Treatment of disorder
Dysmenorrhea is the status where pathological symptom is developed along with the menses during menstrual period. Symptoms like menstrual cramps, nausea, headache, jumpiness, and diarrhea are included.
Functional dysmenorrhea is called for no causative disease, and Organic menstrual difficulties is called for causative disease. Women’s three benign diseases, leiomyoma, endometriosis, and adenomyosis of the uterus are listed up as causative disease, and there are cases where they are multiply complicated.
Treatment is started with supportive care by analgesic drugs first, but in case of severe or endometriosis is developed, treatment with using low-dose estrogen, progesterone compounding agent (LEP agent) or levonorgestrel intrauterine system (LNG-IUS) are conducted. Although it is considered as functional dysmenorrhea, there is data where endometriosis exists or having high probability of developing endometriosis in the future so that it is important to consider vigorous treatment.
Uterus consists of muscle called as smooth muscle and endometrial membrane which fringes inner cavity, and Leiomyoma is a benign tumor (lump like clot) consists of smooth muscle tissue in Uterus. It is a highly common disease where 30 to 50% of 30s to 50s female have at least one tumor. There is a case where age 10s to 20s female has this tumor. Female hormone (Estrogen) has a relation with this tumor growth. It will gradually shrink small after menopause (approximately 10%), but never be disappeared naturally.
Leiomyoma is grouped in leiomyoma in the muscle layer, leiomyomas under the serous membrane, and mucosal leiomyomas (Fig.1). Its size and shape vary from rice-grain size to the one large enough to occupy interior of the pelvis and abdominal cavity. The growth of leiomyoma is hard to predict because there are several variations exist from the one which stays in small size, to the one gradually enlarged, or the one suddenly enlarged. Leiomyoma is a benign tumor so that it is considered as not become malignant, but it must pay attention for the merely case which is hard to distinguish from suddenly enlarged tumor or become suspicious with image diagnosis.
There is quite a lot of the case where no symptom has appeared even with leiomyoma has developed. But the common symptom is the change of menses. Menses amount increase, and sometime blood clot has appeared. Therefore, it often become anemia.
The next common symptom is a hypogastric pain and backache, and others are pain during intercourse, frequent micturition, difficulty in micturition (hard to get urine out), and there is a case where constipation is seen. In case of large leiomyoma, one can recognize by hand touch its own tumor from outside of body. There is a case where it becomes a cause for agenesis or abortion. Further as merely case, necrosis occurs inside of the leiomyoma (denaturalization), or acute stomachache has raised due to sub-serosa layer, which has a pedicle, causes the torsion. In large tumor, it becomes the cause of hydronephrotic kidney by the press from urine duct.
For the diagnosis of leiomyoma, it can relatively easily do by internal examination (palpation) or image examination (Echography, MRI). To differentiate this from adenomyosis of the uterus, MRI examination is useful. Uterine Mirror Inspection (possible at outpatients) is also useful for mucosal uterine leiomyomas. In case of mucosal uterine leiomyomas, there is a case that differentiation from ovarian tumor or another tumor may sometime be difficult.
Even though it is diagnosed as leiomyoma, follow-up can be possible in case if tumor is not large enough or if there is no subjective symptom or it is mild one.
Below listed are considered as necessary for the treatment, but it may change depend upon yes/no for future wish for pregnancy.
As for the leiomyoma treatment, drug therapy (analgesic drug, iron preparation) is performed for stomachache or anemia. For the age near menopause case, it is possible to stop menses by drug and to improve symptoms, but they are just tentative measures so that it is unable to make leiomyoma itself disappear by drug only. Also, at this moment, there is no drug available which prevent the upswell (growth) of leiomyoma for longer time.
In surgical treatment for conserving the uterus, there are Enucleate Myomectomy, Uterine Artery Embolization (UAE), Uterine Endometrial Ablation, Microwave Endometrial Ablation (MEA) available. As for the definitive operation, hysterectomy (complete removal, subtotal removal) is conducted. (Fig.2 For details of the surgery, please refer “Gynecological Surgery” section.)
It is important to consult with your primary doctor and decide the plan about whether treatment is necessary, or which treatment is the most appropriate one to yourself.
Fig. 1. Infestation site of Leiomyoma
Fig. 2: Treatment Map of Leiomyoma
Endometriosis is the disease which endometrial membrane (mucosal tunics) fringing uterus inner cavity is developed at external tissue of uterus (pelvic peritoneum, ovaria). Bleedings, inflammation and agglutination are repeated and grew and advanced at each time of menses.
The sites of predilection for endometriosis are peritoneum in the pelvis, ovaria, Douglas’ pouch, merely bladder, urinary duct, gut tract, umbilicus, surgical cut, or chest lining (rare site endometriosis).
The disease, that stomachache, backache, defecation pain, or pain during intercourse are affecting to daily life, study or work, is called as dysmenorrhea, and they can be seen in 90% of endometriosis patients. If there are dysmenorrhea, roughly 25% of the patients has endometriosis, and even there is no endometriosis, it is reported that the prognosis development provability becomes more than two times. It becomes a cause of the situation where pregnancy is difficult (agenesis) (30-40% of endometriosis).
Whether or not the treatment for endometriosis is necessary is determined in considering the degree of extensity or symptom condition (disease advancement level or existence or non-existence of ovarian chocolate cyst), symptom condition, with or without hope for pregnancy, or relation with agenesis, so on.
Treatment for leiomyoma is conducted primary by drug therapy, and it is important to understand leiomyoma is the chronic disease so that it require longer time treatment strategy. In drug therapy, there is a supportive therapy against the aching pain, and endocrine therapy effective for intimal disease itself. Purpose of endocrine therapy is, disappearance of endometriosis lesion, or inhibit to grow further, preventive measure for postoperative recurrence, but it has no treatment effect directly to infertility. Drugs are, low dose estrogen and progesterone compounding agent or synthetic progesterone hormone (Dinagest), GnRH Agonist.
There is a case where surgical treatment is necessary for Ovarian chocolate cyst or deep endometriosis. In the surgical operation which extract ovarian chocolate cyst only, it is expected to conserve ovarian function, but recurrence rate is high so that it is known recently to take low dose estrogen and progesterone compound agent or synthetic progesterone hormone (Dinagest) at postsurgical operation lowers the recurrence rate. Cancer of ovary may be developed from ovarian chocolate cyst (0.7%), therefore when patient has no wish for pregnancy for the age older than 40s, there is a case where ovariosalpingectomy (adnexectomy) is conducted. (Fig.3)
Fig. 3 Treatment for Endometriosis
Uterus Adenomyosis is a disease where tissues like endometrial grows at interstitial uterus, a wall of uterus, so that entire uterus or part of muscle coat is getting thicker, resulted in enlargement of uterus. The disease is grouped into “diffuse form” where adenomyosis spread over entire myometrium, and “localized form (tumor forming type)” which is limited to partial area (Fig.4). There is a case where Leiomyoma is complicated. Cause of the disease is not known at this writing. The peak age of onset is the age of late 30s to late 40s.
Symptoms are, menstrual cramp, epimenorrhagia or anemic condition, however pain itself is severe and there is a case that pain continues for few days after menses is finished. Tumor on uterus can be seen on most of the cases, differentiation from leiomyoma becomes necessary at diagnosis. Diagnosis is assumed from symptoms or pelvic observation and performs diagnostic imaging. Diagnosis can commonly made by echography, but MRI examination is the most effective.
For the enlargement of uterus is mild case, diagnosis is made as follow-up. Symptom will disappear at menopause.
In case symptoms like dysmenorrhea or excessive menses are severe, or in case enlargement of uterus is in high level, treatment is necessary. Drug Therapy treatment is primary supportive treatment first to keep symptoms down. Analgesic drug is used for pain but the combination usage of progestational agent (Dinagest or Mirena) is considered as well for enlargement of uterus is not so big. If there is an anemia, iron preparation is used.
It is difficult to cure adenomyosis of the uterus completely by drug, but there is a case where supportive therapy only be taken for the case of early menopause is expected, or there is a case where observes follow-up with dosing GnRH Agonist. \
It is difficult to cure adenomyosis of the uterus completely by drug, but there is a case where supportive therapy only be taken for the case of early menopause is expected, or there is a case where observes follow-up with dosing GnRH Agonist.
When symptoms are severe and patient is late 40s age, removal of uterus by surgery is considered as radical treatment. Surgery is made by abdominal operation or total hysterectomy by laparoscopic surgery. There is a case where supracervical hysterectomy, extract uterus main part (body area) only while neck of uterus remains, is selected. When there is no abnormality on ovary, it is remained primarily.Or there is a case where extirpation for removing adenomyosis focus is conducted for the case patient has strong wish for pregnancy and adenomyosis is the localized one. Alleviation of symptom is expected but when pregnant, there is a risk for hysterorrhexis.
Summary: Characteristics of women’s three benign diseases
|What disease?||Ectopic growth lesions of Ectopic endometrium||Growth lesions of ectopic endometrium in myometrium||Mass lesion by the growth of Uterine smooth muscle cells|
|Location of lesions||Ovaria, peritoneal membrane, Douglas’ pouch||Uterine corpus muscle layer Diffused type / Localized type||Entire Uterus Under serous membrane, inside of muscle layer, Beneath mucous membrane|
|Primary Clinical symptoms||Aching Pain / Agenesis||Aching Pain / Hypermenorrhea||Hypermenorrhea / anemia|
Leiomyoma and Adenomyosis
|Clinical Condition / Pathology||Uterine smooth muscle tissue well defined||Endometrial-like tissues, Diffused type or Unclear tumor formation boundary.|
|Peak Age of Onset||30s to 40s||30s to 40s|
|Symptoms||Hypermenorrhea||Menses pain, hyper menorrhea|
|Diagnosis||Echography and MRI are useful for diagnosis and differentiation.|
|CA125||Normal Value||High Value (higher than endometriosis)|
|Extraction of Focus(Removal)||Normally prepared||Difficult in diffused type|
|Uterine Artery Embolization||Effective as primarily||Effective but recurrence case are common|