Common problems of adenomyosis

First, what is called adenomyosis?Adenomyosis (adenomyosis) is a benign lesion caused by the invasion of myometrium in the basal layer of th

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First, what is called adenomyosis?

Adenomyosis (adenomyosis) is a benign lesion caused by the invasion of myometrium in the basal layer of the endometrium. In the past, it has been said that the intrinsic endometriosis, and the endometriosis of the non myometrial endometriosis as a manifestation of endometriosis. Adenomyosis occurs more than 30 to 50 years of age, about half of the patients with uterine fibroids, about 15% patients with endometriosis. It can be divided into two types: diffuse and focal type, and the latter is called uterine fibroids. According to the depth of the lesions, the lesions can be divided into three stages: the focus of the lesion is only the superficial layer of the superficial muscle, the infiltration of the lesion to the middle layer of the muscle, and the infiltration of the lesion over the muscularis.

Generally speaking, is the womb muscle and gland has a problem. The uterus is made up of three layers of tissue, the inner lining of the uterus, the middle of which is the muscle, and the outside is a layer of the same. Under normal circumstances, the endometrium should be below the muscular layer, there are boundaries between them. If the endometrium and superficial muscle layer damage, such as childbirth, repeated abortion and curettage, endometrial will take advantage of a weak point. They grow and develop in the uterine muscles, and stimulate the proliferation of peripheral muscle cells, the formation of adenomyosis. In the muscle of the endometrium can be the same as the normal endometrium, with the menstrual cycle changes and the occurrence of periodic congestion, edema and even bleeding, will cause strong uterine contractions and severe abdominal pain. Sometimes, adenomyosis occurs only in a part of the uterus, so that the local uterine muscle cells to form a significant proliferation of mass, then known as uterine fibroids. But it is not really a tumor, does not contain tumor cells, and there is no obvious boundary.

Two, why get uterine adenomyosis?

The real pathogenic mechanism is not clear. Most scholars think that the genetic damage and, (such as uterine curettage and cesarean section), hyperestrinemia, virus infection. Through the examination of serial sections of adenomyosis were found in myometrium endometrium and uterine endometrial surface and some are directly connected, so that multiple pregnancy and childbirth uterine wall trauma and chronic endometritis is a major cause of disease. In addition, due to the lack of basement membrane of endometrial submucosa, and adenomyosis often associated with uterine myoma and endometrial hyperplasia, so some people think that the basal layer of endometrial invasion muscle may be associated with high estrogen stimulation.

The incision of the uterus under the operation of the observation, we can find a fresh or old uterine bleeding, which is ectopic endometrial tissue in the myometrium caused by the performance. Some ectopic endometrial tissue in the myometrium may even have changes in the menstrual cycle, such as proliferation, secretion and decidua. Although the specimens were examined by autopsy and hysterectomy, it was found that 10 to 47% of the myometrium had endometrial tissue, but only about 70% of them had clinical symptoms.

Three, what are the clinical manifestations of uterine adenomyosis?

With menorrhagia, progressive dysmenorrhea as the main performance. The degree of dysmenorrhea is serious, the performance of persistent abdominal pain, low back pain, anal swelling with nausea and vomiting. Often cause infertility or anemia.

Secondary dysmenorrhea occurs in older women, that is, nearly 40 years old, dysmenorrhea gradually increased, often spastic. The performance of a child after a few years began to appear small menstrual cramps, and usually more and more heavy. Generally use painkillers, many patients need to fight pain needle. Some women pain roll on the ground, a pain killer can not completely relieve pain, pain in the course of time, a needle effect is getting worse, and even can not adhere to the daily work. Dysmenorrhea is due to ectopic endometrium in the menstrual edema, bleeding, stimulation of the muscle wall caused by spastic contraction.

Menstrual volume increased, prolonged menstruation, prone to anemia, a small number of menstrual bleeding before and after. This is due to an increase in the size of the uterus, the increase in the area of the uterine cavity, and the uterine wall between the ectopic endometrium affect the contraction of uterine muscle fibers.

Gynecological examination of uterine enlargement, the majority of the uniform increase, but the normal size of the uterus is less than normal or even the presence of adenomyosis. Hard, tender. A small number of patients may have nodular or irregular surface. During menstruation, the uterus can be enlarged, the texture is softer than usual, tenderness can be more obvious. A small number of patients at the time of sexual life pain, facial acne, chloasma, etc..

Four, how to diagnose adenomyosis?

Middle aged women, secondary, progressive dysmenorrhea, uterine adenomyosis should be considered. If accompanied by menorrhagia, menstrual period is too long, uterine enlargement, but also should consider adenomyosis. The best ultrasonic examination in the menstrual period or menstruation just clean, typical performance of uterine muscle increased evenly, there are many scattered cysts in reflection. Hysterosalpingography is visible in one or more into the muscle wall, forming a diverticulum like shadow, but the positive rate is only about 20%, with the identification of uterine leiomyoma. Some patients can do Pelvic MRI, in order to understand the myometrium and lesions. The final diagnosis depends on gross and histopathological examination.

Five, uterine adenomyosis patients can be pregnant?

Adenomyosis often occurs in 30 to 50 year old women, especially in menopausal women. Usually this group of patients have completed fertility tasks, no longer need to worry about infertility. But in recent years, with the increase of repeated abortion or curettage patients, more than and 20 young people aged more than 30 years old, still birth women with adenomyosis were not a few.

For these patients, once adenomyosis is most concerned about the issue, will not affect the fertility of infertility? Generally considered severe adenomyosis, especially with endometriosis patients, easy to cause infertility. Such patients with uterine hypertrophy and easy to have pelvic adhesions, is not conducive to ovulation and embryo bed, natural pregnancy rate is not high. Fortunately, young women with severe adenomyosis are rare. If it is a slight adenomyosis patients still have the opportunity to be pregnant. In addition, if it is limited to the muscle adenoma, surgical removal of the tumor to keep the uterus, the future still has the opportunity to be pregnant.

So, if the patients with long fibroids pregnancy, pregnancy whether there will be the risk of miscarriage? The long muscle adenoma of limit pregnant, will increase the rate of abortion, there is not enough evidence to support. If it is a diffuse uterine adenomyosis, the probability of miscarriage may be relatively high.

Six, uterine adenomyosis how to treat?

The treatment of adenomyosis can be divided into two categories: conservative treatment and surgical treatment:

1 conservative treatment

For the young and family needs of the patient and close to menopause women, using conservative treatment to keep the uterus from total resection is the primary consideration. Recently, for IUD release the clinical levonorgestrel (trade name, Mirena) can significantly improve the adenomyosis patients with dysmenorrhea and pelvic pain, menorrhagia and other symptoms, increase a treatment option for such patients. However, drug treatment is still the main treatment, including:

(1) non steroidal anti-inflammatory drugs can help ease the symptoms, such as indomethacin, painkillers such as ibuprofen.

(2) oral contraceptives is effective, not only can inhibit ovulation cycle use, have a contraceptive effect, also can make the endometrium and ectopic endometrium atrophy, the quantity of dysmenorrhea disappeared. However, long-term use of menopausal women is not appropriate. Side effects include nausea, vomiting, breast swelling, breakthrough bleeding and weight gain. At present, for unmarried or no fertility requirements and obvious in patients with mild dysmenorrhea. But after the withdrawal of dysmenorrhea and relapse.

(3) danazol, can block the adenomyosis tissue aromatic enzyme activity, inhibition of hypothalamic, pituitary, and direct effect on ovary, decreased FSH, LH and E, P level, can be directly combined with endometrial estrogen and progesterone receptors, leading to endometrial atrophy, cause amenorrhea, called false menopause therapy. In recent years, it has been proved that the inhibitory effect of letrozole on the proliferation of endometrial cells. During the menstrual cycle will be suspended, and therefore no longer dysmenorrhea, sustained medication three months to six months can make the uterine muscle thinning, the uterus is also small. The side effects of low estrogen symptoms, such as breast small, vaginal dryness, sweating, hot flashes. This drug is a male hormone derivative, long-term use may appear low voice, acne, long beard and other side effects. In addition can also lead to abnormal lipid metabolism and liver function damage, the heart, liver and kidney dysfunction disabled; during treatment, should also take a drug and monitoring of liver function.

(4) mifepristone, nortestosterone derivatives as synthetic 19-, due to a strong binding force with the progesterone receptor, and has strong anti progesterone action, cause amenorrhea, relieve pain. In earlier years, widely used in anti early pregnancy, the author has tried in the treatment of endometriosis in recent years, some clinical evidence. The normal menstruation menopause after 3~6 weeks, the recurrence rate is high. Some scholars reported that 100mg/d * March, the symptoms improved, but the disease remains; 50mg/d * June, the symptoms and lesions have improved. Domestic low dose of a long course of treatment, menstruation second days, 10mg/d, even for a period of 6 months, is still in the exploratory stage.

(5) pregnant three ketene (nemestran), its mechanism is the inhibition of pituitary FSH, LH secretion, have strong binding ability with progesterone receptor, and estrogen receptor binding ability is weak, so there is a strong anti progesterone and moderate anti estrogen effect. Low dose treatment can play a good effect, suitable for various types of endometriosis. Since the drug has a half-life of 24h in the plasma, the method of administration is 2 times a week, each time 2.5mg, the first day of menstruation and the first four days of taking, after the time of taking the drug every week is fixed, a course of treatment for 6 months. Gestrinone in the treatment of endometriosis is better than that of danazol, side effects compared with danazol light, low recurrence rate, pregnancy rate is high, and the method is simple. But the price is more expensive.

(6) GnRHa (Zoladex, Diphereline, etc.) in recent years is a new drug for the treatment of endometriosis is safe and effective, for the artificial synthesis of natural GnRH analogues. Under normal circumstances, GnRH is released from the hypothalamus in the form of a small pulse, combined with the receptor on the surface of the pituitary gland to form a receptor ligand complex, which is internalized into the cell to stimulate the release of LH and FSH from the pituitary gland. The affinity of GnRHa and pituitary gonadotropin receptor was 100 times higher than that of normal GnRH. Therefore, after a short period of time, due to the majority of receptors occupied and internalized, plasma FSH, LH and E2 increased by about 1 weeks. After the drug sustained effect about 10~15 days, the surface volume sharply reduce the pituitary, this phenomenon is the receptor down-regulation, and LH level decreased significantly, said drug pituitary resection, the ovarian steroid hormone decrease. Because GnRHa is a kind of release agent, constant directional blood release GnRH, thus effectively inhibit pituitary ovarian system, so that the level of serum E2 level in maintenance after menopause (15 days after administration of E2< 50pg/ml), endometrial atrophy. 75 days after the general withdrawal of ovulation, menstruation recovery of the 90 day. GnRHa in the treatment of endometriosis has good curative effect, the clinical symptoms of patients with complete remission, significantly reduced lesions. To improve the rate of 85%~90% GnRHa in the treatment of endometriosis, laparoscopic lesions to improve the rate of 50%~80%, the pregnancy rate was 40%~60%, the recurrence rate was 16%~59%. But the drug is expensive.

GnRHa drugs with fewer side effects, is mainly caused by low estrogen levels similar to menopausal syndrome and osteoporosis, breast smaller, vaginal dryness, sweating, hot flashes, vasomotor dysfunction. Severity varies from person to person, but the general patient can tolerate, more than after the withdrawal of recovery. The drug without danazol, nemestran caused by acne, weight gain, liver damage and other side effects. Long term use of GnRHa induced severe low estrogen status (E2< 20pg/ml) may cause abnormal calcium metabolism, thereby increasing the risk of osteoporosis, most patients can recover after withdrawal. The need for repeat treatment for 12 months or longer recurrence, in order to eliminate the side effects, can be used to add back therapy, at the same time that the application of GnRHa combined with low dose of estrogen or estrogen and progesterone replacement therapy (HRT), the E2 concentration was maintained at 30~45pg/ml, neither stimulated the growth of lesions, but also can to maintain normal bone metabolism, serum bone metabolism index remained in the normal range. So that it can maintain treatment or prolong treatment time.

These drugs are temporarily relieve symptoms and control the disease, but a stop for a period of time, the lesion will gradually recover, no drug can cure the disease, and the cost is expensive, so only for the young and growing needs of the patient.

2 surgical treatment

For the limitations of the muscle adenoma, as long as the operation can be removed from the muscle adenoma, the uterus can be retained, some cases can be used laparoscopic minimally invasive surgery of uterine fibroids. If it is a diffuse uterine adenomyosis, surgery can be cut into the uterine wall thin, and then given after the drug treatment, there is a chance to conceive, but for some time there is still the possibility of recurrence. In recent years, uterine artery embolization has been used in the treatment of adenomyosis. These surgical procedures for the preservation of the uterus are suitable for patients with fertility needs.

For over 35 years, has completed the family, are suffering from severe dysmenorrhea and menorrhagia affect the quality of life of patients, surgical resection is the most effective therapy is the most commonly used.

In recent years, scholars at home and abroad for the treatment of adenomyosis by hysteroscopy, endometrial removed after menstruation is greatly reduced, and some no longer come, dysmenorrhea was also good.

3 pregnancies

Ovarian ovulation during pregnancy is inhibited, not to menstruation, for the treatment of uterine adenomyosis itself is a therapeutic effect. For those who want to have a young child, it is best to take advantage of conservative treatment is still not effective, try to conceive, there is still a chance to succeed in pregnancy. It was reported that the rate of cure was 95%, and the rate of cure was about 30%.

Seven, uterine adenomyosis can canceration?

Endometriosis (EM) canceration incidence of the past that 0.7%% ~ 1%, recently more than 2.5%. It is generally believed that uterine adenomyosis and uterine fibroids, like, little change.

Eight, how to prevent uterine adenomyosis?

The prevention of adenomyosis is still lack of effective measures. But the timely detection and treatment of genital tract stenosis or obstruction, low fertility, less abortion or curettage, may reduce the chance of developing the disease.

 

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