called “pharmacological pituitary gland removal” or “pharmacological ovariectomy”. At present, the drugs commonly used in China are Inhibitors,cheap beats by dre, Norad and Daphylline. Menorrhagia usually occurs 3-6 weeks after the drug is administered. The main side effects are vasomotor syndrome and osteoporosis, the former mainly manifesting as hot flashes, vaginal dryness, decreased libido, breast tenderness, insomnia, depression, irritability and fatigue in the menopausal group. Most of the symptoms can disappear in a short time after stopping the drug and ovulation can be resumed, but bone loss takes 1 year or even longer to recover.
(2) You can try the Mannedel contraceptive ring
The levonorgestrel intrauterine device (Mannorrhea ring) can relieve dysmenorrhea and reduce menstrual flow, and needs to be replaced after 5 years. Some patients have symptoms such as low menstrual flow or amenorrhea and irregular vaginal bleeding after the procedure. The contraceptive ring tends to fall off when the patient’s uterus is too big.
2.Surgical treatment
Total hysterectomy can be used for patients with severe symptoms, older age, no fertility requirement or ineffective medication. Whether the ovaries are preserved depends on the presence or absence of ovarian lesions and the patient’s age.
Compared with uterine fibroids, the most important feature of ADS is that the demarcation with the myometrium is not obvious, and it is difficult to be completely removed in the clinic. Conventional treatment, i.e. total hysterectomy, can cause various problems for young patients in terms of physiology and psychology, reproductive function, pelvic floor anatomy, sexual reflexes, and quality of life.
Young patients with ADS are mainly treated symptomatically for uterine enlargement, excessive menstruation, dysmenorrhea, and infertility.
The combination of Mannorrhea and GnRHa can significantly improve clinical symptoms. The use of Mannorrhea is strictly indicated, and is not indicated for patients with a uterus larger than 10 weeks gestation, excessive menstrual flow combined with anemia, irregular bleeding, or significant dysmenorrhea without strength.
Surgery includes “complete” adenomyectomy and “partial” adenomyectomy, the former should be used for patients with limited lesions and clear boundaries, with better therapeutic effect; the latter should be used for diffuse adenomyosis, mainly to reduce the load of the lesions and provide a good basis for postoperative medication. The latter is used for diffuse adenomyosis, mainly to reduce the load of the lesion and provide a good basis for postoperative medication. The surgery can significantly reduce the pain symptoms and improve the pregnancy rate, which is influenced by the age of the patient. Adenomyectomy has certain disadvantages: the absence of normal myometrium due to resection, the reduction of myometrial volume during pregnancy, the tendency to miscarriage and premature delivery, the increased tension of the myotomy, the difficulty in reconciliation and thus the deformation of the uterus, the weakness of the myometrial wall at the site of the incision, the tendency to rupture the uterus during pregnancy, and the postoperative pelvic adhesions, which affect conception. Therefore, patients with fertility requirements should carefully choose whether or not to undergo surgical treatment.
In addition to traditional focal resection, endometrial resection is currently used in clinical practice. However, this surgical procedure has a high recurrence rate and many patients require pharmacological intervention after surgery. The poor surgical outcome may be due to an oversized uterus, therefore, a uterus larger than 8 weeks of gestation is not suitable for this treatment modality.