The Effectiveness Of Different Therapeutic Strategies For Adenomyosis And Literature Review Of The Treatment Of Adenomyosis

BackgroundAdenomyosis is a benign but invasive growth gynecologic disease which often influences women in their premenstrual period.This disorder is characterized by the presence of endometrial stroma and glands in the myometrium,with the hypertrophy and hyperplasia of adjacent smooth muscle cells.Dysmenorrhea and menorrhagia are the common clinical symptoms of adenomyosis.Adenomyosis is an estrogen-dependent disease and the pathogenesis was unclear until now.the common therapeutic strategies were hormone therapy,surgery and combination of them,without sufficient evidence of the optimal strategy.ObjectiveTo compare the effectiveness of three treatment strategies,namely,conservative surgery,conservative surgery followed by gonadotropin-releasing hormone agonist(GnRH-a)treatment,and levonorgestrel-releasing intrauterine system(LNG-IUS)following GnRH-a treatment after conservative surgery for improvement of adenomyosis associated symptoms.Materials and methods193 patients diagnosed with adenomyosis through histopathology in Qilu Hospital of Shandong University,were recruited in this retrospective study.According to their therapeutic strategies,the patients were divided into three groups:conservative surgery(n=57,group 1),conservative surgery with GnRH-a(n=83,group 2)and conservative surgery with GnRH-a followed by LNG-IUS(n=53,group 3).Dysmenorrhea[Visual Analog Scale(VAS)scores],uterine volumes and pregnancies after surgery were used to evaluate the therapeutic effectiveness.ResultsAccording to the enrolled criteria and exclusive criteria,193 patients in total were recruited in this retrospective study.The patients' mean age was 38.74±4.56 years old(21-45 years old).The mean follow-up period was 38.54±16.43 months(13-72 months).The mean gravidity before surgery was 2.83±1.64.More than half(56.0%)of the patients had myoma and nearly half(47.2%)had menorrhagia at the same time.The adenomyosis lesion was presented at the posterior uterine wall more often than that at the anterior wall.The mean duration of surgery was 79.53±29.24 minutes.The mean estimated blood loss during surgery was 101.17±114.59ml,including 19 patients'blood loss were more than 200ml,who accompanied with heavy pelvic adhesion or enormous uterus.No statistical significance was found among groups about the mean age,follow-up period,gravidity before surgery,duration of surgery and estimated blood loss during surgery.All patients experienced statistically significant improvement in dysmenorrhea(VAS scores reduced from 7.30±1.47,7.15±1.77 and 7.35±1.42 to 0.67±0.59,0.30±0.48 and 0.24±0.54 in groups 1,2,and 3,respectively,p<0.0±at the 6th month after surgery,and the VAS scores were maintained at a low level throughout the whole follow-up period.The VAS scores in group 1 were significantly higher than the other groups(P<0.05).There were 25 patients who had dysmenorrhea recurrence,and the mean recurrent time was 35.08±13.19 months(12-59 months,and 31.43±11.16 months,33.00±12.46months and 51.50±10.47 months in group 1,2 and 3.The mean recurrent time had no statistical significance between group 1 and group 2(p>0.05),but both were significantly higher the group 3(P<0.05).Recurrent rates were 24.56%,8.43%and 7.54%in group 1,group 2 and group 3,respectively.The recurrent rates in group 2 and group 3 were significantly lower than that in group 1(P<0.05),without statistical significance between these two groups(P>0.05).The uterine volumes significantly decreased from 249.83±129.70ml,306.32±241.20ml and 250.68±128.92ml to 84.86±19.84ml,81.72±25.42ml and 82.98±25.92ml in groups 1,2,and 3,respectively,(p<0.05)at the 6th month after surgery,and were maintained at a low level until the 36th month.There were 9 patients conceived after surgery,including 1 in group 1 and 8 in group 2.Conclusion1.Conservative surgery was an effective option with good safety for patients with symptomatic adenomyosis,regardless of treatment maintenance after surgery.2.GnRH-a treatment following surgery can reduce the recurrent rate of dysmenorrhea and can improve the infertility caused by adenomyosis,but was ineffective for shortening the recurrent time.3.Insertion of LNG-IUS after completing the injection of GnRH-a after surgery can significantly reduce the recurrent rate and significantly prolong the recurrent time of dysmenorrhea in patients with adenomyosis.