Adenomyosis

　　The etiology of adenomyosis is still unknown. The current consensus is that due to the lack of submucosal layer of the uterus, the basal layer cells of the endometrium proliferate and invade the myometrium, forming lesions with compensatory hypertrophy and hyperplasia of the surrounding myometrial cells. There are currently four theories about the factors causing the proliferation and invasion of the basal layer cells of the endometrium:
　　1. Related to heredity.
　　2. Uterine injury, such as dilation and curettage and cesarean section, can increase the incidence of adenomyosis.
　　3. Hyperestrogenism and hyperprolactinemia.
　　4. Viral infection.
　　5. Reproductive tract obstruction, increased uterine cavity pressure during menstruation, leading to endometrial implantation into the myometrium of the uterus.

　　Endometriosis adenomyosis was more common in women over 40 years old in the past. The main manifestations are increased menstrual volume and prolonged menstrual period. Long-term bleeding can lead to anemia and concurrent infection.

　　Endometriosis adenomyosis was more common in women over 40 years old in the past, but in recent years, there has been a trend of gradual youthfulness, which may be related to the increase in cesarean section, induced abortion, and other surgical procedures. The specific clinical symptoms of this disease are as follows.

　　1. Menstrual irregularity: The main manifestation is prolonged menstrual period, increased menstrual volume, and some patients may experience spotting before and after menstruation. This is because the increase in uterine volume, the increase in endometrial area of the uterine cavity, and the influence of interstitial lesions on uterine muscle fiber contraction cause the uterine muscle fibers to contract. Severe cases can lead to anemia.

　　2. Dysmenorrhea: The characteristic is secondary progressive worsening dysmenorrhea. It usually starts a week before the menstrual period and subsides when the menstrual period ends. This is because the ectopic endometrium in the uterine myometrium is engorged, swollen, and bleeding under the influence of ovarian hormones during the menstrual period, which also increases the blood volume in the uterine myometrial blood vessels, causing the thick uterine myometrium to dilate, leading to severe dysmenorrhea.

　　3. Some patients have no obvious symptoms: Approximately 35% of patients have no obvious symptoms.

　　Endometriosis adenomyosis refers to the benign infiltration of the endometrium into the myometrium and its diffuse growth. To prevent the occurrence of endometriosis, the following preventive measures can be taken according to the causes of endometriosis adenomyosis:

　　1. Avoid unnecessary gynecological examinations during menstruation. When necessary, do not exert excessive force on the uterus to prevent the endometrium from being pushed into the fallopian tube, which may cause abdominal endometrial implantation.

　　2. Avoid intrauterine surgery during menstruation, such as tubal patency test. It must be performed 3 to 7 days after the menstrual period is clean. If surgery is performed before the menstrual blood is clean, endometrial debris may enter the abdominal cavity through the fallopian tube, causing ectopic implantation.

　　3. Try to avoid gynecological surgery close to the menstrual period. If surgery is necessary, perform it gently to avoid exerting force.

　　4. Try to avoid gynecological surgery during the perimenstrual period. If surgery is necessary, perform it gently and avoid exerting force to prevent blood reflux into the abdominal cavity, which may cause endometrial implantation.

　　5. Extreme retroflexion of the uterus or narrowing of the cervix and vagina, congenital absence of the vagina (with uterus) and other reproductive tract malformations, and cervical adhesions can cause dysmenorrhea or inability to expel menstrual blood, leading to endometriosis due to retrograde menstrual blood flow. Therefore, it is necessary to actively treat these diseases to prevent the occurrence of endometriosis.

　　6. Avoid iatrogenic implantation during hysteroscopic myomectomy, especially for those with transuterine cavity penetration during surgery or cesarean section, it is necessary to protect the surgical incision to prevent the implantation of endometrial debris at the incision, which may cause endometriosis at the abdominal wall incision, or lead to pelvic endometriosis by being implanted into the pelvis.

　　7. Pay attention to menstrual hygiene. Sexual intercourse is prohibited during the menstrual period.

　　Adenomyosis is a diffuse or localized lesion formed by the invasion of endometrial glands and stroma into the uterine muscle layer. The specific clinical examination of this disease is as follows.

　　1. Serum CA125 detectionCA125 originates from the endometrium. In vitro experiments have found that endometrial cells can release CA125, and there is a high concentration of CA125 in the exudate of the endometrium.

　　2. Ultrasound examinationAccording to Buli et al., tissue changes are unrelated to B-ultrasound imaging, with a sensitivity of 63% and a specificity of 97%. The image characteristics of B-ultrasound are that the uterus is uniformly enlarged with a relatively clear contour. The endometrial line may not change or may be slightly curved. The uterine cross-sectional echo is inhomogeneous, and sometimes there may be areas of different sizes without echo.

　　3. MRIT2-weighted imaging is commonly used to diagnose adenomyosis, with the image showing a low signal intensity band surrounding the normal endometrial hyperintensity, an inhomogeneous echo band with a thickness of >5mm, which is a typical imaging feature of adenomyosis. Comparison of images before and after menstruation is of great significance for diagnosis. When there is bleeding in the lesion, there may be strong echo signals of different sizes, and MRI can distinguish uterine fibroids from adenomyosis and diagnose their coexistence, which is of great help in determining the treatment method. This is also the main value of MRI.

　　4. HysterosalpingographySince adenomyosis rarely causes uterine cavity deformation, hysterosalpingography has little diagnostic significance. If the lesion involves the surface of the endometrium, there may be a filling defect.

　　5. Myometrial needle biopsyUnder hysteroscopy, using a biopsy needle to take a myometrial biopsy has a high specificity for diagnosing adenomyosis but a low sensitivity. Most scholars believe that myometrial needle biopsy has no significant value in diagnosis, unless it is severe adenomyosis, which can be performed under the guidance of transvaginal ultrasound or MRI. There is no routine biopsy site for pelvic pain patients.

　　Patients with adenomyosis should pay attention to not indulging in coldness in their diet. Women with poor gastrointestinal function should avoid cold and raw foods during the premenstrual and menstrual periods, such as cold drinks, raw cold dishes, crabs, and snails, to prevent cold blood stasis and exacerbation of dysmenorrhea. Patients should also avoid eating sour and spicy foods and eat more calcium-rich foods. They can also consume active citrate calcium to supplement the deficiency of food calcium.

　　There are many treatment methods for adenomyosis, and clinical decision-making needs to be individualized based on the patient's age, symptoms, and fertility requirements. It is often combined with comprehensive treatment plans that include surgery and medication.

　　1. Drug treatment

　　1. Symptomatic treatmentFor those with mild symptoms who only require relief of dysmenorrheal symptoms, especially those in the perimenopausal period, non-steroidal anti-inflammatory drugs can be used for symptomatic treatment during dysmenorrhea. Because the ectopic endometrium gradually atrophies after menopause, such patients will have their pain relieved after menopause without the need for surgical treatment.

　　2, Pseudo-Menopause Therapy: GnRHa injection can bring the hormone level in the body to menopausal status, causing the ectopic endometrium to gradually atrophy and acting as a treatment method. This method is also called 'pharmacological ovarianectomy' or 'pharmacological pituitaryectomy'.

　　3, Pseudo-Pregnancy Therapy: Some scholars believe that oral contraceptives or progestins can make the ectopic endometrium decidualize and atrophy, thus controlling the development of adenomyosis. However, some scholars believe that the ectopic endometrium of adenomyosis is mostly endometrium from the basal layer, which is insensitive to progestins. Therefore, the efficacy of progestin treatment for adenomyosis is still controversial.

　　Two, Surgical Treatment

　　: It includes radical surgery and conservative surgery. Radical surgery is hysterectomy, and conservative surgery includes adenomyosis lesion (adenomyoma) resection, endometrial and muscularis resection, uterine muscularis coagulation, uterine artery ligation, and sacral preneural and sacral nerve resection, etc.

　　1, Hysterectomy: It is used for patients without fertility requirements, with extensive lesions, severe symptoms, and ineffective conservative treatment. Moreover, to avoid residual lesions, total hysterectomy is preferred, and partial hysterectomy is generally not advocated.

　　2, Adenomyosis Lesion Resection: It is suitable for patients with fertility requirements or young age. Because adenomyosis often has diffuse lesions and unclear boundaries with the normal muscle tissue of the uterus, how to choose the method of resection to reduce bleeding, residual lesions, and facilitate postoperative pregnancy is a very confusing issue. Different scholars have different plans, and there is currently no unified surgical method.

　　Three, Interventional Therapy

　　In recent years, with the continuous progress of interventional treatment technology, selective uterine artery embolization can also be used as one of the treatment options for adenomyosis. Its mechanism of action includes:

　　The necrosis of ectopic endometrium reduces the secretion of prostaglandins, which relieves dysmenorrhea.

　　After embolization, the uterine body becomes soft, the volume and the area of the uterine cavity endometrium decrease, and the amount of menstruation is reduced.

　　The uterine volume continuously decreases and the smooth muscle contracts, blocking the small channels causing endometriosis and reducing the recurrence rate.

　　The local estrogen level and the number of receptors decrease.

　　The establishment of collateral circulation of the endometrial side branches can gradually transition and grow from the basal layer to recover function.