Adenomyosis is a disease in which the inner lining (endometrium) grows into the muscle tissue of the uterus. It is a type of endometriosis. It is manifested by prolonged copious menstruation, bleeding and brownish discharge in the intermenstrual period, severe PMS, pain during menstruation and during sex. Adenomyosis usually develops in patients of childbearing age, fades after the onset of menopause. It is diagnosed on the basis of a gynecological examination, the results of instrumental and laboratory tests. Treatment is conservative, operative or combined.
Adenomyosis is the germination of the endometrium into the underlying layers of the uterus. Usually affects women of reproductive age, more often occurs after 27-30 years. Sometimes it is congenital. Independently fades 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 may 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, however, a direct link between the disease and the inability to conceive and carry a child has not yet been precisely established, many experts believe that the cause of infertility is not adenomyosis, but concomitant endometriosis. Regular heavy bleeding can cause anemia. Severe 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.
Causes of adenomyosis
The reasons for the development of this pathology have not yet been precisely clarified. It has been established that adenomyosis is a hormone-dependent disease. Immune disorders and damage to the thin layer of connective tissue separating the endometrium and myometrium and preventing the growth of the endometrium deep into the uterine wall contribute to the development of the disease. Damage to the dividing plate is possible during abortions, diagnostic curettage, the use of an intrauterine device, inflammatory diseases, childbirth (especially complicated), operations and dysfunctional uterine bleeding (especially after surgery or during treatment with hormonal agents).
Other risk factors for the development of adenomyosis associated with the activity of the female reproductive system include too early or too late onset of menstruation, late onset of sexual activity, oral contraceptives, hormone therapy and obesity, which entails an increase in the amount of estrogens in the body. The risk factors for adenomyosis associated with immune disorders include poor environmental conditions, allergic diseases and frequent infectious diseases.
Some chronic diseases (diseases of the digestive system, hypertension), excessive or insufficient physical activity also have a negative effect on the state of the immune system and the overall reactivity of the body. Unfavorable heredity has a certain significance in the development of adenomyosis. The risk of this pathology increases in the presence of close relatives suffering from adenomyosis, endometriosis and tumors of the female genital organs. Congenital adenomyosis is possible due to disorders of intrauterine development of the fetus.
Adenomyosis is a type of endometriosis, a disease in which endometrial cells multiply outside the lining of the uterus (in the fallopian tubes, ovaries, digestive, respiratory or urinary system). The spread of cells occurs by contact, lymphogenic or hematogenic 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 lining of the uterus, regardless of their location, undergo cyclic changes under the influence of sex hormones. They multiply intensively, and then are rejected during menstruation. This entails the formation of cysts, inflammation of the surrounding tissues and the development of adhesive processes. The frequency 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.
Classification of adenomyosis
Taking into account the morphological picture , there are four forms of adenomyosis:
- Focal adenomyosis. Endometrial cells are embedded in the underlying tissues, forming separate foci.
- Nodular adenomyosis. Endometrial cells are located in the myometrium in the form of nodes (adenomyomas), resembling fibroids in shape. Nodes, as a rule, are multiple, contain cavities filled with blood, surrounded by dense connective tissue formed as a result of inflammation.
- Diffuse adenomyosis. Endometrial cells are embedded in the myometrium without the formation of clearly distinguishable foci or nodes.
- Mixed diffuse nodular adenomyosis. It is a combination of nodular and diffuse adenomyosis.
Taking into account the depth of penetration of endometrial cells , four degrees of adenomyosis are distinguished:
- Grade 1 – only the submucosal layer of the uterus suffers.
- Grade 2 – no more than half of the depth of the muscular layer of the uterus is affected.
- Grade 3 – more than half of the depth of the muscular layer of the uterus suffers.
- Grade 4 – the entire muscle layer is affected, possibly spreading to neighboring organs and tissues.
Symptoms of adenomyosis
The most characteristic sign of adenomyosis is prolonged (over 7 days), painful and very abundant menstruation. Blood clots are often detected in the blood. 2-3 days before menstruation and within 2-3 days after its end, 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. The features of the pain syndrome are determined by the localization and prevalence of the pathological process. The most severe pain occurs when the isthmus is affected and widespread uterine adenomyosis is complicated by multiple adhesions. When localized in the isthmus area, pain can radiate into the perineum, when located in the area of the corner of the uterus – into the left or right inguinal region. Many patients complain of pain during sexual intercourse, which increases on the eve of menstruation.
Clinical manifestations of the disease may not correspond to the severity and prevalence of the process. Grade 1 adenomyosis is usually asymptomatic. At 2 and 3 degrees, both asymptomatic or low-symptomatic course and pronounced clinical symptoms can be observed. 4 degree of adenomyosis, as a rule, is accompanied by pain caused by a widespread adhesive process, the severity of other symptoms may vary.
During the gynecological examination, a change in the shape and size of the uterus is detected. With diffuse adenomyosis, the uterus becomes spherical and increases in size on the eve of menstruation, with a common process, the size of the organ may correspond to 8-10 weeks of pregnancy. With nodular adenomyosis, tuberosity of the uterus or tumor-like formations in the walls of the organ are detected. With a combination of adenomyosis and fibroids, the size of the uterus corresponds to the size of the fibroids, the organ does not decrease after menstruation, the other symptoms of adenomyosis usually remain unchanged.
More than half of the patients with adenomyosis suffer from infertility, the cause of which are adhesions in the fallopian tubes, preventing the penetration of the egg into the uterine cavity, endometrial structure disorders that make it difficult to implant the egg, as well as concomitant inflammatory process, increased myometrial tone and other factors that increase the likelihood of spontaneous termination of pregnancy. In the anamnesis of patients, the absence of pregnancy with regular sexual activity or multiple miscarriages may be detected.
Copious menstruation with adenomyosis often leads to the development of iron deficiency anemia, which can manifest itself as weakness, drowsiness, fatigue, shortness of breath, pallor of the skin and mucous membranes, frequent colds, dizziness, fainting and pre-fainting states. Severe PMS, long menstruation, constant pain during menstruation and deterioration of the general condition due to anemia reduce the resistance of patients to psychological stress and can provoke the development of neuroses.
The diagnosis of adenomyosis is established on the basis of anamnesis, patient complaints, examination data on the chair and the results of instrumental studies. Gynecological examination is carried out on the eve of menstruation. The presence of an enlarged globular uterus or tuberosities or nodes in the uterus in combination with painful, prolonged, copious menstruation, pain during sexual intercourse and signs of anemia is the basis for a preliminary diagnosis of “adenomyosis”.
The main diagnostic method is ultrasound. The most accurate results (about 90%) are provided during transvaginal ultrasound scanning, which, like gynecological examination, is performed on the eve of menstruation. Adenomyosis is indicated by the enlargement and spherical shape of the organ, different wall thickness and cystic formations larger than 3 mm that appear 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 fibroids and uterine polyposis, endometrial hyperplasia and malignant neoplasms. In addition, in the process of differential diagnosis of adenomyosis, MRI is used, during which it is possible to detect thickening of the uterine wall, violations of the structure of the myometrium and foci of endometrial insertion into the myometrium, as well as to assess the density and structure of nodes. Instrumental diagnostic methods for adenomyosis are supplemented with laboratory tests (blood and urine tests, hormone tests), which make it possible to diagnose anemia, inflammatory processes and hormonal balance disorders.
Treatment of adenomyosis
Treatment of adenomyosis can be conservative, surgical or combined. Treatment tactics are determined taking into account the form of adenomyosis, the prevalence of the process, the age and state of health of the patient, her desire to preserve childbearing function.
Initially, conservative therapy is carried out. Patients are prescribed hormonal drugs, anti-inflammatory drugs, vitamins, immunomodulators and means to maintain liver function. Anemia is being treated. In the presence of neurosis, patients with adenomyosis are referred to psychotherapy, tranquilizers and antidepressants are used.
If conservative therapy is ineffective, surgical interventions are performed. Operations for adenomyosis can be radical (pangisterectomy, hysterectomy, supravaginal amputation of the uterus) or organ-preserving (endocoagulation of endometriosis foci). 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 agents for 3 months and contraindications to hormone therapy.
As indications for removal of the uterus, the progression of adenomyosis in patients older than 40 years, the ineffectiveness of conservative therapy and organ-preserving surgical interventions, diffuse grade 3 adenomyosis or nodular adenomyosis in combination with uterine fibroids, the threat of malignancy are considered.
Therapy during pregnancy
If adenomyosis is detected in a woman planning pregnancy, she is recommended to attempt conception no earlier than six months after undergoing a course of conservative treatment or endocoagulation. During the first trimester, the patient is prescribed gestagens.
The question of the need for hormone therapy in the second and third trimester of pregnancy is determined taking into account the result of a blood test for progesterone content. Pregnancy is a physiological menopause, accompanied by profound changes in the hormonal background and has a positive effect on the course of the disease, reducing the rate of proliferation of heterotopic endometrial cells.
Adenomyosis is a chronic disease with a high probability of recurrence. After conservative therapy and organ-preserving surgical interventions during the first year, recurrent adenomyosis is detected in every fifth woman of reproductive age. Within five years, relapse is observed in more than 70% of patients. In patients of preclimacteric age, the prognosis for adenomyosis is more favorable, due to the gradual extinction of ovarian function. After a pangisterectomy, relapses are impossible. In the menopausal period, an independent recovery occurs.