- Adenomyosis of the uterus: what is it?
- The relationship between adenomyosis and endometriosis
- Causes of adenomyosis
- Classification of uterine adenomyosis
- Stages of adenomyosis
- Symptoms of adenomyosis
- Diagnosis of adenomyosis
- Treatment and prognosis for adenomyosis
Adenomyosis of the uterus: what is it?
Adenomyosis is the germination of the endometrium into the underlying layers of the uterus. Usually affects women of reproductive age, often occurs after 27-30 years. Sometimes it’s congenital. It self-extinguishes after the onset of menopause. It is the third most common gynecological disease after adnexitis and uterine fibroids and is often combined with the latter.
Currently, gynecologists note an increase in the incidence of adenomyosis, which can be due to both an increase in the number of immune disorders and the improvement of diagnostic methods.
Patients with adenomyosis often suffer from infertility, but a direct link between the disease and the inability to conceive and bear the child has not yet been established, many experts believe that the cause of infertility is not adenomyosis, but concomitant endometriosis. Regular heavy bleeding can cause anemia. Expressed PMS and intense pain during menstruation negatively affect the psychological state of the patient and can cause the development of neurosis.
Treatment of adenomyosis is carried out by specialists in the field of gynecology.
The relationship between adenomyosis and endometriosis
Adenomyosis is a kind of endometriosis, a disease in which endometrial cells multiply outside the uterine mucosa (in the fallopian tubes, ovaries, digestive, respiratory or urinary system). The spread of cells occurs through contact, lymphogenous or hematogenous pathways. Endometriosis is not a tumor disease, since heterotopically located cells retain their normal structure.
However, the disease can cause a number of complications. All cells of the inner shell of the uterus, irrespective of their location under the influence of sex hormones, undergo cyclic changes. They multiply intensively, and then are rejected during menstruation.
This entails the formation of cysts, inflammation of surrounding tissues and the development of adhesive processes. The incidence of the combination of internal and external endometriosis is unknown, but experts suggest that most patients with uterine adenomyosis have heterotopic foci of endometrial cells in various organs.
Causes of adenomyosis
The reasons for the development of this pathology have not yet been elucidated. It is established that adenomyosis is a hormone-dependent disease. Development of the disease contributes to the violation of immunity and damage to a thin layer of connective tissue that separates the endometrium and myometrium and prevents the growth of the endometrium into the womb wall.
Damage to the separation plate is possible with abortions, diagnostic scraping, use of an intrauterine device, inflammatory diseases, childbirth (especially – complicated), surgery and dysfunctional uterine bleeding (especially after surgery or hormone treatment).
Other risk factors for adenomyosis associated with the female reproductive system are too early or too late the onset of menstruation, late onset of sexual activity, oral contraceptive use, hormone therapy and obesity, which increases the amount of estrogen in the body.
The risk factors for adenomyosis, associated with impaired immunity, include a bad environmental situation, allergic diseases and frequent infectious diseases.
Negative effects on the immune system and general body reactivity are also caused by certain chronic diseases (diseases of the digestive system, hypertension), and excessive or insufficient physical activity. A definite value in the development of adenomyosis has an unfavorable heredity.
The risk of this pathology increases when there are close relatives suffering from adenomyosis, endometriosis and tumors of the female genital organs. Congenital adenomyosis is possible due to intrauterine growth disorders of the fetus.
Classification of uterine adenomyosis
Taking into account the morphological picture, four forms of adenomyosis are distinguished:
- Focal adenomyosis.
Endometrial cells are introduced into the underlying tissues, forming separate foci.
- Nodal adenomyosis.
Endometrial cells are located in myometrium in the form of nodes (adenomyomas), in shape resembling myoma. Nodes, as a rule, are multiple, contain cavities filled with blood, surrounded by a dense connective tissue formed as a result of inflammation.
- Diffuse adenomyosis.
Endometrial cells are introduced into the myometrium without the formation of distinct foci or nodes.
- Mixed diffuse-nodal adenomyosis.
It is a combination of nodular and diffuse adenomyosis.
Stages of adenomyosis
Given the depth of penetration of endometrial cells, four stages of adenomyosis are distinguished:
- 1 stage – only the submucosal layer of the uterus suffers.
- 2 stage – affects not more than half the depth of the muscular layer of the uterus.
- 3 stage – suffers more than half the depth of the muscular layer of the uterus.
- 4 stage – affects the entire muscular layer, possibly spread to neighboring organs and tissues.
Symptoms of adenomyosis
The most characteristic sign of adenomyosis is long (more than 7 days), painful and very abundant menstruation. Clots are often found in the blood. 2-3 days before menstruation and within 2-3 days after its termination, brownish spotting is possible.
Sometimes there are intermenstrual uterine bleeding and brownish discharge in the middle of the cycle.
Patients with adenomyosis often suffer from severe premenstrual syndrome.
Another typical symptom of adenomyosis is pain. Pain usually occurs a few days before the onset of menstruation and stops 2-3 days after its onset. Features of the pain syndrome are determined by the localization and prevalence of the pathological process.
The most severe pains occur with lesions of the isthmus and widespread adenomyosis of the uterus, complicated by multiple spikes. When localized in the region of the isthmus, the pain can be irradiated to the perineum, with the location in the corner of the uterus – in the left or right inguinal region. Many patients complain of pain during intercourse, intensifying on the eve of menstruation.
Inability to get pregnant
More than half of patients with adenomyosis suffer from infertility, caused by adhesions in the fallopian tubes, preventing the penetration of the egg into the uterine cavity, disturbances in the structure of the endometrium, impeding the implantation of the egg, as well as concomitant inflammation, increased myometrium tone and other factors that increase the probability of spontaneous abortion.
In the anamnesis, patients may experience a lack of pregnancy with a regular sexual life or multiple miscarriages.
Abundant menstruation with adenomyosis often leads to the development of iron deficiency anemia, which can manifest weakness, drowsiness, fatigue, shortness of breath, paleness of the skin and mucous membranes, frequent colds, dizziness, fainting and pre-fainting conditions.
Severe PMS, long menstruation, persistent pain during menstruation and worsening of the general condition due to anemia reduce the resistance of patients to psychological stress and can provoke the development of neuroses.
Clinical manifestations of the disease may not correspond to the severity and prevalence of the process. 1 degree of adenomyosis, as a rule, is asymptomatic. At levels 2 and 3, asymptomatic or low-symptom course, as well as severe clinical symptoms can be observed. 4 the degree of adenomyosis, as a rule, is accompanied by pain caused by a widespread adhesion process, the severity of the remaining symptoms can vary.
During the gynecological examination, changes in the shape and size of the uterus are revealed. With diffuse adenomyosis, the uterus becomes spherical and increases in size on the eve of menstruation, with a widespread process the size of the organ can correspond to 8-10 weeks of pregnancy.
With knotty adenomyosis, tuberosity of the uterus or tumor-like formations in the walls of the organ is detected. When combined with adenomyosis and fibroid, the size of the uterus corresponds to the size of the myoma, the organ does not decrease after menstruation, the remaining symptoms of adenomyosis usually remain unchanged.
Diagnosis of adenomyosis
The diagnosis of adenomyosis is established based on anamnesis, patient complaints, examination data on the chair and the results of instrumental studies. Gynecologic examination is performed on the eve of menstruation. The presence of an enlarged globular uterus or tuberosity or nodes in the uterus in combination with painful, prolonged, heavy menstruation, pain during intercourse and signs of anemia is the basis for setting a preliminary diagnosis of adenomyosis.
The main method of diagnosis is ultrasound. The most accurate results (about 90%) are provided by transvaginal ultrasound scanning, which, like gynecological examination, is performed on the eve of menstruation.
Adenomyosis is indicated by an increase in the globular shape of the organ, a different thickness of the walls and cystic formations larger than 3 mm, appearing in the uterine wall shortly before menstruation. With diffuse adenomyosis, the effectiveness of ultrasound is reduced. The most effective diagnostic method for this form of the disease is hysteroscopy.
Hysteroscopy is also used to exclude other diseases, including myoma and polyposis of the uterus, endometrial hyperplasia and malignant neoplasms. In addition, during the differential diagnosis of adenomyosis, MRI is used, during which it is possible to detect thickening of the uterine wall, damage to the structure of the myometrium and the foci of endometrial insertion into the myometrium, and to assess the density and structure of the nodes. Instrumental diagnostic methods for adenomyosis are complemented by laboratory studies (blood and urine tests, hormone studies), which can diagnose anemia, inflammatory processes and hormonal imbalance.
Treatment and prognosis for adenomyosis
Treatment of adenomyosis can be conservative, operative or combined. The tactics of treatment are determined taking into account the form of adenomyosis, the prevalence of the process, the age and health status of the patient, her desire to preserve the childbearing function. Initially, conservative therapy is performed.
Patients are prescribed hormonal drugs, anti-inflammatory drugs, vitamins, immunomodulators and means for maintaining liver function. Anemia is treated. In the presence of neurosis, adenomyosis patients are referred to psychotherapy, tranquilizers and antidepressants are used.
If the conservative therapy is ineffective, surgery is performed. Operations with adenomyosis can be radical (panhysterectomy, hysterectomy, supravaginal amputation of the uterus) or organ-preserving (endocoagulation of the foci of endometriosis).
Indications for endocoagulation in adenomyosis are endometrial hyperplasia, suppuration, the presence of adhesions that prevent the egg from entering the uterine cavity, the lack of effect when treated with hormonal drugs for 3 months, and contraindications to hormonal therapy. As evidence for the removal of the uterus, the progression of adenomyosis in patients older than 40 years is considered, the inefficiency of conservative therapy and organ-preserving surgical interventions, diffuse adenomia of grade 3 or nodal adenomyosis in combination with uterine myoma, the threat of malignancy.
If adenomyosis is detected in a woman planning a pregnancy, she is recommended to try to conceive not earlier than six months after taking a course of conservative treatment or carrying out endocoagulation.
During the first trimester, the patient is prescribed gestagens. The question of the need for hormonal therapy in the second and third trimester of pregnancy is determined taking into account the result of a blood test for the content of progesterone. Pregnancy is a physiological menopause, accompanied by profound changes in the hormonal background and positively affects the course of the disease, decreasing the rate of growth of heterotopic endometrial cells.
Adenomyosis is a chronic disease with a high probability of relapse. After carrying out conservative therapy and organ-preserving surgical interventions during the first year, relapses of adenomyosis are detected in every fifth woman of reproductive age.
Within five years, recurrence is observed in more than 70% of patients. In patients with preclimacteric age, the prognosis for adenomyosis is more favorable, which is due to the gradual extinction of ovarian function. After a pangysterectomy, relapses are not possible. In the menopausal period, there is an independent recovery.