Adenomyosis is the invasion of the endometrial glands and mesenchyme into the myometrium.
A small number of endometrium grows in the myometrium in a restricted manner, forming nodules or masses, similar to interstitial fibroids of the uterus, called uterine adenomyoma. It is a common disease in gynecology. Adenomyosis used to occur mostly in menstruating women over 40 years of age, but in recent years there has been a gradual trend toward a younger age, which may be related to the increase in cesarean deliveries and abortions. There are many treatment options for this disease, and clinical decisions need to be individualized, taking into account the patient’s age, symptoms and fertility requirements. And often a combination of surgical and pharmacological treatment options are combined.
The etiology 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 of the surrounding myofibroblasts.
There are four theories on the factors that cause cell proliferation and invasion of the basal layer of the endometrium.
1. genetic association.
2, uterine injury, such as curettage and cesarean delivery both 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.
What diseases are easily confused with adenomyosis?
1. pelvic endometriosis
Patients also have dysmenorrhea and a palpable mass in the pelvic cavity that is inactive, with a normal or slightly large uterus that is fixed in a posterior tilt, and an adnexal mass on one or both sides that can be diagnosed on ultrasound combined with clinical symptoms.
2.Uterine fibroids
Patients are usually not accompanied by dysmenorrhea. In gynecological examination, the uterus is enlarged, the nodules are uneven, hard, without pressure pain, and the uterus is mobile, and the myometrial mass is clearly defined with the surrounding tissues in ultrasound examination.
3.Functional uterine bleeding
The patient does not have dysmenorrhea, irregular menstruation, increased menstrual flow, or prolonged menstrual period. On gynecological examination, there is no abnormality in the uterus and bilateral adnexal areas. on ultrasound examination, there is no abnormal echogenicity in the pelvis. Diagnosis was determined by diagnostic scraping pathology examination.
4.Uterine sarcoma
Most commonly seen in older women with rapid growth and enlargement of existing uterine fibroids, causing abdominal pain, fever and anemia. On gynecological examination, the uterus is significantly enlarged and painful. On ultrasound examination, the uterus is enlarged and echogenic tumor nodules can be seen in the muscle layer.
5.Endometrial cancer
Irregular menstrual period and spotting bleeding should be distinguished from endometrial cancer, which occurs in perimenopausal and postmenopausal women. Irregular vaginal bleeding is the main symptom of endometrial cancer, partly manifested as vaginal fluid discharge, uneven endometrial thickening by ultrasound, diagnosis can be confirmed by segmental scraping and biopsy under direct view of hysteroscopy with accuracy rate close to 100%, MRI can clearly show the size and scope of endometrial cancer lesions, muscle layer infiltration and metastasis of pelvic and para-aortic lymph nodes.
Treatment
There are many treatment options for this disease, and clinical decisions need to be individualized according to the patient’s age, symptoms and fertility requirements. It is often combined with a combination of surgical and pharmacological treatment options.
1.Pharmaceutical treatment
(1) Symptomatic treatment For 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 at the time of dysmenorrhea. Since 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 is a treatment method in which injections can bring the hormone level in the body to the state of menopause, thus causing the ectopic endometrium to gradually shrink. This method is also called “pharmacological oophorectomy” or “pharmacological pituitary gland removal”.
(3) Pseudopregnancy therapy Some scholars believe that oral contraceptive drugs or progestin can make the ectopic endometrium metastasize and atrophy to control the development of adenomyosis, but some scholars also believe that the ectopic endometrium of adenomyosis is mostly the basal endometrium, which is not sensitive to progestin. Therefore, the effectiveness of progestin treatment for adenomyosis is controversial.
Surgical treatment
This includes radical surgery and conservative surgery. Radical surgery is hysterectomy, and conservative surgery includes adenomyosis lesion (adenomyoma) excision, endometrial and myomectomy, myometrial electrocoagulation, uterine artery block, and presacral neurectomy and sacral neurectomy.
(1) Hysterectomy is used when the patient has no requirement for fertility, and the lesion is extensive, the symptoms are severe, and conservative treatment is ineffective. Moreover, in order to avoid residual lesions, total hysterectomy is preferred and subtotal hysterectomy is generally not advocated. It is not applicable to young infertile patients.
(2) Focal hysterectomy for adenomyosis is suitable for patients who have fertility requirements or are young. Because adenomyosis is often diffuse and poorly defined from the normal muscle tissue of the uterus, the choice of resection to reduce bleeding, residual and facilitate postoperative pregnancy is a very confusing issue. Different scholars have different protocols and there is no uniform procedure. Either open or laparoscopic can be done.
(3) Endometrial resection: the results are better for patients with endometrial infiltration depth ≤2.5 mm, and patients with infiltration depth ≥2.5 mm often require hysterectomy after repeated endometrial resections.
Laparoscopic conservative treatment of uterine myometriosis surgery should pay attention to the following aspects.
1, selection of appropriate cases: obvious dysmenorrhea, increased menstrual flow, young age, urgent need to preserve the uterus, and relatively limited lesions.
2. Patients with diffuse lesions should undergo open surgery
3, prevention of bleeding: oxytocin, posterior pituitary hormone, and arterial blockade for those who do not need to have children.
4.The incision alignment facilitates suturing, longitudinal or oblique in the anterior wall and transverse in the posterior wall
5, excision depth of the lesion: traditional focal excision requires the preservation of the endometrium as far as possible, while the concept of endometrium-myometrium junction area proposed that EMI is the “root of the disease”, then the endometrium should be removed at the lesion, and facilitate suturing.
6, the scope of excision of the lesion: the entire adenomyosis lesion.
7, suture: not bound to layer by layer suture
8.Sutures: preferably barbed wire