adenomyosis

Our outpatient clinic for uterine adenomyosis
In response to a large number of inquiries regarding uterine adenomyosis and conservative surgery (which is designed to avoid harm, with less possibility of benefit than more risky actions), we opened an outpatient clinic specialized for uterine adenomyosis in May 2005. In October 2005, the treatment method we proposed, “enucleation of uterine adenomyosis using a high-frequency resection device”, was accepted as the first subject of “Advanced Treatment
http://www.mhlw.go.jp/topics/bukyoku/isei/sensiniryo/index.html
by Ministry of Health, Labor and Welfare of Japan, and was approved for practice at our clinic.

Here is some information about uterine adenomyosis.

1.What is uterine adenomyosis?

A type of tissue called uterine endometrium, which covers the inner surface of the uterus, repeats a cycle of growth and exfoliation through the action of female hormones (estrogen and progesterone) secreted by ovaries. Menstruation occurs when this tissue sheds off. It is not problematic if the endometrium stays inside the uterus, but it sometimes develops in other sites. The commonest site is the ovaries. If endometrial tissue develops in an ovary, the same phenomenon as menstruation occurs and blood accumulates in the organ. As the old blood gradually pools, the ovary becomes swollen and adhesion occurs with surrounding organs such as uterus, peritoneum and rectum, causing menstrual pain. This disease is called uterine endometriosis (hereinafter, referred to as endometriosis). The swelling of the ovary is called a chocolate cyst as the old blood accumulated in this condition looks like chocolate.

The cause of endometriosis is unknown. There are two hypotheses; the first is that menstrual blood flows backward into the peritoneal cavity through the fallopian tube, and the endometrium contained in the blood attaches to the ovary tube and proliferates; the second is that a part of ovarian tissue changes into endometrium for some reason. The endometrium which develops at sites other than the inner surface of the uterus is called ectopic endometrium. It can also develop in the uterine muscle and in such cases is called uterine adenomyosis (hereinafter, referred to as adenomyosis). Endometriosis which develops outside the uterus used to be called external endometriosis, and endometriosis which develops inside the uterus was called internal endometriosis. However, considering that these two diseases develop in completely different ways, it is not appropriate to call them by the same name, and internal endometriosis is now called uterine adenomyosis. Therefore, uterine adenomyosis is not a rare disease and has always existed, although the name itself is new and hence not yet well known. The mechanism of development of adenomyosis is different from endometriosis in that, for some reason, the normal uterine endometrium moves deep inside the uterine muscle. Intense menstrual pain is induced when the depth exceeds 80% of the uterine muscle thickness. Usually, the entire uterus grows and the amount of menstruation increases.

2.Symptoms of uterine adenomyosis

The pain induced by adenomyosis is very intense. For instance, if we ask patients to rate the strength of their menstrual pain on a scale of 0-10, with 0 being no pain and 10 being the worst pain that they can imagine, most of them say “10”. Moreover, the menstrual pain is nothing like the one that they have had since their teenage years; rather, it develops suddenly. For instance, it may develop after passing 30. A patient may say “the pain started to develop since menstruation in summer two years after delivering a child”.

In cases of severe adenomyosis, the pain may not be confined to the lower abdomen but may radiate into the legs or may be felt as anal pain. In addition, the amount of bleeding in one menstruation period is so large that it could induce severe anemia. Moreover, adenomyosis greatly affects fertility (potential to become pregnant); this makes it harder for the patient to become pregnant, or makes the patient more prone to miscarriage even if she becomes pregnant. Since female hormones stimulate the disease progress, the symptoms will continue to worsen until menopause unless otherwise treated.

3.Classifications of uterine adenomyosis

There are several classifications for uterine adenomyosis. It is generally invading surrounding tissues with unclear demarcation, but it may also develop a nodule form in which a solid mass of adenomyosis is formed locally as uterine fibroids. This nodule may contain some old blood at the center, which is just like chocolate cysts in ovaries. This type of adenomyosis is called cystic adenomyosis. Due to the small lesion, it is more difficult to make a diagnosis compared to the focal or diffusion-type adenomyosis and is often missed. However, the menstrual pain and other symptoms are as severe as those in chronic adenomyosis; therefore, doctors must pay particular attention as a patient presenting at the obstetrics and gynecology clinic complaining of severe menstrual pain may appear normal on examination.

Uterine adenomyosis can be also classified according to the location. It is called focal adenomyosis when it develops at particular parts of the uterus such as the anterior or posterior wall. On the other hand, when adenomyosis develops throughout the entire uterus, it is called diffuse adenomyosis. These classifications are important as we select the type of operation according to the classification when performing enucleation of adenomyosis.

4.Treatment methods of uterine adenomyosis

Uterine adenomyosis can be treated either by a surgical method (surgical therapy) or by drug treatment (drug therapy). The drug therapy is mainly a hormone therapy with analgesics (pain relievers) for menstrual pain. The hormone therapy can be effective in patients with uterine endometriosis. However, in patients with adenomyosis, few hormone therapies are effective. The exception is Danazol therapy, which can be effective on relatively small adenomyosis. Therefore, treatment methods such as Lupron or Suprecur which decrease blood female hormone levels may be ineffective; menstrual pain, which is temporarily controlled during the therapy as it induces amenorrhea (cessation of menstruation), will re-appear after the treatment. Contraceptive pills are used in some therapies, but these pills will never treat adenomyosis.

Currently, the standard surgical method for uterine adenomyosis is the removal of the uterus. As adenomyosis often develops in patients who have given birth, patients are usually willing to undergo removal of the uterus, which is not a vital organ. However, it may occur in women who have never been pregnant. Due to the increase in late marriage in women and incidence of adenomyosis itself in Japan, the demand for adenomyosis treatment in women who want to remain fertile has increased significantly. Considering this social background and the fact that, as mentioned earlier, there are hardly any drug therapies available for this disease, we have researched and developed enucleation of adenomyosis (removal of the lesion alone, leaving the uterus) for the past ten years.

5.Enucleation of uterine adenomyosis

Enucleation of a lesion is possible when the lesion can be clearly differentiated from the normal cells and can be separated mechanically. These two conditions cannot be applied in case of adenomyosis. It is too difficult to differentiate adenomyosis from normal uterine muscle by eye, and the location cannot be clearly identified at the time of surgery (1); the adenomyosis tissue has invaded normal uterine muscle deeply with no clear borderline, therefore it is impossible to separate it mechanically from the normal uterine muscle. Thus, traditional concepts of enucleation, which is performed using a scalpel and scissors as seen in the treatment of uterine fibroids, cannot be applied straightaway in enucleation of adenomyosis. New concepts need to be introduced to the operational style itself, including new methods to identify of the lesion, revision of the tools being used, and other factors.

Here are the new operational styles used at our clinic to address these two points.

*Identification of adenomyosis

Firstly, the most important thing with enucleation is to identify the location of the lesion precisely. A diagnosis of adenomyosis is made by patient’s chief complaint and physical findings, as well as transvaginal ultrasound image and CA125 level. The main location of the lesion can be found on the MRI image. However, upon surgical operation, it is difficult to precisely locate the borderline between the normal muscle layer and the adenomyosis lesion by eye. Therefore, we consider the hardness of the adenomyosis. As the adenomyosis tissue feels harder than normal uterine muscle, the location of the adenomyosis can be found by palpation. Hard parts found during palpation are indicators of adenomyosis. If there is no such hardness, the tissue is normal muscle Thus, adenomyosis can be identified very precisely with this technique especially when we decide the size of enucleation. In addition, through our surgical experience, we came to be able to differentiate adenomyosis from normal uterine muscle by the tone of the color on the resection surface obtained using a high-frequency resection device. Thus, we can now differentiate the lesion and its location precisely by palpation and inspection based on experience; the problem of locating the lesion has been resolved.

*Tools used to perform enucleation of adenomyosis

Secondly, we developed a resection tool which can be adjusted freely according to the complex distribution of the lesion. Initially, we performed enucleation of adenomyosis as a solid mass, as we do with fibroids. However, it is not possible to precisely dissect the borderline between the adenomyosis and normal muscle tissues with this method. Therefore, we used a newly introduced ring guide (special ring-tip type T), which is connected to the high frequency resection device (Dr. Shimodaira’s High Frequency Surgical Unit MGI-202) produced by Honest Medical Co., Ltd. The advantages of the ring guide are that resection and coagulation can be performed at the same time, and that resection is possible for all shapes, large or small, by changing the size of the ring guide. The use of this device allows us to perform careful enucleation of the adenomyosis lesion by searching for the borderline between the lesion and the normal muscle layer.

6.Types of operation

We use three operational styles according to the type of adenomyosis.

For nodular adenomyosis, we resect adenomyosis around the focal lesion and close the resected uterine muscle by suture (we call this method the classical technique).

For focal adenomyosis, we reconstruct the uterus into the normal shape after complete resection of the adenomyosis lesion (we call this method the type-I technique).

For diffuse adenomyosis, we vertically dissect the uterus in an asymmetrical manner as it is impossible to remove all the lesions. We resect the adenomyosis lesions of both sides from the resection surface and close the uterus to make it into one organ (we call this method the type II technique).

7.Results of uterine adenomyosis enucleation

We have performed 1,684 adenomyosis enucleations in this hospital: 1263 of these were cases of focal adenomyosis; 421 were cases of diffuse adenomyosis. Of these operations, 1,612 were recognized as “advanced treatment” (as of September 30, 2017). The mean age of the patients was 37.8 years old, in the range of 14 – 52 years old. The mean operation time was 148 minutes, in the range of 43 – 651 minutes. The mean amount of bleeding was 463 g in the range of 1-5596g. The mean amount of resected lesion was 150.5g, in the range of 1.4g-1595 g. Thirty-nine patients received a blood transfusion. No significant complications occurred. When the patients were asked about the intensity of the menstrual pain on the scale of 0-10 in order to compare the degree of improvement, the mean menstrual pain of 9.1 before the operations improved to 1.9 after the operations in 1,534 patients, whose menstruation restarted after operations and therefore it was possible to make a comparison. In addition, heavy menstrual bleeding improved in all cases. Two hundred and sixty-three patients became pregnant after their operation. The recurrence rate among patients who had received operations more than two years previously was 132 out of 1365 cases (9.7%). The following are testimonies of patients who were treated at this hospital.

Characteristics of our consultations

We have seven staff members at the clinic: Dr. Nishida, the houorary director of the hospital, Dr. Arai, the general manager, Dr. Ryota Ichikawa, the head of the department, Dr. Sakanaka, Dr.Itagaki, Dr. Kono, Dr. Yoshihito Ichikawa. Dr. Nishida and Dr. Arai are qualified as supervisory doctors of cytological diagnosis and specialize in gynecologic oncology. Dr. Nishida. Dr. Arai and Dr.Ryota Ichikawa are medical specialists of the Japan Society of Gynecologic Oncology. Dr. Arai has extensive clinical experience as the head of the gynecology department of the Ibaraki Regional Cancer Center. Dr. Nishida have been involved in development of enucleation (removal) of uterine adenomyosis, utilizing their excellent surgical skills. Dr. Ryota Ichikawa is specialized not only in gynecology but also in emergency medicine. Dr. Yoshihito Ichikawa works part-time and is in charge of familial oncology clinic. In addition, two residents are currently training in the obstetrics and gynecology department.

Out experiences in consultation

We performed 821 operations in 2016. Of these, operations for malignant tumors included 11 cases of radical hystectomy (the complete surgical removal of the uterus, parametrium, and uterine cervix along with the partial removal of the pelvic lymph nodes), 14 cases of modified radical hysterectomy (an extended hysterectomy in which a portion of the upper vagina is removed), 12 ovarian cancer operations, and 51 cases involving conization (excision of a cone of tissue, mucosa of the cervix uteri) of early-stage uterine cervical lesions. In radical hysterectomy, a nerve-sparing technique allows us to keep the risk of the post-operational urinary functional disorders to a minimum. In squamous cell carcinoma, ovaries are spared if the lesion is in or below the Ib stage; in some cases, ovary function is spared by transplanting the organs outside the irradiation field if the lesion is pedunculated. Ovaries are often spared, even in cervical cancer requiring removal of the uterus, by using chemotherapy concomitantly with the treatment. Radical treatment of ovarian cancer entails the removal of a vast area including the para-aortic lymph nodes (the lymph nodes around the aorta). In germ cell tumors in young patients, the main treatment is chemotherapy, sparing the uterus and ovaries. Malignant tumors are treated not only by surgery but also in combination with chemo- and radiotherapy. For chemotherapy, the most sensitive anti-cancer drugs are selected according to the organ of onset and to the type of the tissue concerned. In cases of advanced cancer, pre-operational chemotherapy, in which the patient receives chemotherapy before going through the operation, is actively performed in order to improve the prognosis.

In addition, 130 cases of simple hysterectomy mainly for uterine fibroids, 45 cases of enucleation of uterine fibroids, 56 cases of salpingo-oophorectomy and ovarian cyst enucleation for benign tumors and endometriosis, and 19 operations for genital prolapse have been performed, and all have a good prognosis.

Moreover, as Dr. Nishida, the hospital director, is one of the leading specialists in Japan for reproductive surgery (surgical operations of uterine fibroids/adenomyosis or cancer while sparing potential for pregnancy, or operations to induce pregnancy in infertile patients), 164 cases of enucleation of uterine adenomyosis, 16 uterine anomaly operations, 60 cases of endoscopic removal of uterine fibroids or endometrial polyps (TCR: transcervical resection), and 84 laproscopic operations have been performed.

For uterine anomaly, laparotomy (open procedure) is performed in all cases, applying the method best suited to each type of anomaly. Laparotomy is performed because post-operative pregnancy rate is higher and the risk for uterine rupture during postoperative pregnancy among other complications is lower with this technique compared to peritonioscopic or hysteroscopic operation. Dr. Nishida has performed around 130 operations to correct uterine anomalies. Of these, 93 patients had septate uterus (a uterus divided into two cavities by an anteroposterior septum), 15 had bicornuate uterus (a uterus that is more or less completely divided into two lateral horns as a result of imperfect union of the paramesonephric ducts), and 13 had unicornuate uterus (a uterus in which only one lateral half exists, the other half being undeveloped or absent). Post-operative pregnancy rate is 90% and successful live birth rate is about 75%, whether or not the patient had primary infertility or episodes of recurrent abortions, unless there is other cause for infertility.

We do not perform infertility treatment using gamete transfer techniques such as in-vitro fertilization or embryo transfer at our clinic. However, all other examinations and treatments, including artificial insemination, are available.

Last year, 252 patients gave birth at our clinic after the 28th week of pregnancy. Of these, 69 patients underwent cesarean section. Being a part of a general hospital, not only maternity patients without any complications, but also patients whose case has been complicated by gynecological diseases such as uterine fibroids or medical/surgical diseases and those with a precious child conceived through IVF treatment are well managed at our clinic with cooperation of doctors in other departments.

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