Adenomyosis

Introduction to adenomyosis Adenomyosis refers to the benign infiltration of the endometrium into the muscular layer and diffuse growth therein, characterized by the appearance of ectopic intima and glands in the myometrium, accompanied by hypertrophy of the surrounding myometrial cells. Hyperplasia. Therefore, there is the terminology of endometriosis in the uterus, and endometriosis in the pelvis is called extrauterine endometriosis. Many scholars believe that the two are not the same disease, and the similarity is that both are regulated by ovarian hormones. basic knowledge The proportion of sickness: 10%, more common in women over 40 years old Susceptible people: women Mode of infection: non-infectious Complications: anemia

Cause of adenomyosis

Fertility status (25%):

Adenomyosis is more common in women who have already given birth than women who have not given birth. Therefore, it is believed that the trauma of the uterine wall during pregnancy and childbirth causes the endometrium and interstitial energy to grow into the muscular layer, which is the cause of the disease. The main reason, but also reported that adenomyosis can also be young and unfertile women and infertile women.

The role of sex hormones (20%):

(1) Prolactin (PRL): Animal experiments have shown that prolactin plays an important role in the pathogenesis of adenomyosis. The transplantation of anterior pituitary leaves in syngeneic mice induces elevated blood PRL and leads to the incidence of adenomyosis in transplanted mice. Elevated, Mori et al. injected prolactin into newly born mice and adult mice to induce adenomyosis, and the incidence of adenomyosis was significantly reduced after 4 weeks of bromocriptine administration at 4 weeks after birth. However, if the treatment time is shorter than 3 weeks or the treatment time is later than 11 weeks after birth, the treatment is ineffective. They also found that the blood PRL of these mice is elevated, and the decrease of progesterone level can cause the increase of the incidence of adenomyosis in mice. This phenomenon suggests that the production of PRL-induced adenomyosis may be indirect, possibly by affecting the body's estrogen levels.

(2) Estrogen, progesterone: Animal experiments show that long-term estrogen treatment in mice (at least 8 months) can induce the production of adenomyosis, and the implantation of progesterone in mice can increase the production of adenomyosis, but Not all experimental results support the above conclusions, and it is impossible to prove in the human body.

(3) Steroid hormone receptors: Most studies have reported that the estrogen receptor (ER) in the ectopic endometrial tissue of patients with adenomyosis, the progesterone receptor (PR) is significantly lower than the eutopic endometrium, and the androgen receptor Exist in the ectopic endometrium of adenomyosis, there are also reports that the estrogen receptors in adenomyosis tissue decreased and progesterone receptors increased, which is inconclusive. Recently, 78 cases of uterus reported by Zhang Hua and Gu Meizhen ER and PR in eutopic endometrium and ectopic endometrium were positive, and the positive rate was not significant. However, the positive rate of ER and PR in eutopic endometrium was significantly higher than that in ectopic endometrium. Androgen therapy In patients with good efficacy, the positive rate of ER and the positive rate of PR in the ectopic endometrium were significantly higher than those with poor efficacy. Therefore, it was concluded that ER and PR are related to the pathogenesis of adenomyosis.

Immunity factor (15%):

It has been reported that autoantibodies in patients with adenomyosis increase, and IgG, C3, and C4 deposits in ectopic endometrial tissue of adenomyosis are also increased. The number of macrophages in adenomy myometrium is twice that of uterine fibroids. It is speculated that the ectopic endometrium may produce a substance as an antigen, which is recognized by macrophages and presented to T cells, which mediates the production of antibodies to the glandular epithelial surface and binds complement to induce an immune response.

Pathogenesis

The pathogenesis of adenomyosis is unknown. The widely accepted theory is that the endometrium grows directly from the basal layer into the myometrium. Histopathology has confirmed that there is a direct relationship between the intimal island and the endometrium of adenomyosis. The continuation relationship, regardless of how deep the ectopic endometrial tissue, continuous section can confirm its connection with the endometrium.

There are many theories about the pathogenesis of adenomyosis, but the pathogenesis mechanism is still not clear, and further research is needed.

Adenomyosis prevention

According to the cause of endometriosis, in order to prevent the occurrence of endometriosis, the following preventive measures can be taken:

1. Unnecessary gynecological examination should be avoided during menstruation. It is necessary to prevent excessive force from squeezing the uterus during the examination to prevent the endometrium from being squeezed into the fallopian tube and causing intraperitoneal implantation.

2. Avoid intrauterine surgery during menstruation, such as tubal patency test, must be carried out 3 to 7 days after menstruation is clean, if the menstrual blood is not clean, the endometrial debris can enter the abdominal cavity through the fallopian tube, causing ectopic Planting.

3. Try to avoid gynecological surgery near the menstrual period. It must be gentle when moving, and avoid squeezing hard.

4. Adhere to contraception, do not or less artificial abortion, due to the use of negative pressure suction, if the pressure and use method used during the operation is not appropriate, it can also cause blood to flow into the abdominal cavity, causing endometriosis .

5. The uterus is extremely deformed or cervix, vaginal stenosis, congenital vaginal (with uterus) and other genital malformations. Cervical adhesions can cause poor discharge of menstrual blood or can not be discharged. Endometriosis is caused by menstrual blood flow. The above diseases should be actively treated to prevent the occurrence of endometriosis.

6. Avoid iatrogenic implantation in the treatment of uterine fibroids, especially those who penetrate the uterine cavity during surgery, or cesarean section, cesarean section surgery, should protect the surgical incision, so as not to break the endometrium The scutellum is implanted in the incision to cause abdominal wall incision endometriosis, or brought into the pelvic implant to cause pelvic endometriosis.

7. Pay attention to menstrual hygiene and prohibit sexual life during menstruation.

Adenomyosis complications Complications anemia

Long-term bleeding can lead to anemia and infection.

Symptoms of adenomyosis common symptoms sports amenorrhea menstrual bleeding hyperemia endometriosis uterine amenorrhea edema

Symptom

(1) dysmenorrhea: women over the age of 30, secondary, progressively increased dysmenorrhea is the main symptom of this disease, because the endometrial ectopic foci of the myometrium also periodically changes with the menstrual cycle Changes, the endometrial ectopic foci of periodic congestion, edema, hemorrhage, these bleeding is wrapped by the muscle layer, and the muscle layer expansion is limited, with a large tension, this change causes the uterus to contractively and seriously Dysmenorrhea, Bird believes that dysmenorrhea is related to the depth of intima-infiltrating muscle layer. 83.3% of grade III have dysmenorrhea, while only 4.3% of grade II have dysmenorrhea, and dysmenorrhea is also related to the extent of endometrial ectopic foci. Bleeding lesions often have dysmenorrhea, and dysmenorrhea is generally mild in patients without bleeding. Among the cases counted in our hospital, there are 67.1% of dysmenorrhea symptoms, and 86.5% of them have dysmenorrhea.

(2) Menstrual disorders: mainly manifested as increased menstrual flow, prolonged menstruation, the causes of which are mostly: 1 due to endometrial ectopic foci within the muscular layer, can not effectively contract the myometrium and cause menorrhagia, 2 Patients with adenomyoma are generally in a high estrogen state, often accompanied by excessive endometrial hyperplasia, can also cause menorrhagia or prolonged menstruation, the literature reported that the incidence of adenoma with endometrial hyperplasia is about 25%, 3 As the uterus increases, the area of the uterine cavity also increases accordingly, so the amount of bleeding increases. According to Bird, the wider range of infiltration of the muscular layer, the higher the incidence of increased menstruation, and the increase in the volume of mild infiltration accounts for 23.3. %, while severe patients were 82.3%. If adenomas and fibroids had more menstrual flow, the menstrual abnormalities accounted for 73.4%.

2. Signs

The uterus is enlarged, spherical, and the texture becomes hard. The uterus generally does not exceed the size of the uterus at 12 weeks of gestation. In the near menstrual period, the uterus is tender. If the lesion is limited, the uterus is irregularly enlarged and the nodule is uneven. In combination with uterine fibroids, menstrual period, due to lesion congestion, edema and hemorrhage, the uterus can be enlarged, the texture becomes soft, tenderness is more obvious than usual; after the menstrual period, the uterus is found to shrink again, this periodic appearance The change of vital signs is one of the important basis for the diagnosis of this disease. If pelvic endometriosis is combined, the uterus enlarges, leans back, fixes, the patellofemoral ligament is thickened, or there is painful nodules in the uterus depression.

Examination of adenomyosis

CA125 detection: CA125 is derived from the endometrium. In vitro experiments revealed that endometrial cells can release CA125, and there is a high concentration of CA125 in the endometrial leaching solution. Kijima measured CA125 in the endometrial gland of adenomyosis. The concentration is higher than the normal endometrial glandular epithelial cells, the diagnostic criteria is 35U / ml, Halila and other similar criteria can not diagnose adenomyosis, CA125 has a certain value in monitoring the efficacy.

1. B-ultrasound: Buli et al believe that histological changes are not related to the sonogram of B-ultrasound. The sensitivity of B-ultrasound diagnosis is 63%, and the specificity is 97%. It has been reported that vaginal B-ultrasound is used to diagnose adenomyosis. 73% is consistent with histological diagnosis, the sensitivity is 95%, the specificity is 74%, the accuracy of abdominal B-ultrasound and vaginal B-ultrasound is similar. The image characteristics of B-ultrasound are: 1 The uterus is uniform and the contour is still Clear, 2 endometrial lines can be unchanged, or slightly curved, 3 uterine incision echo is uneven, and sometimes there are anechoic areas of varying sizes.

2. MRI: commonly used T2 re-image to diagnose adenomyosis, the image shows a strong echo in the normal endometrium, surrounded by a low-intensity signal, the uneven echo band of >5mm thickness is typical of adenomyosis Image, contrast examination before and after menstruation, image changes, is of great significance for diagnosis, there are strong echo signals of different sizes when there is bleeding in the lesion, MRI can distinguish between uterine fibroids and adenomyosis, and can diagnose both at the same time It is of great help to the decision-making method, which is also the main value of MRI.

3. Hysterosalpingography: Because adenomyosis rarely causes uterine cavity deformation, the diagnosis of hysterosalpingography is of little significance. For example, the lesion involves the surface of the endometrium, and the filling defect can be seen.

4. Muscle acupuncture biopsy: Muscle biopsy with hysteroscopic needle biopsy has higher specificity for diagnosis of adenomyosis, but the sensitivity is low. Most scholars believe that muscle acupuncture biopsy has no important value in diagnosis. Except for severe adenomyosis, it can be performed under the guidance of vaginal ultrasound or MRI, and there is no place for routine biopsy in patients with pelvic pain.

Diagnosis and differentiation of adenomyosis

Generally, according to the patient's reproductive age, for the mother, there are secondary symptoms that aggravate the typical symptoms of dysmenorrhea and special signs of adenomyosis. The diagnosis of the disease is not difficult, and those who have difficulty in diagnosis can also pass B-ultrasound. Uterine tubal iodine angiography, MRI, laboratory tests, determination of CA125 values, etc., further confirm the diagnosis, but should be differentiated from certain diseases during the diagnosis.

Differential diagnosis

1. Pelvic endometriosis: The patient is also accompanied by dysmenorrhea. At the same time, the pelvic cavity can touch the mass, inactivity, the uterus is normal or slightly larger, and the posterior tilt is fixed. B-ultrasound can be seen on one or both sides of the accessory mass. And combined with clinical symptoms can be diagnosed.

2. Uterine fibroids: patients are generally not accompanied by dysmenorrhea, gynecological examination, uterus enlargement, uneven nodules, hard, no tenderness, good uterine activity, B-ultrasound examination of the uterine muscle wall mass and surrounding tissue boundary is clear.

3. Functional uterine bleeding: patients without dysmenorrhea, irregular menstruation, increased menstrual flow, or prolonged menstruation, gynecological examination, uterus and bilateral attachment areas are no abnormalities, B-ultrasound, pelvic no abnormal echo, through diagnostic curettage Pathological examination confirms the diagnosis.

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