Definition of the disease. Causes of the disease
Adenomyosis is a type of endometriosis — a pathology in which the uterine layer of the endometrium grows beyond the mucous membrane of the uterus (ovaries, fallopian tubes, organs of the urinary, respiratory and digestive systems). This form of the disease is characterized by damage to the myometrium of the uterine cavity by endometrial cells. However, adenomyosis should be considered not only together with endometriosis, but also as an independent nosological unit[1].
At the moment, the incidence of adenomyosis has increased significantly in the population and is on the same level with adnexitis (inflammation of the ovaries, fallopian tubes) and uterine fibroma (tumor) in terms of prevalence[2].
Proliferation of the endometrium of the uterus
Causes of adenomyosis
As with many other gynecological diseases, surgical intrauterine interventions (abortions, diagnostic curettage, resection of polyps without hysteroscopy control) can become triggers for the development of adenomyosis. At the time of these procedures, damage to the basal plate separating the endometrium from the myometrium may occur, resulting in invasion (infection) of endometrial cells into the thickness of the uterine wall. Complicated childbirth, prolonged use of intrauterine contraception (spirals), dysfunctional uterine bleeding should also be attributed to possible causes of adenomyosis.
It is worth noting a number of reasons that negatively affect the state of the reproductive system: the age of menarche (too early or too late onset of the first menstrual bleeding), late defloration (rupture of the hymen), prolonged use of COCs and other hormonal drugs, age (presence of hormonal activity), obesity.
Factors associated with high risks of developing adenomyosis:
the general condition of a woman (a decrease in the immune forces of the body, a burdened allergic history (tolerance of allergens); recurrent infectious diseases, chronic processes, hypertension (increased pressure), inactivity — sedentary lifestyle)
unfavorable social environment in which a woman is exposed to severe stress;
bad environmental situation.
In patients whose close relatives suffered from adenomyosis, endometriosis and tumor-like formations of the organs of the reproductive system, the probability of adenomyosis is significantly higher[3][4]. Congenital adenomyosis due to disorders at the stage of intrauterine development is not excluded.
Adenomyosis and menopause
Adenomyosis is a hormone—dependent disease that completely regresses with the onset of menopause.
If you find similar symptoms, consult a doctor. Do not self-medicate – it is dangerous for your health!
Symptoms of adenomyosis
The most typical clinical symptom of adenomyosis will be a change in the nature of menstruation: an increase in duration (more than seven days), increased profusion and soreness, the presence of clots. Signs of uterine adenomyosis also include intermenstrual bleeding and “smearing” discharge in the middle of the cycle[5]. Often, patients are faced with the appearance of scanty brownish discharge for several days before and after the menstrual cycle.
A distinctive feature of such patients is the severe course of premenstrual syndrome. In addition, menstruation is always accompanied by painful sensations that arise in the run-up and subside in the first two days after their onset. In many ways, the intensity and nature of pain is determined by the localization and extent of the spread of foci of adenomyosis. Irradiation (spread of pain symptoms) in the perineum is caused by the formation of foci in the isthmus of the uterus. Pain in the groin area indicates the presence of foci of adenomyosis in the uterine angle in the uterus. Often women complain about the appearance of sharp pains and a feeling of discomfort during sexual contact.
Patients suffering from adenomyosis, emotionally labile (causeless mood swings occur) [6], often note excessive irritability, spontaneous appearance of frequent headaches, flashing “flies” in front of their eyes, dizziness.
A significant number of patients who were observed by a reproductologist for infertility or miscarriage were diagnosed with adenomyosis[7].
The clinical picture of adenomyosis may be erased and does not always correspond to the degree of prevalence and severity of the disease.
Pathogenesis of adenomyosis
Adenomyosis refers to hormone-dependent pathologies, however, science cannot give an unambiguous answer to the question: “What actually leads to adenomyosis?” at the moment. There are a number of theories explaining the pathogenesis of this disease.
One of the hypotheses highlights hyperestrogenism, which leads to increased proliferation (reproduction) of cells, which in turn is the cause of hyperplastic changes in the endometrium. Uterine adenomyosis is often combined with endometrial hyperplasia, which indirectly confirms the theory. Among other things, it often occurs in combination with uterine fibroids (benign neoplasm)[8]. This indicates a certain similarity of the pathogenetic aspects of these pathologies. Hyperestrogenism enhances the growth of cells of the basal layer of the endometrium, which increases its permeability and penetration into the muscle tissue of epithelial cells.
Inflammatory diseases are directly related to an increase in the incidence of adenomyosis[9].
To date, many researchers are studying the theory of the development of endometrioid heterotopias (outside the uterine cavity) from the elements of the endometrium and its displacement into the thickness of the uterus.
Classification and stages of development of adenomyosis
The code of adenomyosis according to ICD-10: N80.0 Uterine endometriosis (Adenomyosis).
The classification of adenomyosis is based on morphological features, as well as on the degree of depth of the myometrial lesion. Based on this , four forms of adenomyosis can be distinguished:
focal – local adenomyotic foci are formed in the underlying tissues by endometrial cells;
nodular – endometrial cells located in the myometrium, which in their shape resemble nodules (adenomyomas). The connective tissue formed due to inflammation surrounds numerous nodes filled with blood;
diffuse – endometrial cells do not form obvious nodes or foci;
mixed – a combination of nodular and diffuse adenomyosis.
Forms of uterine endometriosis
According to the depth of penetration of the endometrium is divided into:
Grade 1 – only the submucosal layer is involved;
Grade 2 – the muscle layer is affected by no more than half;
Grade 3 – lesion of more than half of the muscle layer;
Grade 4 – total lesion of the muscle layer, adjacent organs and tissues may be involved in the process.
Complications of adenomyosis
Most women who have been diagnosed with adenomyosis are being monitored for infertility resulting from the formation of adhesions in the fallopian tubes that impede or hinder the passage of an egg into the uterus. Anamnesis in such patients, as a rule, the absence of pregnancy for a long time with regular sexual life without contraception is revealed, or the anamnesis is burdened with multiple spontaneous spontaneous miscarriages. This is due to a change in the state of the endometrium, which complicates the process of egg implantation, in combination with developing inflammation and an increase in the tone of the muscle layer.
One of the most serious complications of adenomyosis is iron deficiency anemia[10], which develops as a result of copious discharge during menstruation and blood discharge from the uterine cavity in the middle of the cycle. The clinical manifestations of this disease are often attributed to fatigue by women: weakness is expressed, drowsiness is not associated with the number of hours spent on sleep, fatigue is increased; shortness of breath may increase, frequent colds, pallor of the skin and mucous membranes are noted. However, do not underestimate these symptoms. An untimely visit to a doctor can lead to serious consequences, such as the development of sideropenic syndrome, manifested not only by the fragility of hair and nails in the early stages, but with the progression of the disease — paresthesia (a feeling of numbness and “goosebumps” in the extremities), muscle weakness, dyspeptic and dysuric disorders (digestive disorders and urination). Constant dizziness, repeated fainting indicate an aggravation of the severity of the disease and the need for emergency etiotropic treatment!
Prolonged, copious menstrual cycles, accompanied by severe pain and preceding severe premenstrual syndrome, adversely affect the psychoemotional state of the patient, her stress resistance decreases. In the future, this can lead to the development of neurosis-like and depressive states.
In addition, adenomyosis creates problems for women both socially (intense discharge during menstruation forces them to reduce physical activity and temporarily abandon their favorite things) and intimately: sexual acts become painful, their frequency decreases.
Diagnosis of adenomyosis
You should consult a doctor for the following symptoms of adenomyosis:
copious periods with clots lasting more than seven days;
spotting spotting for several days before and after menstruation;
painful periods;
pain and spotting during sexual intercourse.
Sometimes adenomyosis can be asymptomatic or with weak clinical symptoms, so it is necessary to carefully carry out a set of diagnostic measures, including:
collection of complaints and anamnesis;
gynecological examination on a special chair;
additional instrumental and laboratory research methods.
Inspection
At the time of examination on the gynecological chair, the doctor can detect a change in the shape, structure, size of the uterus. The examination should be carried out 3-4 days before the date of the expected menstruation.
Tuberosity of the uterus and tumor—like formations may indicate the presence of adenomyosis in a nodular form; an enlarged, spherical shape of the uterus indicates the prevalence of a diffuse process. Sometimes adenomyosis is a pathology combined with fibroids, in such situations, the symptoms of adenomyosis remain classical. The exception is the size of the uterus at the end of the menstrual cycle: it does not become smaller and is proportional to the fibroid. The combination of the above signs with the presence of intense painful and prolonged menstruation in the patient makes it possible to make a preliminary diagnosis — “adenomyosis”.
Ultrasound for adenomyosis
Ultrasound scanning with a transvaginal sensor[11][12][13] provides the most informative data on pathology. For a more accurate diagnosis, the study should also be carried out shortly before the start of menstruation. However, the reliability of ultrasound examination is significantly reduced with a diffuse form of adenomyosis.
Transvaginal ultrasound
Hysteroscopy and laparoscopy
In the diffuse form of adenomyosis, it is advisable to use a modern endoscopic method for diagnosing intrauterine pathologies – hysteroscopy[14]. Often during the procedure, if adenomyosis is suspected, other abnormalities that could not be visualized during ultrasound are detected and eliminated[15] – polyps in the uterus, hyperplastic changes in the endometrium, uterine fibroids.
Laparoscopy shows foci of endometriosis on the inner surface of the abdominal wall, adhesions in the tubes and ovarian endometriosis. During the procedure, you can remove these foci and separate the adhesions.
MRI and CT for adenomyosis
If there are difficulties in differential diagnosis, MRI is resorted to. The advantages of this method are non-invasiveness (penetration into the body that does not damage the skin) and the accuracy of the data obtained, as well as obtaining a clear three-dimensional image, which eliminates the possibility of diagnostic errors.
CT can be an additional diagnostic method for adenomyosis. During the examination, foci of endometriosis in the uterine myometrium will be visible.
Laboratory diagnostics
For timely detection and prevention of anemia and inflammatory processes, it is necessary to perform:
general blood test with leukocyte formula, general urine analysis;
hormonal studies – CA125 (allows you to assess the severity of the disease and the effectiveness of the therapy).
Incorrect diagnosis of adenomyosis is fraught with the danger of prescribing severe and aggressive therapy.
Treatment of adenomyosis
The age of the patient, the prevalence and localization of the disease, its severity and form, as well as the presence of concomitant somatic diseases in the patient determine the treatment tactics (conservative or operative).
Surgical treatment
Surgical treatment of adenomyosis can be organ-preserving and radical. The latter method includes such an operation as hysterectomy – removal of the uterus, which is the operation of choice in patients of the older age group with the progression of the disease [16][17], in combination with other pathologies of the uterus, the ineffectiveness of the therapy. Despite the data from numerous sources, clinical practice shows that organ-preserving operations do not exclude relapses of the disease [18][19]. High efficiency of excision of foci of adenomyosis with suturing of the uterus is achieved with rare cystic forms of the disease.
Conservative treatment
If adenomyosis is detected in young patients, it is necessary to preserve reproductive function. Combined hormonal contraceptives act as first-line drugs [20] (they are prescribed for a long time). The use of norsteroid derivatives is also practiced. Anti-inflammatory treatment is carried out, vitamins and drugs are prescribed, the effect of which is aimed at reducing pain, as well as measures that help to increase immunity.
If necessary, patients with severe degrees of adenomyosis, against which neurosis-like and depressive states develop, are recommended to consult a psychologist, conduct psychotherapy. In severe depression — transcranial stimulation of the brain (using magnetic pulses) [5].
Treatment of adenomyosis during pregnancy
During pregnancy, treatment is not carried out — usually against its background, as with lactation, the foci of adenomyosis decrease independently.
Physical therapy
Radon baths for adenomyosis reduce bleeding, bischofite and coniferous baths have a calming effect. Sinus-modeled currents, magnetic therapy and climatotherapy can also be prescribed.
With endometriosis, warming procedures with sand, paraffin and mud, massage of the lumbosacral zone, hydrogen sulfide and turpentine baths, high frequency currents are not recommended.
Diet for adenomyosis
Proper nutrition indirectly affects the course of adenomyosis, since it allows you to normalize metabolism and remove excess weight. It is recommended to eat less easily digestible carbohydrates, animal fats and smoked food. These products negatively affect the functioning of the gastrointestinal tract and liver, lead to hormonal imbalance. Alcohol is excluded for the same reason. Nutrition for adenomyosis should be light, low-calorie, rich in fiber, protein, complex carbohydrates, vegetable fats, trace elements and vitamins.
Forecast. Prevention
Is it possible to completely cure adenomyosis
Adenomyosis cannot be cured completely, surgery often solves the problem only for a while. That is why the prevention of adenomyosis is incredibly relevant.
Does adenomyosis go away on its own
Adenomyosis cannot go away on its own. Especially ovarian endometriosis, which is treated only surgically.
Prevention of adenomyosis
The timely detection of the disease plays a significant role, therefore it is important to pay attention to the state of your health, regularly visit a gynecologist, perform ultrasound examination of the pelvic organs.
The complex of measures aimed at preventing the development of adenomyosis can include:
limiting excessive physical exertion that leads to overwork;
reducing the time spent in the solarium and in the open sun;
reducing the impact of stress factors.
Normalization of the work and rest regime also has a beneficial effect on the general state of life.
