Adenomyosis (internal endometriosis ) is a benign systemic disease of the uterus, which is accompanied by pathological proliferation of endometrial tissues outside the body (fallopian tubes, vagina, ovaries) and its other layers. Endometriotic growths can be observed in postoperative wounds, lungs, digestive organs and urinary tract.
More often, adenomyosis occurs in patients of the reproductive period, mainly after 27-30 years. Often the disease is inherited (genetically). After menopause, internal endometriosis fades on its own.
Stage and degree of uterine adenomyosis
Given the morphological picture of the pathological process, the following forms of internal endometriosis are distinguished :
- Nodular adenomyosis of the uterus. Endometrioid cells are in the myometrium in the form of adenomyomas (nodes). Usually multiple nodular formations have a cavity filled with blood. Around them is dense connective tissue, which forms against the background of inflammation.
- Focal adenomyosis . This form of pathology is characterized by the spread of endometrial cells into surrounding tissues with the subsequent formation of individual foci.
- Diffuse adenomyosis . Endometrioid cells invade the myometrium . In this case, the formation of nodes or distinct foci does not occur.
- Diffuse-nodular adenomyosis . The combination of diffuse and nodal internal endometriosis .
Given the distribution and depth of endometrioid growths, the following degrees of adenomyosis are distinguished :
- 1 degree – the submucous layer of the uterine cavity is affected;
- 2 degree – part of the muscle layer is included in the pathological process;
- Grade 3 – endometrial tissue grows over a large half of the muscular uterine layer;
- Grade 4 – endometriotic foci affect the entire muscle layer. Often, the pathological process spreads to neighboring tissues, organs.
Causes of uterine adenomyosis
The mechanism of development of internal endometriosis is quite simple and consists in the germination of the endometrium into muscle tissue under the influence of certain factors. At the same time, the functional abilities of tissues are fully preserved. With the transition of the female body to the menstrual phase, endometrial cells begin to increase, due to which implantation of a fertilized egg occurs . The endometrium, which has sprouted into the myometrium , functions according to a similar principle .
If conception has not occurred, endometrioid cells exit the uterine cavity in the form of menstrual bleeding. The muscle layer of the uterus is not able to excrete overgrown endometrial cells, as a result of which they remain in the body cavity. Against this background, a minor hemorrhage occurs in the myometrium , which provokes the inflammatory process.
The exact causes of the formation of adenomyosis have not yet been determined. Specialists identify a number of factors that cause the growth of endometrial cells and their subsequent increase. According to statistics, most patients with adenomyosis have had an abortion or underwent surgery on the uterine cavity. Another risk group includes patients older than 35 years.
Some gynecologists believe that a genetic factor can provoke the development of adenomyosis . However, there is no clear statement regarding this theory. If one of the women in the family suffered from internal endometriosis , this does not mean that representatives of the next generations will be prone to the development of the disease.
Other reasons that provoke the development of uterine adenomyosis include:
- Frequent stresses, emotional overstrain;
- Prolonged physical activity;
- Constant tension, excessive activity;
- A passive, sedentary lifestyle that leads to stagnation of blood in the pelvic organs;
- Endocrine disorders;
- Disorders of the adrenal gland and pituitary gland;
- Hormonal dysfunctions.
Also, the development of internal endometriosis can be the abuse of a solarium and sunbathing. This is especially true for patients after 30 years. At this age, the body is much more susceptible to ultraviolet rays.
Signs and symptoms of uterine adenomyosis
The most striking and characteristic symptom of adenomyosis is a prolonged period of menstruation (more than 7 days). The discharge is abundant and accompanied by severe pain. Blood clots may occur in menstrual flow. Before menstruation and for 3-4 days after their completion, a discharge of a brownish tint can be observed. In patients with severe adenomyosis , intermenstrual discharge appears, followed by a pronounced premenstrual syndrome.
Painful sensations with adenomyosis appear 2-3 days before the onset of menstruation. They continue throughout the cycle and pass after 3-4 days from the end of menstrual flow. The localization of pain depends on the focus of the inflammatory process. If the isthmus is damaged and adhesions form, pain will occur in the perineum. Inflammation in the corner of the uterus is accompanied by pain in the groin area. However, most women complain of painful sexual intercourse in the premenstrual period.
60% of patients with adenomyosis have problems with conception. Infertility is caused by numerous commissures formed on the fallopian tubes. Due to the violation of the structure of the endometrium, they impede the progress of the fertilized egg to the implantation site.
Another sign of adenomyosis is iron deficiency anemia, which occurs due to a large loss of blood against the background of heavy menstruation. This provokes the appearance of the following symptoms:
- Fast fatiguability;
- Constant drowsiness;
- Dyspnea;
- Fainting conditions;
- General malaise;
- Headaches, dizziness;
- Pallor of the skin;
- Disorders of the psycho-emotional state, neurosis caused by the inability to become pregnant, severe pain and severe PMS.
Depending on the severity of the pathology, the severity, intensity and set of clinical manifestations may vary.
If we talk about the signs of adenomyosis , which are determined during a gynecological examination, these include changes in the shape and size of the uterine cavity. With diffuse adenomyosis, the uterus enlarges before menstruation and becomes spherical in shape. With a common pathological process, the organ looks like at 2 or 3 months of gestation. The nodal form of adenomyosis is accompanied by the formation of small tubercles that are on the uterine walls. With complex adenomyosis, the uterus corresponds to the size of the fibroids and does not return to normal after menstruation.
Diagnosis of adenomyosis
To diagnose internal endometriosis , a gynecologist is consulted, which includes studying the patient’s complaints, collecting medical history information and a gynecological examination. Laboratory and hardware studies are also prescribed.
A gynecological examination is performed before menstruation. The detection of nodes, tuberosity, or an enlarged spherical uterus in combination with abundant, prolonged and painful periods, as well as signs of anemia and painful sensations during sexual contact are a reason for suspicion of the development of adenomyosis .
The main method for diagnosing adenomyosis is ultrasound. You can get the most accurate research results (85-90%) by transvaginal diagnosis (through the vagina). The ultrasound scan procedure as well as the examination in the chair is performed on the eve of menstruation. Signs of adenomyosis on ultrasound include various thicknesses of the walls of the uterus, a spherical and enlarged form of the organ, the presence of cystic formations with a diameter of more than 3 mm, which appear in the uterine wall before menstruation.
Diagnosing the diffuse form of adenomyosis with ultrasound is much more difficult. For this, the method of hysteroscopic examination is used. In addition, hysteroscopy eliminates endometrial hyperplasia, polyposis , uterine fibroids, malignant neoplasms and other gynecological pathologies.
As part of the differential diagnosis, MRI can be prescribed, which makes it possible to detect changes in the structure of the myometrium , thickening of the uterine walls and foci of the spread of endometrioid tissues in the myometrium . MRI also allows you to evaluate the structure and density of nodes.
To detect hormonal disorders, inflammatory processes and signs of anemia in adenomyosis, laboratory tests of blood and urine are prescribed.
How to treat adenomyosis
Treatment of adenomyosis is prescribed by the doctor based on the results of laboratory diagnostics and a comprehensive examination. Therapy of internal endometriosis can be carried out using conservative (medication), surgical or combined methods. The choice of tactics of therapeutic effects depends on the stage and form of the pathological process. The prevalence of endometrioid growths, the age and general condition of the patient, as well as the need to maintain reproductive function (the possibility of subsequent conception) are also taken into account .
The treatment of adenomyosis begins with the use of conservative methods. In this case, the following drugs can be prescribed:
- Hormonal drugs;
- Medications for stopping inflammation;
- Vitamin complexes;
- Preparations for the normalization of liver activity;
- Medicines to increase immunity (immunostimulants).
All patients are prescribed iron deficiency anemia therapy. According to the testimony, the woman is sent for a consultation with a psychotherapist who can recommend taking tranquilizers or antidepressants.
If the use of conservative methods has not brought positive results, surgical treatment is indicated. There are two areas of surgical treatment of adenomyosis :
- Organ-saving intervention – aimed at coagulation of endometrioid growths;
- Radical surgery ( hysterectomy , panhisterectomy , supravaginal amputation) – consists in the removal of the uterus and appendages.
The fundamental factors in the appointment of surgery with preservation of the organ include the presence of suppuration, the degree of hyperplasia and the number of adhesions formed. The question of choosing such a method of treatment is considered only after the patient undergoes a course of hormonal therapy (90 days), which did not give results and if there are restrictions on the use of hormonal agents.
If, after drug treatment, adenomyosis continues to progress and the woman’s age exceeds 40 years, the doctor decides on the advisability of a radical operation. Surgery of this type can be prescribed in the following cases:
- Ineffective hormone therapy and previous organ-preserving surgery;
- The development of diffuse adenomyosis of the third degree;
- Progression of the nodular form of internal endometriosis in combination with myoma.
After organ-preserving operations and drug therapy, relapse of adenomyosis during the first year is diagnosed in every fifth patient. Within 5 years, the recurrence rate increases to 70%. In women of the premenopausal period, the prognosis for internal endometriosis is more favorable, due to the gradual fading of ovarian activity. After radical surgery, relapses of adenomyosis are impossible.
Pregnancy with uterine adenomyosis
If the diagnosis of adenomyosis is made to a woman who is planning a pregnancy, attempts to conceive are recommended not earlier than 6-8 months after organ-preserving intervention or completion of a course of conservative therapy.
If adenomyosis is diagnosed in a pregnant patient, during the first trimester she is shown taking gestagens. The need for hormone therapy in the second and third trimester of gestation is determined on the basis of laboratory blood tests for progesterone levels.
Pregnancy is a physiological menopause, which is accompanied by serious hormonal changes. This favorably affects the course of the pathology, reducing the rate of endometrial hyperplasia. In some women, after gestation, a complete cure occurs.
What is the danger of adenomyosis
In the absence of timely therapy or illiterate tactics of therapeutic effect, endometrial adenomyosis can provoke the development of a number of adverse complications:
- The formation of chronic, acute anemia;
- The spread of foci of adenomyosis on other tissues, organs (hemothorax, intestinal obstruction);
- Malignancy (malignant degeneration) of pathological endometrial cells.
To prevent the development of internal endometriosis and its consequences, a woman should visit a gynecologist at least 2 times a year and consult a doctor if symptoms of adenomyosis are detected .