ADENOMYOSIS

Adenomyosis is still a condition that leaves clinicians in dilemma regarding diagnosis and treatment. It is characterized by the penetration of the intrauterine tissue (endometrium tissue) into the muscle layer of the uterus, which thickens in each menstrual cycle and is removed by bleeding if there is no pregnancy. How the disease begins and what the triggering factors are is still unknown, but many theories are being discussed. To date, none of these theories has been proven.

80% of adenomyosis cases are seen above the age of 40. The incidence of adenomyosis confirmed by MR imaging is 1.3% under the age of 30, 2.6% between the ages of 30-33, and 13% between the ages of 34-37. It can be focal, that is, regional, or diffuse, that is, widespread.

The clinical diagnosis process begins with the suspicion of the disease. This suspicion develops in line with the clinical complaints of the patient. Complaints ; pain during menstrual period, pain during intercourse, pain outside of menstrual period for more than 6 months, excessive menstrual bleeding, intermittent bleeding, recurrent miscarriages, unexplained infertility, etc. are non-specific. In other words, these complaints can be seen in individuals who have other ailments other than adenomyosis. There is no specific complaint for adenomyosis. In women with complaints, ultrasound and MR (magnetic resonance) examinations are performed to try to diagnose. However, in the course of this disease, which has many subgroups, it is still debated which subgroup causes pain, bleeding and how much problem in reproductive potential, and there is no accepted standard.

The diagnosis of adenomyosis is traditionally made by examining all or part of the surgically removed uterus under a microscope in the pathology laboratory. Even in pathological examination, different diagnosis rates (between 10% and 88%) were reported among different pathologists.It can be overlooked, especially in the disease that is not common and has a regional location. Of course, since it is not possible to remove the uterus in every case and you have to protect the uterus in couples who want to have children, it has become essential for us clinicians to research and develop different diagnostic methods. For this purpose, different methods have been developed in the last ten years, classification criteria have been determined and studies have been designed in accordance with these. While determining the criteria, 2 or 3 dimensional ultrasound and MR (magnetic resonance) examinations were used. Uterine film (HSG) was not included in these examinations. In a uterine film examination performed in the presence of adenomyosis, you can observe the changes caused by the disease in the muscle layer of the uterus, but the presence of a normal uterine film does not mean that there is no adenmiosis.The diagnostic methods currently used in adenomyosis are as follows:

1- Endo-myometrial biopsy method performed during hysteroscopy: In this method, the uterus is examined with a hysteroscope instrument and a biopsy is taken from suspicious areas under ultrasound guidance. Its sensitivity and specificity were determined as 54% and 78% in the studies performed. It is not frequently used in the diagnosis of adenomyosis due to its low sensitivity and specificity and operational risks.

2- Transvaginal ultrasound: Today, 2 or 3 dimensional ultrasound examination is used first in the diagnosis of adenomyosis. Many international organizations have worked on the diagnostic criteria used and accepted by everyone in order to speak the common language and have determined 8 (eight) “ultrasound criteria”. These criteria, which were determined in 2015, were revised by FIGO (The International Federation of Gynecology and Obstetrics) in 2018. Unfortunately, the clinical significance and diagnostic validity of these eight ultrasound findings as a result of all these efforts have not been confirmed.It has not been confirmed which criterion is more important, which criterion is most closely related to the diagnosis of adenomyosis. In addition, the technology of the instrument used in ultrasound examination also varies according to the experience and perspective of the user. In a valuable study conducted in 2019, the rate of agreement among different doctors who performed 2D ultrasound for the diagnosis of adenomyosis was 69%, and this rate was 21% among those who performed 3D ultrasound.

3- Magnetic Resonance (MR): It is a secondary diagnostic method used in the diagnosis of adenomyosis. It is a relatively more accurate diagnostic method than ultrasound, as it can show the soft tissue better and has less difference of opinion among the examiners compared to ultrasound. However, its sensitivity varies between 70-93% and specificity between 86-93% in different studies.

4- Sonohysterography: By injecting fluid from the cervix into the uterus, the boundaries of the inner layer of the uterus are examined under ultrasound guidance.It is determined whether there is irregularity in these borders. It is not a valid diagnostic method on its own. Because it does not give information about the outer layer of the uterus, that is, the muscle tissue.

Even today, in the treatment of adenomyosis, there is no medicine specifically assigned to this disease, and there is no specific treatment for the disease. In addition, there is no guideline that determines the best method in the treatment of the disease. Progestins (intrauterine device containing norethindrone acetate, danazol, dienogest, levonorgestrel) used in cases with complaints such as bleeding and pain, birth control pills, non-steroidal anti-inflammatory pills, aromatase inhibitors, selective progesterone receptor modulators, oral GnRh tablets, valproic acid drugs help to regress the complaints, but these drugs cannot be used in someone who wants to get pregnant.There are studies showing that the success of pregnancy increases after the embryos obtained by in vitro fertilization are stored by freezing and the hormones are suppressed with long-term GnRh agonist needles in women who want to be pregnant, and after the transfer of these stored embryos/embryos into the uterus.

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