Endometriosis of the uterus (adenomyosis). Adenomyosis is a form of genital endometriosis in which heterotopies of endometriotic tissue are found in the myometrium.
Macroscopically, endometriosis of the uterus body is manifested by its dispensation, myometrial hyperplasia. In the area of endometriosis, the appearance of cystic cavities with hemorrhagic contents or the formation of nodal elements with the predominance of stromal endometriotic tissue.
Adenomyosis can be diffuse, focal or nodular. According to the existing classification, internal endometriosis of the uterus is divided into the following stages:
Stage I – germination of the mucous membrane to the myometrium (the pathological process is limited to the submucosa of the body of the uterus);
Stage II – damage to the middle of the myometrium thickness;
Stage III – lesion of the endometrium to the serous cover;
Stage IV – involvement in the pathological process, except for the uterus, parietal peritoneum, pelvis and adjacent organs.
Clinical picture. The leading symptom of the disease is algodysmenorrhea. Menses are profuse and prolonged. Pathognomonic appearance of spotting dark blood discharge 2-5 days before and after menstruation. With common forms of adenomyosis, uterine bleeding occurs during the intermenstrual period (metrorrhagia). Patients with adenomyosis often develop post-hemorrhagic anemia and all manifestations associated with chronic blood loss.
Pain syndrome develops gradually; with endometriosis, pain is expressed in the first days of menstruation (algomenorrhea). In order to determine the localization of endometriosis, the irradiation of pain is taken into account: if the corners of the uterus are affected, pain is given to the corresponding inguinal region, and in case of endometriosis, the uterus isthmus – into the rectum or vagina. As a rule, with the end of menstruation, the painful sensations disappear or significantly weaken.
Diagnostics. After collecting the history and physical examination, a two-handed gynecological examination is carried out; more informative it is on the eve of menstruation. Depending on the severity of adenomyosis, the size of the uterus may be in the normal range or correspond to 5-8 weeks of pregnancy. The size of the uterus after menstruation, as a rule, decreases.
With the defeat of the isthmus of the uterus marked its expansion, increased density and tenderness during palpation, especially in the area of attachment of the sacro-uterine ligaments. Morbidity is expressed on the eve, during and after menstruation. In addition, often with the defeat of the isthmus of the uterus, there is a restriction of its mobility and increased pain when the uterus moves forward.
Ultrasound sonography. For a detailed assessment of the structural changes in the endometrium and myometrium, ultrasound is used using transvaginal sensors; the accuracy of diagnosis of endometriosis exceeds 90%.
Echographic signs of adenomyosis are an increase in the anteroposterior size of the uterus, the uneven thickness of its walls. Endometriosis is characterized by a change in the structure of the myometrium with the appearance of the “honeycomb” symptom (alternation of echo-dense areas and small liquid inclusions; Fig. 13.1). The nodular form of endometriosis is reflected in the sonograms by a zone of increased echogenicity of a round or oval shape, with uneven and fuzzy contours. In the focal form of adenomyosis, the cystic component prevails in the affected area with perifocal consolidation.
To increase the informativeness of ultrasound in the diagnosis of primary forms of adenomyosis, Gyrosondography (GHA) is used. In adenomyosis, small (1-2 mm) hypoechoic inclusions are observed in the basal layer of the endometrium. The thickness of the basal layer of the endometrium is uneven, in the subepithelial layers of the myometrium separate areas of reduced echogenicity are detected.
In adenomyosis, the use of an X-ray hmsography remains effective. On radiographs, the area of the uterus is increased, the deformation and the jagged edges of the uterine cavity are determined. During contrasting, the endometrioid heterotopies are filled in, which makes it possible to identify the contour shadows in adenomyosis.
The diagnostic value of hysteroscopy reaches 92%. Hysteroscopic signs of adenomyosis depend on its shape and severity. The prevalence of adenomyosis reflects its hysteroscopic classification.
Stage I – the relief of the walls is not changed, the endometrioid passages are determined in the form of dark-blue “eyes” or open bleeding passages. The walls of the uterus when scraping normal density.
Stage II – the relief of the walls of the uterus is uneven, has the appearance of longitudinal or transverse ridges or fibrous muscle tissue, endometrioid passages are visible. The walls of the uterus are rigid, its cavity is poorly stretchable.
Stage III – on the inner surface of the uterus, protrusions of various sizes are determined, without clear contours. On the surface of these protrusions, open or closed endometrial passages are sometimes visible. When scraping the wall of the uterus is rigid, uneven and ribbed.
This classification is important for the choice of treatment tactics. The absence of endoscopic signs of adenomyosis does not exclude the foci and nodes of adenomyosis in the interstitial and subserous parts of the myometrium.
The diagnostic value of MRI exceeds 90%. Diagnosis is based on an increase in the anteroposterior size of the uterus, identifying the spongy structure of the myometrium with a diffuse form and nodal deformity with focal and nodular forms of adenomyosis.