Adenomyosis is a dyshormonal disease, which is based on the germination of the endometrium in the uterus muscle. It is clinically manifested by prolonged and abundant menstruation, periodic bleeding, the appearance of dark spotting before and after menstruation, pronounced premenstrual syndrome and pain syndrome (algomenorrhea, dyspareunia). The diagnosis is made after a gynecological examination, laboratory tests and instrumental examinations. Treatment may be conservative (hormone therapy), surgical or combined.
Adenomyosis (endometriosis of the uterus) is a form of endometriosis in which tissue begins to grow outside the uterine mucosa, in structure and function similar to endometrium. Pathology refers to internal endometriosis (external – endometriosis of the ovaries, cervix and other varieties). Adenomyosis is characterized by immunity (that is, in its development the state of immunity matters) and refers to genetically determined diseases (heredity plays the role). Since adenomyosis is endometriosis of the uterine body, it is incorrect to use the phrase “adenomyosis of the uterine body”. ICD 10 code: endometriosis of the uterus N88.0. Since pathology refers to hormone-dependent, adenomyosis in the female body can only develop with the onset of puberty, respectively, disappears on its own after menopause. Adenomyosis ranks third in the list of gynecological diseases (the first is inflammation of the appendages, the second is uterine fibroids). A marked increase in the incidence of uterine endometriosis in the last fewdecades, which is associated with an increase in the number of immune disorders and improved diagnostic methods.
Women of reproductive age, mainly 27 – 35 years, suffer from adenomyosis. Endometriosis is diagnosed in 10% of women, among them 15% of cases have adenomyosis. The frequency of nodular adenomyosis is 30%, the combination of this form with uterine myoma occurs in 60%.
Adenomyosis is systematized according to the depth of germination of the endometrium in the layers of the uterus by 4 degrees:
- I degree – the pathological process is limited to the organ mucosa;
- Grade II – germination of endometrioid cells until the middle of the myometrium;
- Grade III – endometrial cells invaded the entire thickness of the muscle layer of the uterus, but did not come out in its serous membrane;
- IV degree – the process captures the myometrium, serosa of the uterus and nearby organs.
Asymptomatic adenomyosis and with a pronounced clinical picture. Since endometriosis of the uterus does not apply to inflammatory diseases, such as endometritis (inflammation of the uterus), it is inappropriate to speak of acute or chronic adenomyosis.
There are several morphological forms of adenomyosis:
- diffuse – refers to the common and is characterized by diffuse implantation of endometrial cells in the uterine layers, nodes and foci are not formed;
- focal – characterized by local areas (foci) of endometriosis in the thickness of the uterus;
- nodular – the formation of individual nodes (adenomyomas) in the muscular layer of an organ, similar to myomatous nodes, but unlike them have cavities with blood surrounded by connective tissue;
- focal nodal – mixed form, combines the presence of nodes and foci of endometriosis.
The occurrence of endometriosis is explained by several theories, the main ones are considered:
- implantation – based on the reflux (reflux) of menstrual blood from the uterus through the oviducts into the abdominal cavity;
- metaplastic – explains the formation of endometrioid heterotopies from residues of embryonic tissues;
- induction – the occurrence of endometrial foci under the action of exogenous and endogenous adverse factors.
Factors contributing to the development of pathology include:
- heredity (there are relatives in the family with adenomyosis, uterine cancer, fibromyoma);
- traumatization of the uterine lining (curettage of the uterus, hysteroscopy, hysterosalpingography, insertion / removal of the IUD, abortion, removal of uterine polyps);
- long, complicated childbirth;
- inflammatory processes in the uterus, organ surgery;
- hormonal disorders (later menarche and onset of sexual activity, irregular cycle, treatment with hormonal drugs, COC use, obesity);
- chronic pathology that weakens the immune system (diseases of the digestive tract, hypertension, allergic reactions, diseases of the thyroid gland);
- frequent infectious diseases;
- stress, intense exercise;
- disturbed ecology, frequent climate change, long-term insolation, low social level;
- late first childbirth, abandonment of pregnancies.
Adenomyosis is characterized by a long, and in the absence of treatment, a progressive course. Spontaneous cure is possible only in postmenopause. The clinical picture of the disease on the extent of the spread of the process and form. Adenomyosis of 1 – 2 degrees is more often asymptomatic or with slightly pronounced manifestations. Pain is considered a constant and characteristic symptom of pathology. First of all, the disease should be excluded in adolescents in the case of existing algomenorrhea. The intensity of pain is also determined by the degree of germination of endometrial cells in the thickness of the uterus. When all layers of the organ are involved in the process, including its serous cover, the pain is almost always disturbing, increasing on the eve and on the days of menstruation. Adenomyosis is characterized by dyspareunia (pain during intercourse), which is noted on the eve of menstruation. During the germination of endometrial cells in the isthmus, pain can be transmitted to the perineum and lower extremities, and when uterine corners are affected, to the inguinal areas. The disease is often accompanied by severe premenstrual syndrome.
The third – the fourth degree of pathology is accompanied by hyperplasia of the myometrium and, during a gynecological examination, it is possible to palpate a round, painful, dense and enlarged uterus. Characterized by an increase in the size of the body on the eve of menstruation, and with a common process, its size can reach 8 – 10th pregnancy. In case of nodular adenomyosis, the surface of the uterus is bumpy, often a combination of the disease with myoma and / or endometrial hyperplasia is noted.
The second characteristic sign of adenomyosis is a disorder of the menstrual function. The appearance of brown spotting before and after menstruation, the occurrence of intermenstrual bleeding or spotting, lengthening and profusion of menstrual discharge are typical. Chronic blood loss leads to anemia (pallor of the skin, dry and brittle hair, weakness, fatigue, dizziness, possible fainting).
Adenomyosis is often accompanied by infertility due to adhesive and inflammatory processes in the uterus, endometrial structure disorders, and hormonal function of the ovaries. These factors interfere with fertilization of the egg and its subsequent implantation and ends with spontaneous abortion in the early stages.
The temperature increase for adenomyosis is not typical, since pathology does not apply to inflammatory diseases, and inflammation accompanying endometriosis (which causes adhesion formation) is always aseptic. When the temperature rises (especially regular, in the second phase of the cycle), latent sexually transmitted infections should be excluded.
The preliminary diagnosis of adenomyosis is made on the basis of anamnesis, characteristic complaints and gynecological examination. The pathology is indicated by palpation of the spherical or bumpy enlarged uterus, polymenorrhea, pain syndrome and signs of anemia. The diagnosis is confirmed by conducting methods of instrumental examination:
- Ultrasound of the pelvic organs. It is advisable to perform at the end of the menstrual cycle with a vaginal probe. Echo signs: the size of the uterus is larger than normal, the thickness of the walls is uneven, the echogenicity of the myometrium is increased, the presence of the “honeycomb” symptom: dense areas alternate with small cystic inclusions, the presence of strokes from the endometrium into the body. Adenomy cells are visualized as rounded areas of increased echogenicity without clear contours and capsules.
- Hysterography The introduction of X-ray contrast into the uterine cavity reveals its enlargement, deformation and jagged edges of the contour in the pictures.
- Hysteroscopy. Allows you to confirm adenomyosis and determine its degree. Grade 1 is characterized by a constant wall topography, the presence of endometrial moves (dark bluish “eyes” or open bleeding wounds). For grade 2 – the unevenness of the uterine walls, poor distensibility of the uterus, the presence of endometrial moves. For degree 3, protrusion into the uterine cavity without clear contours, rigidity of its walls, open / closed passages.
- MRI Increase in the size of the uterus, thickening of its walls, impaired structure of the myometrium, endometrial passages.
- Scraping the uterus and cervix. It is carried out after hysteroscopy, histological examination of the scraping allows to confirm the presence of endometrioid heterotopies, exclude / confirm hyperplasia, endometrial cancer.
From laboratory tests, OAK is assigned (confirms anemia), OAM, blood for sex hormones, and CA-125 tumor marker (its level increases with endometriosis).
Adenomyosis is differentiated with the following pathologies:
- Uterine fibroids. Combination with adenomyosis reaches 85%. The symptoms of uterine fibroids and endometriosis of the uterus are similar. With a small size of fibroids, the pain syndrome is usually absent, menstrual disorders are more common with a submucosal location of the node. A gynecological examination allows you to identify an enlarged, dense uterus with nodes, its palpation is painless, mobility is preserved. In adenomyosis, the mobility of the organ is limited, there is pain on palpation and the relationship of the size of the uterus with the phase of the cycle. The final diagnosis confirms the conduct of instrumental methods of research.
- Endometrial hyperplastic processes (hyperplasia, polyp). Pain, as a rule, is absent, there is a cycle disorder in the form of prolonged menstruation and an increase in the volume of blood loss, intermenstrual discharge. Pre- and postmenstrual discharge with polyp / endometrial hyperplasia is not characteristic. On ultrasound: the increase in the thickness of the M-echo diffuse (hyperplasia) or focal (polyp / polyposis), the contours of the uterus are even, the dimensions correspond to the norm.
- Endometrial cancer. It is characterized by the occurrence of acyclic uterine bleeding and spotting, which are often accompanied by an unpleasant odor and discharge of pus. In the absence of bloody discharge, there is abundant watery leucorrhoea, sometimes with an admixture of blood in the color of “meat slop”. The pains are disturbing at the advanced stage, not related to the phase of the cycle. The diagnosis is confirmed by the performance of ultrasound, hysteroscopy, hysterography, curettage of the uterus.
The gynecologist-endocrinologist deals with the treatment of adenomyosis. Pathology therapy can be conservative, operative and combination. When choosing a treatment strategy, consider:
- age of the patient;
- desire to preserve reproductive function;
- the prevalence and severity of the process;
- concomitant gynecological diseases.
Based on the admission or administration of hormonal drugs:
- Oral combined contraceptives. Block cyclic processes in the endometrium and endometrioid heterotopies. With long-term use cause sclerosis and obliteration of endometrial moves. Use drugs of the new generation (Janine, logest, Vizanna, Marvelon and others).
- Progestins (pure progestins). Contribute to the atrophy of endometrial foci (duphaston, norcolute, premalyut).
- Androgens. Suppress ovulatory synthesis of gonadotropins. They block receptors of progesterone, estrogen, androgens, inhibit the growth of endometriod heterotopias and the formation of new (danazol).
- Analogs Gonadoliberin. They block the production of gonadotropins, which reduces the production of sex hormones in the ovaries (gosererelin, buserilin).
In addition to hormone therapy, iron preparations are also prescribed for the treatment of chronic post-hemorrhagic anemia, NSAIDs (indomethacin, ibuprofen) for relieving a painful attack, vitamins, drugs that normalize the functioning of the liver, sedatives, and in severe psycho-emotional state disorders, antidepressants and tranquilizers. The introduction of the Mirena Navy (contains a gestagen) for a period of 5 years (reduces menstrual flow) is successfully applied.
It is the only reliable way to get rid of the disease. There are mild and radical surgery. Surgical intervention is carried out with:
- nodal forms;
- a combination of diffuse adenomyosis and uterine fibroids;
- high risk of malignancy;
- 3 degree process.
For sparing techniques include electrocoagulation (endometrial ablation) of endometrial foci and intrauterine adhesions by an electrocoagulator during hysteroscopy. For radical operations – supravaginal amputation of the uterus, extirpation of the uterus, panhysterectomy. Before surgery, hormone therapy is carried out for several months, which stabilizes the course of adenomyosis, prevents the growth and formation of new endometriotic foci (combined treatment).
Pregnancy planning and management
Patients with established adenomyosis are advised to try to become pregnant no earlier than 6 months after the end of hormone therapy or endometrial coagulation. The indications for IVF are:
- no pregnancy for a year;
- obstruction of the pipe;
- persistent anovulation.
Pregnancy is diagnosed in 30% of patients with 1 – 2 degrees of adenomyosis, in 14% with 3 – 4 degrees. In the first trimester of gestation, progestogens are prescribed (duphaston, utrogestan), subsequent hormone therapy is indicated (indications of interruption, low progesterone levels). Pregnancy has a positive effect on the course of the process, inhibiting the growth of endometrial foci.
Complications of endometriosis of the uterus include:
- chronic post-hemorrhagic anemia (in 90-95%);
- adhesive pelvic disease (3–4 degrees of the process);
- obstruction of the pipe;
- infertility (in 50 percent or more of cases);
- habitual miscarriage;
- psycho-emotional disorders (neurosis, depression) with severe disease.
Adenomyosis does not belong to malignant processes, but its long existence in the absence of treatment can provoke the development of endometrial cancer due to hormonal imbalance. The prognosis for adenomyosis depends on the degree of spread of the process, its combination with another gynecological pathology and the treatment carried out, but generally favorable for life, doubtful for pregnancy. High risk of relapse after hormone therapy for 5 years in 2/3 patients. Performing radical operations allows you to get rid of the disease completely. Postmenopausal adenomyosis regresses.
Specific methods for the prevention of adenomyosis is not developed. Non-specific preventive measures include: regular (every 6 months) visits to a gynecologist, normalization of the day and rest regimen, elimination of stressful situations, refusal of insolation and thermal procedures (visits to baths, saunas).