Definition of Adenomyosis
Definition: Adenomyosis refers to the thickening of the uterine muscle layer with the advancement of endometrial tissue, which should only limit the inner surface of the uterus, into the uterine muscle layer. Penetration and growth of endometrial tissue into the myometrium, which is the uterine muscle. adenomyosisor internal endometriosis is named. this disease external endometriosisIt can be seen together with endometriosis, which is called the uterine muscle and located on the ovaries and peritoneum.
Adenomyosis islets are sometimes seen as cystic masses in the myometrium. If not carefully evaluated, especially those close to the endometrial cavity may give the impression of a gestational sac.
Endometrial tissues that penetrate the myometrium and function either diffuse diffusely or cause swelling locally in an area. adenomyosis is called. Adenomyosis can mimic other masses such as uterine fibroids. Adenomyosis is often misdiagnosed as uterine fibroid (myoma). Both tumors originate from an abnormal cell and gradually grow under the influence of estrogen hormone. Although the entire fibroid can be removed during surgery without damaging the normal uterine tissue, the adenomyosis mass cannot be separated from the uterine muscle as it penetrates into the uterine tissue (myometrium) and can only be removed with it.
Symptoms of Adenomyosis
– Prolonged heavy menstrual bleeding
-Painful periods with increasing severity
– Groin pain in intercourse
While adenomyosis sometimes does not cause any symptoms, in some cases it can cause severe stabbing, abnormal menstrual bleeding and pain in the pelvic region. Adenomyosis pain can also occur during non-menstrual times. The uterus may be globular, large or localized mass. In addition to excessive long-lasting abnormal menstrual bleeding with clots, in some cases, there may be spotting or more bleeding between periods.
This disease is more common in women over the age of 30 who have given birth, had a cesarean section or another uterine surgery. Adenomyosis occurs in approximately 17% of women over the age of 35. The chance of pregnancy with adenomyosis is quite low. However, if pregnancy does occur, conditions that cause severe and dangerous bleeding such as uterine perforation (uterine rupture), atony bleeding in the uterus or excessive bleeding, placenta accreta-increata may be encountered.
Diagnosis of Adenomyosis
adenomyosis; It can be detected during ultrasonography, MR imaging, and HSG for infertile patients. The most accurate diagnosis of adenomyosis can be made with MRI.
Adenomyosis, focal adenomyosis areas are observed in heterogeneous echo structure and thick on USG. Although myoma is suspected on USG, although the mass cannot be clearly observed, various parts of the fundus are observed as thick and the endometrial cavity is irregular. In this case, MRI may be requested for a clearer understanding of the mass.
The myometrium is known as a homogeneous mass composed mostly of smooth muscle. However, with magnetic resonas studies, the myometrium subendometrial myometrium (junctional zone)and outer myometrium It is seen that it consists of two separate zones. The junctional zone is structurally and functionally different from the outer myometrium. Depending on the cycle days in non-pregnant women, myometrial contractions usually originate from the junctional zone layer. Irregular thickening in the junctional zone in magnetic resonance imaging diffuse adenosis diagnostic criteria. In the MR examination, it is observed that the junctionel zone is 1 cm or more thick, especially in the anterior or posterior fundus of the uterus, diffusely or focally in the heterogeneous myometrial echo. This magnetic resonance image demonstrates disruption of the internal myometrial structure secondary to smooth muscle hyperplasia, but this is not evidence of mucosal invasion of the myometrium. Adenomyosis is a disease that means the deterioration of internal myometrial structure and function and secondary infiltration of endometrial elements due to various conditions. While adenomyosis is detected to a large extent in patients with dysfunctional uterine bleeding, the uterus is larger than normal and its contours are irregular.
Adenomyosis is the extension of endometrial tissue into the myometrium. adenomyosisin the uterus common (diffuse)or focal it could be. A massadaptive focal area adenomyoma is called. If the extensions of the endometrial tissue in the myometrium reach the uterine cavity in the pathological examination performed after surgery, adenomyosis may be considered.
In HSG spot radiography, the uterine contours are irregular, and it is observed that the contrast agent used in HSG forms small pockets (protrusions, diverticulum). In this case, diffuse adenomyosis is suspected. Patients with adenomyosis often have pelvic pain and abnormal bleeding.
Although pain relievers, contraceptives, GnRH analogues, and progesterone-containing IUDs can be used as medical treatment in the treatment of this disease, their effects are limited. Surgical treatment is mandatory in cases with very severe symptoms and excessive menstrual bleeding.
A. Medical Treatment of Symptomatic Adenomyosis
In moderately large uterus, treatment is unnecessary unless there is severe pelvic pain and excessive menstrual bleeding during menstruation. In cases with severe symptoms, GnRH analogues can be used to temporarily relieve symptoms. However, these drugs can stop the function of the ovaries and cause some menopausal symptoms such as hot flashes, sweating, osteoporosis, and increased cholesterol levels. Therefore, such drugs should not be used for more than six months. In women who develop iron deficiency anemia due to excessive menstrual bleeding, GnRH drugs can be used for six months until the blood level returns to normal. Thus, blood transfusion is not needed in women who develop anemia due to adenomyosis, and possible complications related to transfusion are prevented. Painful periods return after the GnRH analogs are discontinued.
Although patients with adenomyosis usually have infertility, successful pregnancy cases are also encountered after six months of treatment with GnRH analogues in studies. However, in women with advanced adenomyosis, no results can be obtained from this treatment. In adenomyosis, the effects of birth control drugs and progesterone-only drugs are limited, but they can provide temporary relief. Intrauterine systems containing levonorgestrol (such as MIRENA) may also be temporarily effective in patients with adenomyosis.
B. Surgical Treatment of Adenomyosis
Surgical removal of the focal focus of adenomyosis, which is usually localized in the anterior or posterior fundus, both prevents the re-growth of adenosis masses and the uterus returns to its normal size, and its painful and excessive bleeding periods return to normal.
However, removing the adenosis mass alone increases patient satisfaction as it protects patients from the disadvantages of hysterectomy (removal of the entire uterus).
Since diffuse adenomyosis is localized deep into the uterine wall, methods such as endometrial ablation or uterine artery embolization do not improve the symptoms of patients.
In young women with very severe symptoms, hysterectomy may be considered as a last resort.
Kiss. Dr. Kutlugul Yuksel