What is adenomyosis?
Adenomyosis is a non-neoplastic lesion of the uterus, but many of the signs and symptoms are very similar to those of fibroids. Adenomyosis is a diffuse or limited invasion of the endometrial glands and mesenchyme into the myometrium. During menstruation, bleeding from these ectopic endometrial tissues directly into the myometrium can cause pain. As the blood accumulates, the surrounding muscles swell and form fibrous tissue. This swelling is located within the muscle layer of the uterus and is called an adenomyoma because it feels like a fibroid on ultrasound and is often confused with a fibroid. Adenomyosis can be mildly symptomatic or completely asymptomatic, or it can be very symptomatic and can cause severe bleeding and menstrual pain during menstruation. Adenomyosis is present in about 10% of women and is therefore not as common as fibroids, but it has been reported in the literature in 70% of women in their 40s and 50s. If it is only detected by imaging without symptoms, it can be followed up and observed without any urgency to treat.
Illustration: on the left is a normal uterine pattern image, on the right is a pattern image of an adenomyotic uterus with endometrial implantation into the myometrium, visible as diffuse thickening of the uterine base with patchy implanted endometrium (this is the culprit of the symptoms of adenomyosis)
The causes of adenomyosis are still unknown. Experts believe that the possible causes include:
1. implanted tissue growth Some experts believe that adenomyosis stems from the direct implantation of endometrial tissue cells from the endometrium into the muscle layer. Some surgical operations on the uterus, such as cesarean sections and abortions, may implant endometrial cells directly into the myometrium.
Other experts speculate that adenomyosis originates in the fetal period when the uterus is formed and some endometrial tissue is deposited in the muscular layer of the uterus.
3. Inflammation of the uterus associated with childbirth Another theory suggests a relationship between adenomyosis and childbirth. Inflammation of the endometrium in the postpartum period may lead to a break in the normal layers of tissue, resulting in implantation of the endometrium.
4. A recent theory of stem cell origin suggests that bone marrow stem cells may invade the uterine muscle and cause adenomyosis.
Regardless of how adenomyosis is formed, its growth depends on the secretion of cyclic hormones in the female body. When the production of estrogen decreases after menopause, adenomyosis eventually disappears.
Clinical manifestations of adenomyosis
1, symptoms some times adenomyosis is not symptomatic, or mild discomfort, some patients symptoms will be more serious.
(1) Menstrual disorders: mainly manifested as prolonged periods, menstrual disorders, increased menstrual volume, which can lead to anemia in serious patients.
(2) Dysmenorrhea: severe colicky or knife-like pain during menstruation that lasts throughout the period and worsens with age, which is usually the main reason for patients to seek medical attention. The lesion is located in the posterior wall of the uterus often accompanied by anal cramping during menstruation. Initially, pain medication can provide relief, but as the condition progresses, the dose of pain medication required for dysmenorrhea increases significantly, making it intolerable for the patient. As the condition progresses it can cause a prolonged duration of dysmenorrhea, up to a constant pain during non-menstrual periods. The site of pain may also be pan-waist, with self-induced extra-uterine pain.
(3) Painful intercourse: It affects normal married life and even becomes a cause of divorce.
(4) Bleeding between periods.
2, physical signs gynecological examination of the uterus enlarges to 2-3 times the normal size. Tenderness of the uterus near your period. Although you may not be aware that your uterus is enlarged, you may notice that your belly seems larger or has tenderness. In patients with adenomyosis, about half of them have a combination of fibroids.
The initial diagnosis of adenomyosis can be made based on typical history and signs, combined with imaging tests such as pelvic or vaginal ultrasound, MRI, CA125, etc. The diagnosis can be confirmed by surgery to obtain lesions for pathological examination.
Imaging is the most effective means of preoperative diagnosis of the disease. The sensitivity of vaginal ultrasonography is 80% and the specificity is 74%, which is more accurate than the abdominal probe. In the case of adenomyosis, ultrasound shows a homogeneous enlargement of the uterus with uneven echogenicity; in the case of adenomyoma, ultrasound shows a heterogeneous enlargement of the uterus with localized elevation and heterogeneous hyperechoic lesions; MRI can objectively understand the location and extent of the lesion before surgery, which is helpful in deciding the treatment. In diffuse adenomyosis, MRI shows diffuse thickening of the uterine binding zone on T2WI; in limited adenomyosis, T2WI shows a low-signal mass with similar signal to the binding zone and blurred borders.
Figure: Magnetic resonance examination of adenomyosis, it can be seen that the myometrium is significantly thickened, and the internal dotted-sheet signal is the ectopic endometrium implanted into the myometrium repeatedly causing pain
2, serum 125 some patients with adenomyosis have elevated serum CA125 levels, which has some value in monitoring the efficacy of treatment.
How to treat adenomyosis There are many treatment options for this disease, and clinical decision making needs to be individualized with the patient’s age, symptoms and fertility requirements.
Surgical and pharmacological treatment options can be chosen simultaneously.
1.Pharmacological treatment
(1) Pharmacological pain treatment: symptomatic treatment for those who have mild symptoms and only require relief of dysmenorrhea, can choose to give symptomatic treatment with non-steroidal anti-inflammatory drugs such as fenbendazole, anti-inflammatory pain or naproxen during dysmenorrhea.
(2) Hormone therapy: Patients with significant dysmenorrhea can be treated with hormone therapy, such as levonorgestrel extended-release intrauterine device (trade name: Manuel), aromatase inhibitors and gonadotropin-releasing hormone analogs.
2.Surgical treatment includes radical surgery and conservative surgery. The radical surgery is hysterectomy, and the conservative surgery includes adenomyosis lesion (adenomyoma) excision, endometrial and myomectomy, myometrial electrocoagulation, uterine artery blocking, presacral neurectomy and sacral neurectomy, etc.
(1) 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.
Figure: Complete specimen of adenomyosis surgically removed, the brown area in the figure is the area with more serious lesions.
(2) Excision of adenomyosis lesions: for patients who have fertility requirements or are young. Since adenomyosis is often diffuse and poorly defined from the normal muscle tissue of the uterus, it is a difficult problem to choose the way of excision to reduce bleeding, residual and facilitate postoperative pregnancy.
3.Interventional treatment. Selective uterine artery embolization (UAE) is one of the treatment options for adenomyosis. This is a minimally invasive interventional procedure, through only 1-2mm thin catheter into the blood supply artery of the uterus, and then inject very tiny PVA microspheres (300-500um), causing the interruption of nutrient and nutrient supply of adenomyosis tissue and necrosis and detachment, to achieve the purpose of disease treatment, and its mechanism of action are: necrosis of ectopic endometrium, reduction of prostaglandin secretion, relief of dysmenorrhea, reduction of menstrual flow, and reduction of recurrence rate.
Figure: Diagram of the surgical model of selective uterine artery embolization, where the catheter selectively enters the uterine artery and then injects the embolic substance.
The advantages of interventional treatment of uterine fibroids, also called selective uterine artery embolization (UAE), have the following advantages.
1. Non-hormonal treatment will not affect women’s endocrine and menstrual cycles.
2. Preservation of the uterus can be treated without damaging the normal tissues and organs of the uterus.
3, minimal trauma without surgery, only through the puncture eye of the femoral artery at the root of the thigh can complete the treatment, without general anesthesia or semi-anesthesia, only about 2 cm of skin surface anesthesia near the puncture eye, the patient is awake throughout. The patient can be discharged from the hospital 1-2 days after the operation.
4, the efficacy is exact according to the 10-year experience review of major foreign centers, the long-term efficiency of symptom relief is 75.7%-92.9%, and the latest literature released (2015) shows that with the improvement of technology and equipment, the clinical efficiency of the 3-year follow-up period reached 97%.
5. No serious side effects. There is pain in the perioperative period (but it can be controlled by analgesic pumps). There is little effect on ovarian function, and there is a possibility of early menopause in women close to menopause (on the other hand, this disease will be completely cured after menopause).
Effects on the ovaries after uterine artery embolization
The above table shows that uterine artery embolization did not have a significant effect on the normal secretion of ovarian hormones, and there was no significant decrease in hormone levels before and after the intervention (uterine artery embolization) procedure. (p>0.05 indicates no difference)
It is inconclusive whether there is an effect on pregnancy or not, and from the available data it is not significant.
Effect of various treatments on pregnancy
The above table shows: the effect of various treatments on conception after uterine fibroid surgery, it is seen that interventional procedures have relatively the least effect on conception. (Interventional procedures for adenomyosis and fibroids are basically the same)
Interventional treatment procedure
The procedure of adenomyosis intervention is as follows: the femoral artery is touched at 0.5 cm below the midpoint of the inguinal ligament as a puncture point, and the arterial system of the human body is accessed through the puncture point. -The uterine artery is then embolized by pushing a certain size and amount of embolic pellets through the catheter to embolize the blood vessels supplying the uterine adenomyosis and the end vessels of the normal uterine artery branches. The whole procedure usually takes about 30 minutes. The patient is awake throughout the procedure, no special cooperation is needed, please relax. The lower extremity of the punctured side (usually the right side) is braked for 4 hours after the operation, and the patient can get out of bed after 8 hours after the operation, and can usually be discharged home to recuperate 1-2 days after the operation.
Diagram: Uterine fibroid intervention model, catheter selectively enters the blood supply artery of adenomyosis and then embolization is performed
Diagram: Interventional treatment of uterine fibroids with catheter entering bilateral uterine arteries for embolization
Principle of interventional treatment of adenomyosis
1.It can directly cut off the blood supply to the ectopic endometrium of adenomyosis, and the ectopic endometrial tissue cells will be completely ischemic and necrotic in a short period of time.
2. Adenomyosis is sex hormone dependent, and estrogen can promote the growth of ectopic endometrial tissue. Cutting off the blood supply of adenomyoma can block estrogen from entering the ectopic endometrial tissue via blood flow, and the estrogen level of the lesion will drop significantly, forming a local hormonal environment similar to menopause and further shrinking of the lesion.
3. After uterine artery embolization, the uterine blood supply decreases significantly, the endometrial growth is inhibited and the menstrual volume decreases, and the menstrual period returns to normal. Anemia was gradually improved and restored.
Figure: In vitro magnification of the PVA microspheres we chose in embolization and their embolic response under microscope. Compared with conventional embolization particles, the 300-500um microspheres are more likely to enter the vascular end of the adenomyosis lesion, and the efficacy is more complete and long-lasting.
Frequently asked questions about choosing interventional treatment
1.Schedule of surgery
(1) The timing of the procedure is decided according to the patient’s individual physiological cycle, usually 3-7 days after the end of the menstrual cycle. Please reserve a bed in advance so that you can be hospitalized in time for treatment.
(2) The patient’s recent (within 3 months) ultrasound and other imaging examinations can be used as a reference for surgery, and no additional examination is needed. For some special patients, an MRI may be added depending on the situation.
(3) The surgery will be performed safely immediately after the perfect examination. Fasting for more than 6 hours before surgery.
(4) You need to get out of bed the night after surgery, and you can be discharged home to recuperate 1-2 days after surgery.
2.Treatment effect
(1) The most thorough treatment for adenomyosis is hysterectomy, which is the only means to cure it, and all other treatments have the theoretical possibility of recurrence.
(2) Uterine artery embolization is one of the most effective means to preserve the uterus and treat adenomyosis, and the efficiency rate for severe dysmenorrhea and excessive menstruation caused by adenomyosis is over 90%.