Adenomyosis is a lesion resulting from the invasion of the endometrium into the myometrium and its growth. The endometrium can diffusely invade the entire myometrium causing a diffuse increase in the size of the uterus, or it can confinedly enter part of the myometrium in a nodular form, called adenomyoma.
The main clinical manifestations are progressive dysmenorrhea, increased menstruation, and infertility. The average age of onset of the disease is 42-45 years old, so it is generally believed that the disease develops when the endometrium or superficial muscle layer is damaged by childbirth or uterine surgery, and the basal endometrium invades and grows into the myometrium.
The diagnosis of this disease in China is mainly made by ultrasonography, especially transvaginal color Doppler ultrasound, which can make a more definite diagnosis. The two-dimensional ultrasound images of the disease can be divided into diffuse, focal and mixed types.
Typical sonograms are.
1. uniform enlargement of the uterus in a spherical shape.
2. thickening of the uterine wall with localized echogenic roughness and small anechoic areas visible in scattered distribution between the muscle walls.
3, limited uterine adenosis or adenomyoma manifests as a mass in the uterine wall with poorly defined normal myometrium, which should be differentiated from fibroids.
4, CDFI shows that the distribution of blood flow within the uterine adenomyosis is fragmented, with sparse dot and strip-like signals within and around the uterine adenomyosis, while focal adenomyosis shows no or stellar blood flow signal within the uterus and no or little blood flow signal around the uterus (uterine fibroids have a rich blood flow signal in the form of clear strips, semi-strips or spheres around the uterine fibroids due to the blood supply from the uterine artery, and rich dot and short lines within the uterus). (The blood flow such as dots, short lines, etc., should be distinguished.)
Because adenomyosis occurs in middle-aged women, most of whom have already given birth, and because the dysmenorrhea and increased menstrual flow caused by this disease are often severe, surgical removal of the uterus has been the most common and effective treatment.
However, in recent years, there is a tendency for the disease to become younger, and patients often have the requirement to preserve their reproductive function, and some patients cannot accept hysterectomy, so conservative drug therapy and conservative surgical treatment become more important, and choosing the best treatment for adenomyosis and reducing the occurrence of adverse effects is the focus of clinical research.
Surgical treatment.
1. Total hysterectomy.
Total hysterectomy is generally advocated for patients who have no reproductive requirements, whose clinical symptoms seriously affect their quality of life and for whom conservative treatment is ineffective, and whether the ovaries are preserved or not is decided according to the patient’s age. Depending on the actual situation, laparoscopic surgery or open surgery is chosen.
2. Fertility-preserving hysterectomy of adenomyosis lesions.
That is, through laparoscopy or open abdomen, without cutting the endometrium, all lesions are removed as far as possible and then sutured to repair the uterus. For patients with adenomyosis with clear borders, especially adenomyoma patients, adenomyectomy can be performed, and the current situation of dysmenorrhea and excessive menstruation can be improved more obviously after surgery, but this method cannot achieve the purpose of radical cure of adenomyosis.
3.Hysteroscopic endometrial debridement.
For older patients or those who have no fertility requirements, this method can remove most of the endometrium and superficial adenomyosis lesions to achieve the treatment purpose, but for deeper lesions can not achieve the therapeutic effect, so this method should be used to understand the depth of infiltration of lesions in the muscle layer by ultrasound.
4.Laparoscopic uterine neurectomy and laparoscopic presacral neurectomy.
That is, the nerves within the uterosacral ligament or the presacral nerve are cut off by cauterization under laparoscopy using electric knife or laser, which makes the nociceptive nerve uploading of the uterus blocked. For women with strongly preserved fertility, although this procedure is difficult to perform, it has excellent results for long-term pain control compared to traditional surgery.
Non-surgical treatment.
1. Placement of the Mannorrhea (trade name of LNG-IUS) ring.
After being inserted into the uterine cavity, it releases 20μg of levonorgestrel into the uterine cavity every day to create a high progesterone level in the uterine cavity, which causes a temporary atrophy of the endometrium and inhibits growth, resulting in a reduction in the amount of menstrual blood with each menstrual period and relieving the patient’s dysmenorrhea without affecting the patient’s reproductive function. The most common adverse effect is a small amount of vaginal bleeding, but basically disappears after 3 months.
2. Danazol.
Danazol is a synthetic steroidal heterocyclic compound, i.e. a derivative of androgen 17a-ethynyltestosterone, with anti-gonadotropic effect and mild androgenic effect, which can promote the degeneration of ectopic endometrium and improve the symptoms. The general usage is 400-600 mg daily for 6 months. Topical use of intrauterine devices containing danazol has also shown relatively good efficacy. However, the use of this drug is very limited due to its androgenic side effects, such as acne, hirsutism and voice coarsening. However, because Danazol can also reduce pain, it is worth considering when other treatments are not available.
3. Gonadotropin-releasing hormone agonists (GnRHa).
It is arguably the most effective drug for the treatment of endometriosis and adenomyosis, and is commonly used at present, such as darifenacin and inhibitor of natriuretic. It inhibits the secretion of estradiol, thus putting the ectopic endometrial tissue at rest. In the case of Daphylline, for example, treatment should be started on days 1-5 of the menstrual cycle, one injection at a time, every 4 weeks, and a course of treatment should last for at least 4 months and up to 6 months. However, this therapy may still have recurrence after discontinuation of the drug.
4.Targeted ablation.
(1) Ultrasound ablation: that is, high-intensity focused ultrasound (HIFU), which is a non-invasive treatment technique developed rapidly in the past 20 years, focuses ultrasound on the hyperplastic adenomyosis tissue on the uterine wall, converts ultrasound mechanical energy into thermal energy at the focal point of the target area, causes coagulative necrosis by increasing the temperature of the target tissue, and then the body will remove the necrotic tissue by phagocytosis, thus reducing the size of the adenomyosis lesion, improving This reduces the size of the adenomyosis lesion, improves the menstrual cycle, and relieves menstrual pain.
Studies have also shown that this method not only does not affect fertility, but also has the potential to improve the uterine environment and enhance fertility. Although this option cannot completely cure adenomyosis, it has good efficacy and high safety in the near future, and the long-term effects need further observation and research.
(2) Radiofrequency ablation: its principle is to use high-frequency AC electromagnetic waves through the tissue generated by bioheat to destroy the ectopic endometrial tissue, so as to achieve the therapeutic effect, but because adenomyosis has no envelope, so this program, like ultrasound ablation, can only achieve the purpose of “reduction” but not “cure”.
5. Allopathic medicine.
The symptoms of dysmenorrhea caused by this disease can be treated symptomatically with anti-prostaglandin drugs such as fenbendazole, ibuprofen and other non-steroidal anti-inflammatory and analgesic drugs. Do not take them on an empty stomach, and do not take them continuously for a long time.