Adenomyoma

　　It is generally believed that the trauma to the uterine wall during multiple pregnancies and deliveries and chronic endometritis may be the main causes of adenomyosis. In addition, due to the lack of the submucosal layer beneath the basalis of the endometrium, adenomyosis often occurs with uterine fibroids and hyperplasia of the endometrium.　　

　　The etiology of adenomyosis is still unknown. The current consensus is that due to the lack of the submucosal layer of the uterus, the basal layer cells of the endometrium proliferate and invade the uterine muscle layer, accompanied by compensatory hypertrophy and hyperplasia of the surrounding muscle layer cells, forming lesions. There are currently four theories about the factors causing the proliferation and invasion of endometrial basal layer cells:

　　1. Related to heredity;

　　2. Uterine injury, such as dilatation and curettage, and cesarean section, both increase the incidence of adenomyosis.

　　3. Hyperestrogenemia and hyperprolactinemia;

　　4. Viral infection;

　　5. Obstruction of the reproductive tract increases uterine cavity pressure during menstruation, leading to the ectopic location of endometrial tissue within the uterine muscle layer.

　　1. Red degeneration Red degeneration of uterine fibroids is common during pregnancy or postpartum, and can also occur in women during menopause. Macroscopically, the fibroid section appears dark red, without luster, soft like spoiled beef. It often occurs in the second trimester of pregnancy, with subserosal fibroids being common. Patients may experience severe abdominal pain, accompanied by fever, usually around 38℃, with an increase in white blood cells. Examination shows marked tenderness locally in the tumor. Generally, symptoms improve gradually with symptomatic treatment, and can recover in about a week without surgery. However, sometimes due to the aggravation of symptoms of ischemia and necrosis, ineffective symptomatic treatment, or inability to rule out other possibilities, a laparotomy may be necessary at the last resort to perform a hysterectomy. Generally, it is not recommended to perform a fibroid resection during pregnancy because it increases the risk of miscarriage, and surgery is also prone to bleeding. If it occurs in non-pregnant women, the clinical course is usually milder, not so acute, symptoms may last for 1-2 days or worsen, and if there are indications for laparotomy, the decision to perform a fibroid resection or hysterectomy is made based on the situation.

　　2.Infection Uterine fibroid infection often occurs in submucosal fibroids or cervical submucosal fibroids that protrude into the vagina, caused by infectious bacteria in the vagina. Once infected, there is a large amount of vaginal discharge, mixed with blood or pus, with an odor. Examination shows the fibroid surface is edematous, covered with a white membrane or necrotic tissue, grayish-black, even with necrotic tissue falling off. The tumor is soft to the touch, the cervix is soft, and the fornix is soft. If there is no other tumor in the uterus, it is of normal size, mobile, the parauterine tissues on both sides are soft, and there is no tenderness. Submucosal fibroid infection usually has unobstructed drainage, rarely causes pelvic inflammation, and can lead to systemic symptoms such as fever and abdominal pain. Subserosal fibroids may cause central necrosis of the tumor due to reasons such as red degeneration, poor blood supply due to torsion, or cystic transformation between muscle fibers, leading to secondary infection. The patient may present with acute abdominal pain and fever, and gynecological examination shows tenderness in the fibroid. Treatment involves actively controlling infection and surgical treatment.

　　3.Torsion Uterine fibroid torsion mainly occurs in subserosal fibroids. Generally, fibroids have a short pedicle and are thicker, although torsion can occur, it is far less common than ovarian cyst pedicle torsion. Occasionally, a large subserosal fibroid can be associated with uterine torsion. After torsion, patients may experience sudden lower abdominal pain and twisting pain. If the tumor is incarcerated in the pelvis after torsion, there may be a feeling of lower abdominal pressure, palpation of the lower abdomen can feel a mass, with tenderness, and the tenderness is most obvious at the base of the pedicle near the uterus. Vaginal examination shows the uterus to be normal or enlarged. The uterus can be palpated with tenderness, and sometimes the fibroid is on one side of the uterus and is difficult to distinguish from ovarian tumor pedicle torsion. Ultrasound examination can assist in distinguishing the source of the tumor. Generally, there is no fever, but if there is secondary infection for a long time, fever may occur. Once diagnosed, surgical treatment is required.

　　1,Dysmenorrhea (40-50%): The main manifestations include prolonged menstrual periods, increased menstrual volume, and some patients may experience spotting before and after menstruation. This is because the uterus increases in size, the uterine cavity endometrial area increases, and the lesions between the uterine muscle walls affect the contraction of uterine muscle fibers. Severe cases can lead to anemia.

　　2,Dysmenorrhea (25%)The characteristic is secondary progressive worsening dysmenorrhea. It often starts one week before the menstrual period and subsides when the period ends. This is because the ectopic endometrium in the uterine muscle layer becomes congested, swollen, and bleeding under the influence of ovarian hormones during the menstrual period, and at the same time, it increases the blood volume in the uterine muscle layer blood vessels, causing the thick uterine muscle layer to dilate, leading to severe dysmenorrhea.

　　3,About 35% of patients have no obvious symptoms.

　　4.Changes in menstruation. Any woman over 30 who has more menstrual blood, longer menstrual periods (40% to 50%), and progressively worsening dysmenorrhea (25%) should be considered. Dysmenorrhea often begins one week before the menstrual period and ends with the end of the period.

　　5.Infertility. There is a 40% chance that uterine adenomyosis can cause infertility.

　　1.Women should not eat刺激性 foods during their periods. Spicy and cold foods can cause uterine contraction, increase uterine cavity pressure, and may push the endometrium into the uterine wall.

　　2.Unless it is unavoidable, women should not have a gynecological examination during their periods.. Gynecological examination is inevitable and will also cause an increase in uterine cavity pressure.

　　3.Women may experience abdominal pain in the days before menstruation, especially if they have already experienced it,Do not have sex during slight spotting or just after the end of the menstrual period, because women may experience intense uterine spasmodic contractions during orgasm, increasing the pressure in the uterine cavity.

　　4.Women must practice reasonable contraception to avoid unexpected pregnancy.Abortion or induced labor is the most likely factor to cause injury to the uterine wall. If it is necessary to terminate pregnancy, it is essential to go to a regular hospital and not to blindly choose some street clinics. Because regular doctors and operation techniques have less trauma and postoperative care is more in place.

　　Uterine adenomyosis, also known as intrinsic endometriosis, is a special type of endometriosis. Therefore, its diagnostic examination is the same as that of endometriosis, and common examination methods include:

　　1. Gynecological examinationDuring the examination, the uterus appears to be uniformly enlarged or has localized nodular protuberances, is hard and painful, and the pain is particularly pronounced during the menstrual period. In such cases, uterine adenomyosis should be considered first.

　　2. Ultrasound examinationIrregular echo enhancement can be seen in the myometrium caused by the implantation of endometrium.

　　1.Do not overindulge in coldnessWomen with poor gastrointestinal function should avoid cold and cold foods during their periods, such as cold drinks, raw cold dishes, crab,螺蛳, clam, leech, pear, persimmon, watermelon, banana, bitter melon, mountain peach, mung bean, cucumber, water chestnut, grapefruit, orange, etc., to prevent cold blood stasis and exacerbate dysmenorrhea.

　　2.Eat less acidAcidic foods have astringent and constrictive effects, causing blood to become thick and not conducive to the smooth flow and discharge of menstrual blood. Therefore, those with dysmenorrhea should avoid using such foods during their periods. Acidic foods include vinegar, sour and spicy dishes, pickled vegetables, pomegranate, umeboshi, myrica, strawberry, starfruit, cherry, hawthorn, mango, apricot, plum, lemon, etc.

　　3.Avoid spicy food: For some dysmenorrhea patients, who naturally have a large amount of menstruation, eating spicy, warm, and strong刺激性 food will worsen pelvic congestion and inflammation, or cause excessive contraction of the uterine muscle, thereby exacerbating dysmenorrhea. Therefore, patients with dysmenorrhea should eat as little as possible or not eat chili, pepper, garlic, scallion, ginger, chive, chicken soup, rambutan, and other spicy seasonings.

　　1. Medication treatment

　　Symptomatic treatment: For those with mild symptoms who only require relief of dysmenorrhea, especially those in the late 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 be relieved of pain after menopause without the need for surgical treatment.

　　Pseudo-menopausal therapy: Injection of GnRHa can bring the hormone level in the body to the state of menopause, causing the ectopic endometrium to gradually atrophy and thereby achieving a therapeutic effect. This method is also known as 'pharmacological oophorectomy' or 'pharmacological pituitaryectomy'. Generally, within 3-6 weeks of taking the drug, the serum estrogen level in the body reaches castration level, which can alleviate dysmenorrhea. Moreover, after the application of GnRHa, the uterus can be significantly reduced, which can be used as preoperative medication for patients with larger lesions and difficult surgery. After the uterus becomes smaller, surgery can be performed, which will significantly reduce the risk and difficulty. However, long-term use of GnRHa may cause menopausal symptoms, even leading to serious cardiovascular and cerebrovascular complications and osteoporosis, so it is recommended to add estrogen reversely after 3 months of application of GnRHa to alleviate complications. In addition, the cost of GnRHa is high, about 1000-2000 yuan per month, so it is not currently used as a long-term treatment plan. Once medication is stopped, the return of menstruation may lead to the recurrence of the lesion. Therefore, currently, GnRHa is often used as a drug of choice for preoperative reduction of lesions and postoperative reduction of recurrence.

　　Pseudo-pregnancy therapy: Some scholars believe that oral contraceptives or gestagens can cause the decidualization and atrophy of the ectopic endometrium, thus controlling the development of adenomyosis. Some patients choose to use Mirena to continuously release high-efficiency gestagens locally in the uterus to control the ectopic endometrial lesions between the uterine muscle walls. However, some scholars also believe that the ectopic endometrium of adenomyosis is mostly basal endometrium, which is not sensitive to gestagens. Therefore, the efficacy of gestagens (oral contraceptives and Mirena) in treating adenomyosis is still controversial.

　　Traditional Chinese Medicine treatment: According to the understanding of traditional Chinese medicine, adenomyosis is related to blood stasis, and the formation of blood stasis is related to pathogenic factors such as cold conglomeration, qi stagnation, and phlegm dampness. Therefore, in treatment, it is necessary to take both blood-activating and blood-removing as the principle, and also take into account the cause of blood stasis formation and the degree of weakness.

　　2. Surgical treatment

　　Surgical treatment includes radical surgery and conservative surgery. Radical surgery refers to hysterectomy, while conservative surgery includes the resection of adenomyosis lesions (adenomyoma), resection of the endometrium and myometrium, uterine myometrial electrocoagulation, uterine artery ligation, and resection of the sacral nerve and sacral bone nerve, etc.

　　Hysterectomy:

　　Applicable to patients without the desire for childbirth, with extensive lesions, severe symptoms, and ineffective conservative treatment. Moreover, to avoid residual lesions, total hysterectomy is preferred, and partial hysterectomy is generally not recommended.

　　Uterine Adenomyosis Lesion Resection:

　　Applicable to patients with the desire for childbirth or young patients. Because uterine 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. Takeuchi et al. reported that a transverse H-shaped incision could be made on the uterine lesions under laparoscopy to reduce the risk of penetrating the uterine cavity during resection of the lesions, and the muscle layer surrounding the lesions could be folded and sutured. Wang Bin reported the U-shaped resection of the uterine muscle layer by laparotomy. Masato Nishida chose a central longitudinal resection of the uterine body, did not use auxiliary treatment after surgery, and could become pregnant within 3 months after surgery.

　　3. Interventional Treatment

　　In recent years, with the continuous progress of interventional treatment technology, selective uterine artery embolization can also be one of the treatment options for uterine adenomyosis. Its mechanism of action includes: 1, necrosis of ectopic endometrium, reduction in prostaglandin secretion, and relief of dysmenorrhea; 2, the uterus becomes softer after embolization, the volume and area of the uterine cavity endometrium shrink, and the menstrual volume decreases; 3, the uterus continuously shrinks and the smooth muscle contracts, blocking the tiny channels causing endometriosis, reducing the recurrence rate; 4, the local estrogen level and receptor number decrease; 5, the establishment of collateral circulation on the side of the located endometrium can gradually migrate and grow to recover function. Ravina et al. reported that the uterine artery embolization treatment of uterine adenomyosis reduced the menstrual volume by about 50%, and the relief rate of dysmenorrhea reached more than 90%. Wang Yitang et al. reported that in 128 cases of uterine artery embolization treatment for uterine adenomyosis, 80 cases (62.5%) had complete disappearance of dysmenorrhea after surgery, 42 cases (32.8%) had significant relief, and 6 cases (5%) had partial relief. 21 cases became pregnant and delivered healthy infants normally within 9 to 36 months after surgery.

　　However, some scholars believe that uterine artery embolization may affect the blood supply to the uterus and ovaries, thus having an adverse effect on pregnancy. It may lead to infertility, abortion, preterm delivery, and increase the rate of cesarean section.