The invasion of the endometrium into the myometrium is called adenomyosis. Adenomyosis is a common gynecological condition, however, it is not unique to humans, as many animals, such as primates and rodents, also have similar changes in the uterus, the cause of which is not well understood.
Because it is most often seen in married women who have given birth, it is thought to be closely related to pregnancy, curettage, abortion and childbirth. About 20% to 50% of adenomyosis is combined with endometriosis, about 30% is combined with fibroids, and it is also common to combine with pelvic inflammatory disease.
Dysmenorrhea is the main symptom of adenomyosis and is seen in about 80% of patients. Patients mostly present with secondary dysmenorrhea with progressive worsening. As the disease progresses, the pain may start about 1 week before menstruation or may extend to 1 to 2 weeks after menstruation, and in a few patients, the pain is still cyclical before and after menstruation. Heavy menstruation is another major symptom of adenomyosis and often leads to anemia.
In a few patients, heavy bleeding occurs and is easily misdiagnosed as functional uterine bleeding. In addition, a few patients are infertile. On gynecologic examination the uterus is enlarged, mostly homogeneous, harder and usually no larger than the size of 12 weeks of pregnancy, otherwise it may be combined with fibroids. If the lesion grows only in one part of the uterus (uterine adenomyoma), it may also show asymmetric enlargement.
A preliminary diagnosis will be made based on symptoms and gynecologic examination, and MRI is the most reliable and non-invasive method. However, MRI is expensive and should only be done when relying on other non-invasive diagnostic methods is still not diagnostic and affects the decision of surgical treatment.
Ultrasound is usually done most often in clinical practice and shows an enlarged uterus with a thickened myometrium and more pronounced posterior wall, resulting in an anterior shift of the endometrial line. Compared to the normal myometrium, the lesion is often isoechoic or slightly strong echogenic, sometimes with punctate hypoechogenicity visible in between and no clear boundary between the lesion and its surroundings.
Vaginal ultrasonography can improve the positive rate and accuracy of diagnosis. In recent years, some scholars have used color ultrasound to study uterine adenomyosis and found that vascular index determination may be more accurate than morphological observation of the mass. If iodine oil imaging of the uterus is done, iodine oil is seen to enter the myometrium, and the positive rate is about 20%. Recently, hydrogen peroxide sonography has been used and is thought to increase the positive rate.
Endoscopic endometrial pathology can also be done when available to clarify the diagnosis. The examination has a significant diagnostic value as an aid to adenomyosis and helps to differentiate it from fibroids.
Treatment of adenomyosis is divided into two categories: surgical treatment and pharmacological treatment. The choice of treatment depends on the patient’s symptoms, age and the presence of fertility requirements. Hysterectomy is the main method of surgical treatment, which can cure dysmenorrhea and excessive menstruation and is suitable for older patients without fertility requirements.
The uterine artery is embolized to cause necrosis and absorption of the lesions in the uterus. The following changes occur in the lesions after uterine artery embolization.
1. Due to the loss of blood supply, the ectopic endometrium and hyperplastic connective tissue become necrotic due to ischemia and hypoxia, and then gradually dissolve and absorb, making the lesion shrink or even disappear.
2.After the lesion shrinks, the irritating substances released by the lesion that make the uterus contract are reduced, thus improving the symptoms of dysmenorrhea.
3.The shrinkage of lesions makes the uterus soft, the volume of the uterus and the area of the uterine cavity are reduced accordingly, and the menstrual volume can be reduced accordingly.
4.After necrosis of ectopic endometrium, the necrotic part closes, while the myometrium compresses the original tiny channels due to the corresponding decrease in volume, resulting in their closure, and the normal endometrium also loses the access to the myometrium. The possibility of recurrence is greatly reduced.
5. The necrosis of ectopic endometrium reduces the amount of local estrogen and its receptors. The vicious cycle of the spread of adenomyosis is controlled. It also eliminates a possible disease factor of adenomyosis and reduces the possibility of recurrence.
6. After embolization, although normal endometrium may also show mild necrosis, it can regrow and resume normal function after revascularization or establishment of collateral circulation. In contrast, ectopic endothelium cannot regenerate after necrosis due to the lack of basal lamina support.
Clinical efficacy.
Dysmenorrhea relief rate: 70% to 90% of patients showed significant or marked improvement in dysmenorrhea symptoms within 1 to 3 months after the intervention.
In more than 89% of patients, the menstrual flow is reduced after the intervention, especially in those with blood loss anemia due to excessive menstruation, and the menstrual flow can be reduced to 20% to 80% of the preoperative level.
For patients with fertility requirements, most of them can get pregnant normally after the procedure.
Anemia. Patients with anemia symptoms can usually recover to normal or near-normal hemoglobin level after 3 months postoperatively, i.e., the anemia is effectively corrected.
Gynecological examination: Uniform enlargement and hardness of the uterus are the characteristics of this disease. Gynecological examination 1-6 months after the interventional treatment can reveal a softer and smaller uterus than before the operation.
Changes in vaginal discharge: Some patients with adenomyosis have excessive leucorrhea and blood before the intervention, or various vaginitis caused by repeated infections due to increased leucorrhea. They are completely cured after the intervention.
Improvement of other symptoms: the quality of sexual life is improved, and facial acne disappears.