1 Sun-Wei Guo Shanghai OB/GYN Hospital Fudan University AdenomyosisSun-Wei GuoShanghai OB/GYN HospitalFudan University
2 Parsing the word…“Adeno-”: glands“myo-”: muscle“-osis”: condition
3 Adenomyosis Definition: A common gynecologic disorder A disorder that is characterized by the benign invasion of endometrial glands and stroma deep and haphazardly into the myometriumUsed to be called “endometriosis interna”A common gynecologic disorderwith a poorly understood pathogenesis
6 Symptomology a soft and diffusely enlarged uterus About 1/3 of women with adenomyosis are asymptomaticCyclic and non-cyclic pelvic painIntense debilitating pain all the time and/orAcute & increasing pain at menstration and ovulationStrong 'contraction' feel of uterusAbdominal crampsA 'bearing' down feelingPressure on bladderDragging sensation down thighs and legsAbnormal uterine bleedingHeavy bleeding and floodingLarge blood clotsProlonged bleeding i.e.; up to 8–14 daysSubfertilityHall mark:a soft and diffusely enlarged uterus
7 Two subtypes Focal adenomyosis Diffuse adenomyosis Less common: ~ 1/3 More common: ~2/3Diffusely spread throughout the uterusEven or unevensymmetric or asymmetric
8 Diagnosis Gynecological examination (not definite) Transvaginal sonography (TVS)Accuracy of ~85%Highly dependent on experienceMRISimilar to or slightly higher accuracy than ultrasoundLess dependent on experience
13 Diffuse adenomyosis.Sagittal T2-weighted image shows indistinct zonal anatomy. Widening of the junctional zone is clearly seen in the region around the distorted endometrium (arrowheads). The myometrium has decreased signal intensity with tiny spots of high signal intensity (arrows).
16 Epidemiology Incidence Prevalence Risk factors Unknown Mostly from women who underwent hysterectomyRanges from 14%-66%In our hospital, ~ 43%Risk factorsParity, age (older than those with endometriosis), number of abortions, endometrial surgery, endometrial hyperplasia, menorrhagia
17 Some known factsNo consensus on diagnostic criteria to define presence, depth of penetration, degree of extension, and configuration of adenomyosisMenorrhagia and dysmenorrhea are associated with severe forms of adenomyosisOften co-exists withEndometriosisUterine leiomyomas
19 Some considerations Drug treatment has a high rate of recurrenceSide-effectsHysterectomy can be very traumaticEspecially for women who still desire a family
20 Some known molecular aberrations Increased local production of estrogensIncreased production of proinflammatory cytokinesTNFalpha, IL-6, IL-8Increased gene and protein expression of COX-2Increased angiogenesisIncreased uterine contractility
21 Novel treatment on the horizon Histone deactylase inhibitorsValproic acidGnRH antagonistsAromatase inhibitors
23 QuestionsAs with eutopic endometrium, endometriotic lesions also experience cyclic bleeding. Some authors argue that by stopping bleeding, one can relieve endometriosis-associated symptoms. Does this argument has any merit at all? Why?
24 QuestionsMany endometriotic lesions are often found to contain fibrotic tissues. In fact, adhesion is one cause for pain.How do you think they come into being? Why?What would be the best approach to eliminate the fibrotic tissues? Why?
25 QuestionsIn many hospitals in China, traditional Chinese medicine (TCM) is practiced and for endometriosis in particular, TCM medications are prescribed to patients. However, a recent systematic review indicates that, despite well over 150 publications—all in Chinese journals, no affirmative conclusion can be reached regarding the efficacy, indications, and side-effects of TCM in treating endometriosis, due mostly to poor quality in study design, execution, analysis, or reporting.If you or your loved one had endometriosis, would you consider using TCM? Why?Why no single TCM study could show the efficacy of TCM?Why many physicians are still prescribing TCM even though there is no well-established evidence?Would ancient medicine books sufficient for the TCM practice?