Adenomyosis of the uterus, symptoms and treatment

April 18, 2018 01:00 | Gynecology
Among benign tumors of the uterus are often found special forms, which in their structure significantly differ from the usual fibroids and myomas of the uterus: in the enlarged uterus, the myomatous tissue does not have its own capsule and without special boundaries passes into the tissue of the uterine wall. On a section of the tumor, macroscopically, small and minute cavities, sometimes filled with a transparent secret, can be seen. Microscopically, the tumor is a neoplasm consisting of a muscle and connective tissue that includes glandular formations lined with a cylindrical epithelium identical with the glandular epithelium of the endometrium. Adenomyosis is considered one of the special cases of endometriosis.

Adenomyomas, which are a true neoplasm, need to distinguish adenomyosis, which is not essentially a neoplasm. They appear heteroplastically in the muscular or connective tissue in the form of glandular dilations similar to the glands of the uterus and are endometriotic heterotopias - adenomyosis, if they are accompanied by hyperplasia of the muscle tissue, and adenomyosis, if they are accompanied only by cytogenic tissue without muscle hyperplasia.

Adenomyosis occurs not only in the uterus, but also in various parts of the body, for example, in the abdominal wall, especially in the navel, in postoperative scars of the abdominal wall, in the fallopian tubes in the backbone and in the okolovaginal carcass, in various organs of the abdominal cavity and especially inovaries. In the cases observed by AA Kulikovskaya, endometriosis of the ovaries was almost always accompanied by a cystic degeneration of the ovaries. Adenomyosis arising in the uterus( or in the tube) is usually called internal adenomyosis, the same ones that are formed outside these organs are called external adenomyosis. A distinctive feature of adenomyosis is their ability to respond to hormonal influences like the mucous membrane of the uterus, ie, with the womb to make a menstrual cycle, and in the presence of pregnancy - a decidual reaction. In the ovaries with adenomyosis, the so-called "chocolate" cysts are formed - the result of repeated menstrual bleeding into the lumen of glands and cystic formations, and the deposits in the stroma of the blood pigment are a trace of former hemorrhages.

Often, endometriosis reveals the property of infiltration and germination in neighboring organs and tissues.

The incidence of adenomyosal formations at different periods of a woman's life is extremely similar to the distribution of age by the uterine fibroids. At the termination of ovarian function, i.e. in post-menopausal age, endometrioid heterotopy is rare. If they occur, they can see a picture of the reverse development( which is similar to fibromiomas).In girls not yet menstruirovali, endometriosis has not been observed to date. Symptoms of adenomyosis .If we take into account that in all cases of adenomyosis we do not have infiltrating growth and the reaction to the ovarian-menstrual process is not always clearly expressed, it becomes clear that the clinical picture of endometriosis can be quite diverse. Of great importance in clinical and diagnostic terms is the localization of the process( the uterus body, cervix, corners of the fallopian tubes, ligaments, ovaries, pelvic peritoneum, bladder, rectum, navel, postoperative scar, etc.).Although endometrioid formations may be isolated in all the above mentioned organs and remain there, without giving typical symptoms, nevertheless, three main groups of endometriosis that give characteristic symptoms and require definite treatment can be noted: 1) endometriosis developing heterotopically in the uterus body;2) endometriosis, localized behind the cervix;3) endometriosis, developing outside the uterus( endometriosis of the ovaries with the formation of so-called "chocolate" cysts, fallopian tubes, pelvic peritoneum with the formation of conglomerate tumors).

Some symptoms are so characteristic that they force you to immediately think about eidometriosis( for example, periodic bleeding from the navel, from the abdominal postoperative fistula, from the bladder, from the rectum, coinciding with the menstruation).

Internal adenomyosis .Are endometriosis inclusions in the uterus body the immediate cause of certain symptoms or, affecting the normal function of the uterine lining, do they cause these or other symptoms? Most researchers indicate that the glands of endometrioid formations in cases of internal adenomyosis do not often undergo typical cyclic changes, others completely deny these changes, while others observe premenstrual changes in heterotopic glands. Apparently, the symptoms with internal adenomyosis should be explained by the heterotopy itself, that is, the localization of these formations in the wall of the uterus.

The main symptom for internal adenomyosis is strengthened and elongated menstruation.

Intermenstrual intervals often with internal adenomyosis are shortened. Menorrhagia depends mainly on heterotopy, and not on concomitant diseases, since the percentage of the latter with adenomyosis is significantly less than the frequency of bleeding. The cause of menorrhagia in internal adenomyosis, some authors see in mechanical moments, namely, in the compression of the vessels with glandular inclusions and in reducing the contractility of the uterine muscle. Other authors believe that bleeding sometimes does not depend on hormonal influences, since bleeding occurs in the post-menopausal period.

The next symptom is dysmenorrhea. This symptom is not constant, but when it is present, it is expressed sharply and extremely characteristic. Dysmenorrhea, especially severe, is observed in cases of endometrioid heterotopy in tube corners. Pain appears several days before menstruation, but they can be in the first days of menstruation. From an anamnesis it is often possible to find out that a woman did not always suffer from dysmenorrhea, and pains appeared only in the last months or years. With internal adenomyosis, the uterus, as a rule, is enlarged, elongated, and has a dense consistence. Unlike the uterus in fibroids, the uterus is uniformly enlarged, protrusions( nodes) are usually not present.

An accurate diagnosis of internal adenomyosis is difficult. A very important symptom is a sharp increase in the uterus with internal adenomyosis before menstruation and its significant decrease after menstruation. Uniform increase in the uterus( up to the goose egg or fist), its density, polymenorrhea and characteristic dysmenorrhea make the diagnosis of internal adenomyosis very likely.

While the diagnosis of a polyp or submucous fibromioma can be excluded by curettage or sensing, the diagnosis of adenomyosis can not be made on the basis of scraping, since the scraped mucosa can not histologically differ from the endometrium in hemorrhagic metropathy. In suspicious cases it is recommended to examine a woman before and after menstruation. Significant cyclical fluctuations in the size of the uterus are said( in the presence of other symptoms) for internal adenomyosis. Scraping with this disease can only give a transient effect. In the opinion of a number of authors, in most cases X-ray castration remains ineffective( in contrast to the effective action of X-rays in hemorrhagic metropathies).Other authors note the beneficial effect of radiant energy. Of course, there is no reason to object to X-ray therapy at pre-menopausal age. If X-ray therapy does not help, you should resort to the operation of removing the uterus usually by the vaginal route. In the presence of extensive adhesions, the abdominal path should be preferred.

Acute adenomyosis of the .In vaginal-rectal examination, an unclearly contoured, irregularly shaped tumor or a limited infiltrate located behind the cervix is ​​usually determined. Before menstruation, the tumor grows and becomes painful. Behind endometrioid sprouts can go to the rectum and even penetrate into its lumen. Much more often endometrioid growths pass to the sacro-uterine ligaments, thickening and shortening them. Clearance of the rectum in such cases can narrow and even become completely impassable. However, there is no doubt that in some cases, endometrioid enlargement may be located behind the cervix, not extending to surrounding organs and tissues, and undergo reverse development in postmenopausal age. It should be noted that friable cephalic fiber is very favorable for the spread of endometrioid growths.

The danger of these forms of adenomyosis is the tendency to extensive infiltrating growth.

It should be borne in mind that primarily benign endometrial growth cells may undergo malignant degeneration. And on the other hand, primary cancer of the rectum can find in adenomyosis a fertile soil for spreading. All this forces us to consider posterior adenomyosis as a very serious disease.

Small, well-delineated endocervical endometrioid proliferation is best removed surgically through the posterior vaginal fornix. X-ray therapy in the near-entered cases is shown only at the age close to the climacteric. Turning off the function of the ovaries relieves the pain associated with premenstrual swelling of endometrioid sprouting, while the sprouts themselves do not always undergo the reverse development. With a significant development of endometrioid growths with infiltration of surrounding tissues and organs( for example, the rectum), radical surgery should be used to remove the uterus, leaving at least one ovary in young women. It should be noted that during the operation there may be significant technical difficulties. Occasionally it is necessary to resect the rectum, as the endometrioid formations can germinate through its wall. In accordance with this, the percentage of postoperative complications and mortality is relatively high. It is clear that the sooner they operate, the better the result of the operation. A careful attitude towards the intestinal wall during surgery is important for a favorable outcome of the operation. The final conclusions concerning the danger of peristaltic endometriosis and the further fate of patients can be made only after observing a large number of systematically conducted cases.

Intraperitoneal adenomyosis .Intraperitoneal adenomyosis as a clinical form is most often found in the form of adenomyosis of the ovaries. This form of adenomyosis occurs in the form of conglomerate tumors, which include the appendages and the uterus with infiltration of the rectum-uterine cavity, often sacro-uterine ligaments, ovaries, and sometimes the tubes representing cystic cavities made with chocolate-colored contents. The fistulas are often so dense and extensive that it is usually impossible to get a whole preparation during surgery - it consists of ruptured membranes, strings, etc.

Intraperitoneal endometrioid growths constantly and intensively react to ovarian-menstrual cyclic processes. In glands and stroma, the patterns of cyclic changes are more common than with internal adenomyosis. Maybe it depends on purely mechanical moments - glandular inclusions with extraperitoneal adenomyosis have more free space for swelling than endometrioid inclusions in the thickness of the muscular wall of the uterus. Whatever it was, but intraperitoneal endometrioid heterotopies respond more intensely to cyclic hormonal stimulation, they have more pronounced hemorrhages, which serve as a material for the contents of ovarian cysts and give it the characteristic color of chocolate. Hemorrhages in the abdominal cavity with the separation of glandular elements are the cause of the further spread of endometrioid heterotopy.

Severe dysmenorrheic events occurring a few days before menstruation and during menstruation are extremely characteristic for intraperitoneal adenomyosis. Drawing pains in the lower abdomen, a feeling of pressure and various disorders from the bladder, rectum and other organs( depending on the degree of spread and localization of adenomyosis) can continue for several days after menstruation. The strength and duration of pain and other disorders associated with menstruation, with intraperitoneal adenomyosis increases with each month. Enhanced and prolonged menstruation is not typical for this type of adenomyosis. It should be noted that with intraperitoneal adenomyosis, minor bleeding may occur between the two menstruation, especially after physical exertion or sexual intercourse. As already mentioned, intraperitoneal adenomyosis is often taken for chronic or subacute inflammation of the appendages, or chronic pelvioperitonitis, and often for many years are exposed to various types of resorptive treatment that does not give a result in these cases. If there is no history of gonorrhea, postpartum or postabortion disease, and at the same time, there are certain complaints( severe dysmenorrheal events that increase with each month), and if, despite treatment, the disease does not decline, it is necessary to assume endometriosis of the appendages. It should also be borne in mind a possible combination of inflammation of the appendages or chronic appendicitis with endometriosis.

From the objective data for endometriosis speaks the presence of small-hummocky infiltration in the area of ​​one or both utero-sacral ligaments, on the peritoneum of the rectum-uterine cavity, in the peri-fat cellulose, on the posterior surface of the uterus, fixed in retroversion. Sometimes it is necessary to differentiate from tuberculosis of the female sexual sphere, for or against which can tell an anamnesis and objective data obtained during the study of the whole organism. Unlike tuberculous tubercles, the infiltrate with endometriosis is more dense;it is even denser than a cancer infiltrate. In addition, with ovarian cancer often develop ascites, the pain is more permanent and does not depend on the menstrual-ovarian cycle. The general condition of the patient and her state of health suffer from endometriosis significantly less than in ovarian cancer.

Adenomyosis of rectum-vaginal septum .With the development of endometrioid heteropathies in the rectum-vaginal septum, the results of a vaginal or rectal examination may cause suspicion of cancer from the rectum. But even in these cases, the significant density of small-hail infiltrate speaks more for adenomyosis than for cancer. With endometrioid heterotopy near the posterior vaginal wall, when viewed by mirrors, one can detect individual bubbles of the size of a pinhead or somewhat larger with a perfectly smooth surface through which bluish contents appear through. The presence of these vesicles repeatedly helped us to establish a diagnosis of external adenomyosis, as if the data of the anamnesis and objective research of the patient were confused and contradictory. If we do not find such bubbles, then for a differential diagnosis between the endometriosis of the rectum-vaginal septum and a cancerous tumor originating from the rectum, it is necessary to perform a rectoscopy or a biopsy.

Treatment of adenomyosis .Details of the treatment of the disease in the article Treatment of adenomyosis