Adenomyosis, fibroids and endometriosis

Introduction

Good afternoon. Today we are going to talk about a pathology or a new problem of the uterus, which is not new as a pathology, but something else that we have not discussed, which is adenomyosis.

We have talked about endometrial polyps, we have talked about endometriotic cysts or dermoid cysts in the ovary, we have talked about myomatosis but this pathology is called adenomyosis. Remember #KnowIsPower.

Differences between fybroid (myoma), endometriosis and adenomyosis

Remember, we are going to talk about adenomyosis, adenomyosis is a problem of the uterus and also of the endometrium. We talked on many occasions that myoma is a degeneration of the muscle cells of the uterus, adenomyosis is an alteration, but of the endometrial cells, that is, I have my uterus and the central part, which is the endometrium, which month after month patient scales in a menstruation.

That endometrium only has to be inside the uterus but in some circumstances it sows through the tubes in the ovaries, in the bladder, in the uterus or at the back that are called the uterosacral or even in parts of the descending colon. and it is called endometriosis. They are small cells of the endometrium that migrate around the uterine or pelvic cavity and form adhesions or form inflammation. It must be remembered, endometriosis is a problem that can normally be hereditary or genetic, but it can also be acquired by our system or by our lifestyle, or our diet.

Adenomyosis is something very similar: the muscle of the uterus is normal, but what the endometrial cavity does is, it sows these little seeds that we called endometrial, but they infiltrate the muscle of the uterus and can apparently have a tumor. well delimited but when we enter into surgery we realize that there is no differentiation between the muscle of the uterus and this tumor or this adenomyotic pathology.

They will be able to observe it in the different surgeries that we are going to upload, but the difference between fibroids and adenomyosis is that the fibroid is a well-defined solid or soft cystic tumor, it has its capsule, it has where it starts, where it ends and where it merges with the uterine muscle. Not adenomyosis, adenomyosis is an infiltration as if it were a fungus or moisture, an infiltration of that endometrium towards the uterine muscle and when we begin to want to resect, we cannot find the limit between the capsule, the tumor and the muscle, so yes It is important to know and be prepared because sometimes we can confuse it even in the diagnosis of vaginal or abdominal ultrasound or even with a CT scan.

We have three cases, one of which is this one that we are going to present where the patient you do the ultrasound you see the differentiation, you see some cystic, hyaline, degenerative areas there in the ultrasound you do a tomography and it reports a degenerated myoma but when you go into surgery, you start to incise the muscle and you find that you cannot differentiate between the tumor and the muscle. This type of pathology of adenomyosis, the behavior is very similar to myoma, that is, there is growth of the tumor or the uterus, they are tumors that can sometimes reach large sizes between 10 or 12 centimeters when you do an ultrasound and also the main signs or symptoms of the patient is:

• Very significant menstrual pain called dysmenorrhea, significant menstrual bleeding called bleeding.
• Spotting between periods that are called metrorrhagia.
• There are patients who say “hey, it has grown and when I have sexual intercourse it bothers me” that this is called dyspareunia.

It is very important to know it and to differentiate it, however, even in surgery it is up to that point that we can realize that it is not a fibroid and it is an adenomyosis, as happened to us with this 36-year-old patient who also came with symptoms of anemia. because like fibroids, it causes hemorrhages and causes anemia due to important blood loss.

Surgery for adenomyosis

Good afternoon, we are going to start the fifth myomectomy of these seven days that have been very intense, she is a little patient who wrote to us via zoom, I did the consultation on skype and she has a myomatosis of large elements, in fact she already had the diagnosis, but 5 doctors have told her that they were going to remove her uterus, obviously she has a problem of moderate anemia because this fibroid is very large, look, it looks like a pregnancy of more or less 5 or 6 months. She has a uterus of approximately 16-18 cm but the fibroid measures approximately 12. We are going to start the surgery and little by little we are going to tell them, fortunately she already has a baby, but the desire for pregnancy is present, that is why we are going to do only the myomectomy.

Ok, we already inserted Alexis’ separator, I wanted to show you before we start because you can see what amazing blood vessels this fibroid has, here’s a big one, here’s another big one, obviously the tumor is more ovoid towards the lateral surfaces than it is for the abdominal fundic cavity, but we are going to infiltrate here and it will take a while to morcellate. Look, we managed to remove the uterus, this part here is the left part, there is an ovary inserted here, the tube. I just did a little clamping to prevent more bleeding, this is the other tube and the other round ligament and the ovary is on the back here.

The problem with this patient is that it seems to be an adenomyomatous degeneration, that is, it is adenomyosis which later continued to evolve and became myomatosis, but having adenomyosis, the difference between adenomyosis and myomatosis is that the muscle tissue… No there is a delimitation and it degenerates, so here we have the uterine cavity where the whole problem probably began, this red that we see here is the cavity and from there it grew towards the left lateral face of the uterus. We’re going to try to slice all of this part here, but as we’ve said many times, this is going to be just cytoreduction, we definitely can’t do a complete resection because there’s not a muscle or a fibroid if it’s not adenomyosis.

The musculature, rather, this is the serosa of the uterus, inside in theory it should be the musculature, but the musculature and adenomyosis do not have a limit, obviously look at how the uterus looks, it is still huge, thick, but this is a adenomyosis in which we are going to try to close and right now we will see why this uterus has not much remedy, it is a uterus that will surely cause adenomyosis again and it will grow again in all probability.

Conclusions.

Knowledge is Success, the most important thing is that they know that at Creafam we have a multidisciplinary group where the idea is to solve the problem. In surgery, we see how we were unable to dissect or completely remove the tumor for the sole reason that we do not have that limit that we call the border between the tumor and the muscle and we decided to do something called tumor reduction or tissue lysis or cytolysis. tumor, that is, we removed more or less 80% of the tumor, we closed this uterus again and here comes the important part of us who dedicate ourselves to reproduction:

First it is to solve the problem of adenomyosis making a reduction of the tumor, later it is necessary to do an important hormonal management during three or four months, which what it will do is that the uterus and the ovary are “resting” or “not working”. to cool down that tumor and finally assess whether it is possible for this patient to become pregnant, because unlike a fibroid where I remove a large tumor even if it injures and reconstructs the muscle in these adenomyosis patients we do not know how to recover that muscle and especially how it will recover the endometrial cavity to find out if a pregnancy is feasible or not, then call us #KnowledgeIsSuccess