User:DHCopeland/sandbox

This is my sandbox to prep large sections of editing on the Adenomyosis page.

Diagnosis

Hysterectomy

At hysterectomy, often the uterus is enlarged globally, and the surface is smooth. When cut in half, the cut surface often appears spongy with areas of focal hemorrhage

Management

Adenomyosis can only be cured definitively with a hysterectomy or surgical removal of the uterus. As adenomyosis is responsive to reproductive hormones, it reasonably abates following menopause. In women in the reproductive years, adenomyosis is merely managed: the goal is to provide pain relief, to restrict progression of the process, and to reduce significant menstrual bleeding.

Medical management

• NSAIDs: Nonsterioidal anti-inflammatory drugs, such as ibuprofen and naproxen, are commonly used in conjunction with other therapies for pain relief. NSAIDs inhibit the production of prostaglandins by decreasing the activity of the enzyme cyclooxygenase. Prostaglandins have been shown to be primarily responsible for dysmenorrhea or the cramping pelvic pain associated with menses.

Hormones and hormone modulating treatments

• Levonorgestrel-releasing intrauterine devices or hormonal IUDs are an effective treatment for adenomyosis. They reduce symptoms by causing decidualization of the endometrium, reducing or eliminating menstrual flow. Additionally, by helping downregulate estrogen receptors, hormonal IUDs shrink the clusters of endometrial tissue within the myometrium. This leads to reduced menstrual blood flow, helps the uterus contract more properly, and helps to reduce the menstrual pain. The use of hormonal IUDs in patients with adenomyosis have been proven to reduce menstrual bleeding, improve anemia and iron levels, reduce pain, and even result in an improvement of adenomyosis with a smaller uterus on medical imaging. In patients that can tolerate them, the use of hormonal IUDs to treat adenomyosis, as compared to hysterectomy, result in equivalent comparing the treatment of adenomyosis with hormonal IUDs
• Oral contraceptives reduce the menstrual pain and bleeding associated with adenomyosis. This may require taking continuous hormone therapy to reducing or eliminating menstrual flow. Oral contraceptives may even lead to short term regression of adenomyosis.
• Progesterone or Progestins: Progesterone counteracts estrogen and inhibits the growth of endometrial tissue. Such therapy can reduce or eliminate menstruation in a controlled and reversible fashion. Progestins are chemical variants of natural progesterone.
• Danazol (Danocrine) and gestrinone are suppressive steroids with some androgenic activity. Both agents inhibit the growth of endometriosis but their use remains limited as they may cause hirsutism and voice changes.^{[medical citation needed]}
• Gonadotropin-releasing hormone (GnRH) agonists: These drugs are thought to work by decreasing hormone levels. A 2010 Cochrane review found that GnRH agonists were more effective for pain relief in endometriosis than no treatment or placebo, but were no more effective than danazol or intrauterine progestagen, and had more side effects than danazol.
• Aromatase inhibitors are medications that block the formation of estrogen and have become of interest for researchers who are treating endometriosis.
• Gonadotropin releasing hormone (GnRH)-analogues, Danazol, uterine embolization and endometrial ablation have been tried in order to relieve adnomyosis related symptoms and show some effect, but the studies are few in number, mainly with a retrospective study design and have small sample sizes. Long-time use of GnRH-analogues is often associated with heavy side effects, loss of bone densitiy and increased risk of cardiovascular events, and therefore not feasible for young women. Furthermore, all present treatment options are irrelevant options for women trying to conceive. Exogenous progestogenic treatments have been found to be ineffective. In IVF-settings long down-regulation prior to IVF might have a positive effect on pregnancy rates.

Aromatase Inhibitors

Surgical management

Broadly speaking, surgical management of adenomyosis is split into two categories: uterine-sparing and non-uterine-sparing procedures. Uterine-sparing procedures are surgical operations that do not include surgical removal of the uterus. Some uterine-sparing procedures have the benefit of improving fertility or the ability to carry a pregnancy to term. In contrast, some other uterine-sparing procedures may worsen fertility or even result in complete sterility. Non-uterine-sparing procedures, by definition, include the surgical removal of the uterus and consequently they will all result in complete sterility.

Uterine-Sparing:

Uterine Artery Embolization (UAE): This minimally-invasive procedure intentionally blocks the two uterine arteries in order to dramatically reduce the blood supply to the uterus. By doing so, there is insufficient blood and thus oxygen present for the adenomyosis to develop and spread.  57-75% of women who undergo UAE for adenomyosis typically report long-term improvement in their menstrual pain and bleeding. However, treatment fails with recurrence rate of 35%, and UAE has the risk of causing major complications in 5% of women who undergo the procedure. Major complications include infection, hemorrhage, and needing an additional unexpected surgery. UAE has also been shown in some cases to reduce ovarian function. Finally, 26% of women who undergo UAE ultimately require a hysterectomy.

Myometrium or Adenomyoma resection (Adenomyomectomy):

Requires focal spot, diffuse works less well. Successful 50%. Laparoscopic. Can be a difficult surgery. Significantly improves menstrual pain and bleeding. Can result in improved fertility with pregnancy rates as high as 78% with successful delivery occurring in as many as 69%. BUT increased spontaneous abortion rate (as high as 39% of pregnancies) which is higher than the general population. This is likely due to increased scar tissue formation after the surgery.

Myometrial electrocoagulation

Myometrial reduction

MRI-guided focused ultrasound surgery

Endometrial ablation:

Endometrial ablation techniques result in sterility and therefor are suitable only for women who have completed their childbearing. The techniques either include physical resection and removal of the endometrium through a resectoscope, or focus on ablating or killing the endometrial layer of the uterus without its immediate removal. Each method has risk and benefits but the efficacy may be reduced if the adenomyosis is too widespread or deep. Indeed, deep adenomyosis may become trapped behind the scarred region that was ablated, leading to further bleeding and pain. And, resection is commonly limited to relatively shallow adenomyosis as significant bleeding may result from large arteries that are present 5 mm deep within the myometrium. As such, endometrial ablation and resection techniques are most appropriate for shallow adenomyosis.

Non-hysterscopic: These techniques do not require a hysteroscope, are relatively fast, and many can be performed as an outpatient procedure.

High-energy radio-frequency: Using a small expandable mesh placed within the uterus, providers use high-energy radio waves to ablate the endometrium.  

Thermal Ballon: Using a thin expanding ballon placed within the uterus, providers can apply heated fluid and ablate the endometrium. This procedure has been shown to result in amenorrhea or complete cessation of menstrual bleeding for 12 months in 23% of patients. 16% of patients eventually experience treatment failure with pain or bleeding requiring additional treatments or a hysterectomy. Women older than 45, with milder adenomyosis were more likely to experience successful amenorrhea following the procedure. In contrast, women younger than 45, multiple childbirths, a prior tubal ligation, and/or a history of menstrual pain were more likely to experience treatment failure.   

Cryo-endometrial ablation: Using a small probe, providers can directly apply sub-zero temperatures within the uterus to freeze and ablate the endometrium.

Circulating Hot Water: Heated water directly introduced into the uterus and is used to thermally ablate the endometrium.

Microwave: Using a small probe, a provider uses microwave energy to ablate the endometrium.

Hysteroscopic-

Wire-loop resection: Under direct visualization through a hysteroscope, an electric current is passed across a wire loop instrument that permits a provider to ablate the endometrium in strips.

Laser ablation: Under direct visualization through a hysteroscope, laser beams are used to vaporize and ablate the endometrium.

Roller ball ablation: Under direct visualization through a hysteroscope, current is passed through a metallic round ball across the surface of the endometrium. This has been shown to have a coagulative effect to the depth of 2-3 mm into the myometrium. This destroys the endometrium and the nearby expanded dysfunctional smooth muscle. Deeper adenomyosis escapes this coagulative effect.

Non uterine-sparing / Hysterectomy

Vaginal, Laparoscopic, abdominal, and laparoscopic assisted.

Removal of the uterus (hysterectomy) is the most effective treatment of women suffering from adenomyosis and the only causal therapy.

Conservative symptomatic treatment often consists of anti-inflammatory medications, such as ibuprofen or other NSAIDs.

Surgical options may include endometrial ablation, laparoscopic myometrial electrocoagulation and adenomyoma excision. These have demonstrated positive results in several studies, though long-term data is lacking. A non-surgical procedure, uterine artery embolization may also be used to block the blood supply to the uterus. High frequency ultrasound surgical ablation is also being explored as a treatment for both focal and diffuse forms of adenomyosis over complete hysterectomy. Hysterectomy may be warranted in some cases where fertility is not desired, and all other treatments have failed.