Adenomyosis

　　The etiology of adenomyosis is unknown to this day. The current consensus is that the lack of submucosal layer in the uterus leads to the proliferation and invasion of basal layer cells of the endometrium into the uterine muscle layer, accompanied by compensatory hypertrophy and hyperplasia of the surrounding muscle cells, forming lesions. There are currently four theories about the factors causing the proliferation and invasion of endometrial basal layer cells: ① related to genetics; ② uterine injury, such as dilatation and curettage and cesarean section, all increase the incidence of adenomyosis; ③ hyperestrogenemia and hyperprolactinemia; ④ viral infection; ⑤ reproductive tract obstruction, which increases uterine cavity pressure during menstruation, causing endometriosis to the uterine muscle layer. Multiple pregnancies and deliveries can cause uterine wall trauma and some chronic endometritis, and in addition, due to the lack of some submucosal layer beneath the basal membrane of the endometrium, and adenomyosis often also combines with the elongation of uterine fibroids and endometrial hyperplasia, which is also related to high estrogen stimulation.

　　Menstrual irregularities (40-50%): Mainly manifested as prolonged menstrual periods, increased menstrual volume, and some patients may also experience spotting before and after menstruation. This is due to the increased size of the uterus, the increased area of the uterine cavity endometrium, and the influence of the lesions between the uterine muscular wall on the contraction of the uterine muscle fibers. Severe cases can lead to anemia. Dysmenorrhea, characterized by secondary progressive worsening dysmenorrhea, often begins one week before the onset of menstruation, and the pain subsides after the end of the menstrual period. In addition, patients with adenomyosis may also have endometriosis, and about half of the patients have fibroids. Patients with adenomyosis are not easy to conceive.

　　The ectopic endometrium disseminates in the uterine muscular wall, with the posterior wall being more common. The muscle fibers exhibit diffuse reactive hyperplasia. The uterus is uniformly enlarged, hard in texture, and its size may change before and after menstruation. Bimanual examination often reveals a consistent enlargement of the uterus, with tenderness, but adenomyosis can also be present in uteruses of normal size or even smaller. It is often accompanied by endometriosis, fibroids, and pelvic inflammatory adhesions. The clinical manifestations of adenomyosis are mainly dysmenorrhea and menstrual irregularities. Dysmenorrhea is the most typical symptom of the disease, which is usually secondary. Secondary dysmenorrhea occurs in older women, around the age of 40, when dysmenorrhea gradually worsens, with the pain characterized by spasm or colicky pain, so severe that it is difficult to endure, and it may prevent the patient from carrying out daily work. Dysmenorrhea is caused by edema, bleeding, and stimulation of the muscular wall by the ectopic endometrium during menstruation. Some patients may also experience pain during sexual intercourse. Menstrual irregularities are often the first symptom of the disease, commonly manifested as increased menstrual volume, prolonged menstrual periods, or frequent menstruation. Some patients may have vaginal spotting before and after menstruation. This is due to the increased size of the uterus, the increased area of the uterine cavity endometrium, and the influence of ectopic endometrium between the uterine muscular wall on the contraction of the uterine muscle fibers. Adenomyosis may also cause postmenopausal bleeding, although this is not common, it is worth noting. (1) Dysmenorrhea: The congestion, edema, and bleeding of the ectopic endometrium during menstruation stimulate the organs involved, causing severe abdominal pain during the menstrual period. (2) Infertility: Patients often seek medical attention due to infertility. (3) Menstrual irregularities: Commonly manifested as increased menstrual volume, prolonged menstrual periods, or irregular menstrual cycles. (4) Pain during sexual intercourse: The ectopic endometrium in the pelvic cavity often forms nodular lesions in the rectouterine pouch, and pain is caused when the cervix collides and the uterus is elevated during sexual intercourse. About 35% of patients have no obvious symptoms.

　　Effective measures are still lacking in the prevention of adenomyosis of the uterus. Reducing fertility, reducing the number of induced abortions or curettage, and timely detection and treatment of reproductive tract stenosis or obstruction may reduce the risk of occurrence.

　　Macroscopic examination: The uterus is usually uniformly enlarged and spherical, often occurring in the posterior wall of the uterus. The lesions in the muscle layer are of two types: diffuse and localized. The former is called adenomyosis of the uterus, and the latter is called adenomyoma of the uterus. When the uterine wall is opened, the muscle layer is significantly thickened and hardened, and thick muscle fibers and micro-vesicles can be seen in the muscle wall, with occasional old blood in the vesicles, often with unclear boundaries with normal smooth muscle tissue. Clinically, the term 'towel-like change' is often used to describe it. Laparoscopic examination: The endometrial glands and stroma in the uterine muscle layer are distributed in an island-like pattern, which is the microscopic feature of the disease. Because in the uterine specimens of other diseases, 10-30% may be found in the uterine muscle layer with endometrial tissue, so when diagnosing adenomyosis, it is necessary to meet the invasion depth of the endometrial gland cells greater than 3mm or reaching the next low-power field of the basal layer of the endometrial cells. Gynecological examination shows that the uterus is usually uniformly enlarged and spherical, and the adenomyoma can be manifested as hard nodules. The uterus is generally not larger than 12 weeks of pregnancy. During the premenstrual period, the uterus has a tenderness; during the menstrual period, the uterus increases in size, becomes softer, and the tenderness is more obvious than usual; after the menstrual period, the uterus shrinks. Vaginal ultrasound examination is more accurate than abdominal probe. MRI can objectively understand the location and scope of the lesions before surgery, which is of great help in determining the treatment method. Ultrasound shows that the uterine wall is thickened, and there are dark shadows in the internal索条状, unlike normal tissue.

　　Dietary precautions for adenomyosis of the uterus:

　　1. Eat more vegetables, fruits, and coarse grain foods, such as celery, cucumber, mushrooms, tofu, beans, tubers, and so on.

　　2. The diet should be light, avoid greasy, fried, spicy and other刺激性 foods, and adhere to low-fat foods, such as chicken, eggs, grass carp, whitefish, and so on.

　　3. Avoid cold foods, such as crabs, clams, snails, and so on.

　　4. Avoid cold and frozen foods, and pay attention to not eating hot or warm foods.

　　5. Avoid foods that cause heat, such as dog meat and mutton.

　　6. Nutritious dried fruit foods can be eaten, such as peanuts, melons, walnuts, chestnuts, and so on.

　　7. Longans, ejiao, royal jelly, and other foods that belong to hot, hemostatic, and estrogen-containing foods should be avoided.

　　8. Avoid stimulants such as alcohol and smoking.

　　In addition to dietary adjustment, attention should also be paid to daily care, such as maintaining a regular lifestyle, exercising, learning to regulate one's own mindset, and maintaining personal hygiene. In addition to improving diet, pay attention to light food, avoid eating food containing estrogen, and maintain a regular lifestyle, and pay attention to a combination of work and rest. Pay attention to mood regulation, avoid tension, excitement, anger, and so on. In daily life, you can do some slight exercises, such as walking, to enhance the body's immunity. Pay attention to menstrual hygiene, keep warm, and avoid sexual life during menstruation. Avoid taking hormone drugs or using beauty products containing hormones.

　　If the patient is young and the symptoms are not severe, they can be observed and treated symptomatically. Progesterone, androgen, cotton phenoxy, and other medications can alleviate symptoms. For those with severe symptoms or who do not need to retain reproductive function, hysterectomy can be performed to preserve the ovaries as much as possible. If there is also pelvic endometriosis, the lesions should be removed as much as possible to preserve ovarian function, so that the patient can approach natural menopause. Those who wish to have children can use hormone therapy for 6 to 12 months, and stopping the medication may hope to become pregnant in the short term. If it is found during surgery, consideration should be given to removing the adenomyoma while preserving the uterus. 1. Symptomatic treatment: For those with mild symptoms who only require relief of dysmenorrhea, especially those in the perimenopausal period, non-steroidal anti-inflammatory drugs can be used for symptomatic treatment during dysmenorrhea. Because the ectopic endometrium will gradually atrophy after menopause, such patients will be relieved of pain without surgical treatment after menopause. 2. Pseudo-menopausal therapy: 'Pharmacological oophorectomy' or 'pharmacological pituitaryectomy' can bring the body's hormone levels to the state of menopause, causing the ectopic endometrium to gradually atrophy and play a therapeutic role. Generally, the serum estrogen level in the body reaches castration level within 3-6 weeks after taking the medicine, which can alleviate dysmenorrhea. And after the application of GNRHa, the uterus can be significantly reduced, which can be used as preoperative medication for some patients with large lesions and difficult surgery. After the uterus is reduced, the operation will be much safer and easier. However, the long-term use of GNRHa may appear menopausal symptoms, even leading to serious cardiovascular and cerebrovascular complications and osteoporosis. Once the medication is stopped, the return of menstruation may lead to the recurrence of the lesion. Therefore, GNRHa is often used as a drug of choice for preoperative reduction of lesions and postoperative reduction of recurrence. 3. Pseudo-pregnancy therapy: Some scholars believe that oral contraceptives or progesterone can cause the ectopic endometrium to degenerate and atrophy, thus controlling the development of adenomyosis. However, some scholars believe that the ectopic endometrium of adenomyosis is mostly basal endometrium, which is not sensitive to progesterone. Therefore, the efficacy of progesterone (oral contraceptives) in the treatment of adenomyosis is still controversial.