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 to 45 years old, so it is generally believed that the disease develops due to injury to the endometrium or superficial muscular layer caused by childbirth or uterine surgery, and the basal endometrium invades the myometrium and grows.
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 unevenness in the uterine wall, with small anechoic areas visible in scattered distribution between the muscle walls.
3, limited uterine adenosis or uterine adenomyoma manifests as a mass in the uterine wall with poorly defined normal muscle layer, which should be differentiated from uterine fibroids.
4, CDFI shows that the distribution of blood flow in uterine adenomyosis is fragmented, with sparse point and strip-like signals within and around the uterus, while focal adenomyosis has no or star-shaped blood flow signals within the uterus and no or little blood flow signals around the uterus (uterine fibroids have clear strip, half-strip or ball-like rich blood flow signals around the uterine fibroids due to the blood supply from uterine arteries, and rich point-like and short-line blood flow signals within the uterus). (The difference should be noted.)
Since adenomyosis occurs in middle-aged women, most of whom have already given birth, and the painful menstruation 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 medication 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 with no fertility requirements, clinical symptoms seriously affecting the quality of life and ineffective conservative treatment, and ovarian preservation 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 adenomyosis lesion excision: that is, through laparoscopy or open abdomen, without cutting the uterine lining as much as possible to remove all the lesions after suturing 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 excision: for older patients or patients without fertility requirements, this method can remove most of the endometrium and superficial adenomyosis lesions to achieve treatment, 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 through the ultrasound.
4.Laparoscopic hysterectomy and laparoscopic presacral neurectomy: that is, the nerves in the uterosacral ligament or presacral nerves are cut off by electric knife or laser cautery under laparoscopy, so that the painful nerve uploading of the uterus is 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 ring: Mannorrhea is the levonorgestrel intrauterine delayed-release system, which, after being placed in the uterine cavity, releases 20 μg of levonorgestrel into the uterine cavity every day
After levonorgestrel is inserted into the uterine cavity, 20 μg of levonorgestrel is slowly released into the uterine cavity every day, resulting in a high local progesterone level in the uterine cavity, causing a temporary atrophy of the endometrium and inhibiting the growth of the endometrium. 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, namely androgen
17a-ethinyl testosterone derivative, with anti-gonadotropic effects and mild androgenic effects, can promote the degeneration of ectopic endometrium and improve the symptoms. General use is 400-600 mg daily for 6 months.
For 6 months. Topical IUDs containing danazol have also been shown to be more effective. However, its use is 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: arguably the most effective drugs for the treatment of endometriosis and adenomyosis, currently in common use are Daphylline and Inhibiton. They inhibit 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, 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 the menstrual cycle and relieving 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 may also 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: the principle of using high-frequency AC electromagnetic waves through the tissue when the bioheat generated to destroy the ectopic endometrial tissue, so as to achieve the therapeutic effect, but because adenomyosis without envelope, so the program and ultrasound ablation can only achieve the purpose of reduction but not the root cause.
5, symptomatic treatment of drugs: the symptoms of dysmenorrhea caused by the disease can be used symptomatically anti-prostaglandin drugs such as fenbid, ibuprofen and other non-steroidal anti-inflammatory analgesic drugs. Do not take them on an empty stomach, and do not take them continuously for a long time.