Managing adenomyosis


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Managing adenomyosis

  1. 1. MANAGING ADENOMYOSIS ? a dilema……………. narendra malhotra jaideep malhotra neharika malhotra AGRA
  4. 4. What is Adenomyosis?The penetration and growth of endometrial tissue fromthe uterine lining into the myometrium (uterine muscle) iscalled adenomyosis or internal endometriosis. Thisdisease may coexist with external endometriosis in whichendometrial implants are located outside the uterus. Theabnormally located endometrial tissue, like the normalendometrium, tends to bleed with the menses. The bloodand debris may accumulate in these misplaced glandscreating small fluid collections inside the uterine wall. Thispenetrating and functioning endometrial tissue may leadto swelling; the uterus may become larger and globular.Adenomyosis may present as a diffuse condition or it maybe focal. In the latter, there are local areas of swelling, so-called adenomyomas, that may mimic other uterinemasses.
  5. 5. Definitionadenomyoma describes a focus of adenomyosis within a leiomyoma (fibroid). Both conditions are common so it is not surprising that this overlap condition may occur.
  6. 6. DefinitionThe gland tissue grows during the menstrual cycle and then at menses tries to slough, the old tissue and blood cannot escapeThis trapping of the blood and tissue causes uterine pain in the form of monthly menstrual cramps.It also produces abnormal uterine bleeding.
  7. 7. The typical symptoms include • Pelvic pain, • Dysmenorrhea, • And menorrhagia unresponsive to hormonal therapy or uterine curettage. • Subfertility.And pregnancy termination.classic presentationCyclic, cramping uterine pain beginning later in reproductive life(generally after age 35) and often associated with prolonged andheavy menses
  8. 8. Pelvic painIn studies of chronic pelvic pain in which women had hysterectomies, the incidence of adenomyosis is about 15% to 25%
  9. 9. 111 specimens of uteri and cervices17 with 19 with 39 with 36 withadenomyosis adenomyosis with leiomyomas neither.alone leiomyomas alone from patient records the pregnancy terminations rate was: 58.8% 47.4% 20.5% 22.2% Levgur M, Abadi MA, Tucker A.2000 May
  10. 10. ADENOMYOSIS vs FIBROIDS• Most commonly adenomyosis is mistaken for another common condition, uterine fibroids. There is however a fundamental difference between a fibroid (a distinct tumor) and adenomyoma. Each fibroid originates from one abnormal cell. Under the effect of estrogen this cell multiplies. The growing tumor may displace and compress tissues but it does not invade the surrounding uterine muscle. Because of this growth pattern of fibroids, it is possible to remove all of the tumor without removing any normal uterine tissue during myomectomy (surgical removal of fibroids). In contrast, adenomyoma is not a discrete tumor but rather a local swelling of the uterine wall as a result of the penetration of endometrial tissue. Therefore it is not possible to remove tissue affected by adenomyosis without actually removing the involved uterine muscle.
  11. 11. DefinitionAdenomyosis is a benign disease of the uterus characterized by ectopic endometrial glands and stroma within the myometriumIt is associated with myometrial hypertrophy and may be either diffuse or focal.
  12. 12. Diagnosis (Discepoli S, Leocata P, Giangregorio F).examined 1500 surgical bits had been histologically examined.. In all they have found 310 cases of adenomyosis (20,6%); The diagnosis can only be proven by the pathologists A good gynecologist may suspect adenomyosisbased on the clinical factors, but the final diagnosisusually has to wait until hysterectomy is performed
  13. 13. Pelvic examthere may be uterine enlargementfrom about 6-10 weeks pregnancysizeThe uterus can feel soft and boggyon pelvic exam. Sometimesadenomyosis is associated withuterine fibroids (leiomyomata)repeated bimanualexaminations, over severalmonths, just before and aftermenstruation have beenrecommended to detect fluctuatingchanges in contour, size andconsistency of the uterus
  14. 14. Sono-Hysterography the presence of ill defined areas of contrast intravasation extending perpendicularly from the uterine cavity into the myometrium isThe most characteristic feature of adenomyosis on hysterography. Unfortunately, the sensitivity of this technique is too low for clinical practice.
  15. 15. HysterographyFilling of cavities in the uterine wall during hysterography was observed in 54 of 320 surgically excised specimens in which metal threads had been inserted at different levels for identification.Adenomyosis may have accounted for these cavities in 24%. True adenomyomas (encapsulated) are uncommon tumors of the uterus. At hysterosalpingography, detection of Radiological Society a network of fine channels in a very of North America , well-circumscribed area of the Radiology, Vol myometrium, connected with the 118, 581-586,1976 uterine cavity, allows a preoperative diagnosis
  16. 16. Myometrial biopsy laparoscopically or sonographically guided
  17. 17. Myometrial biopsy laparoscopically or sonographically guideda larger study by Popp et al. who took not only needle biopsies immediately after hysterectomy but also at the time of laparoscopy as well as transvaginally under ultrasound guidance A single myometrial biopsy picked up only 8% to 19% of women with adenomyosis. The sensitivity of random needle biopsy is therefore too low for clinical practice.**Popp LW, Schwiedessen JP, Gaetje R. Myometrial biopsy in the diagnosis of adenomyosis uteri. Am J Obstet Gynecol 1993;
  18. 18. CA 125
  19. 19. CA 125 adenomyosis is associated with increased numbers of myometrial macrophages, elevated antiphospolipid auto-antibodies and CA 125 levels in peripheral blood.Ota H, Maki M, Shidara Y, Kodoma H, Takahashi H, Hayakawa M et al.. Effects of danazol at the immunologic level in patients with adenomoysis, with special reference to autoanyibodies: multicenter cooperative study. Am J Obstet Gynecol 1992; 167:481-6.
  20. 20. TVUSThe technique is strongly operator dependent
  21. 21. Transvaginal criteria (used separately or in combination)• • Uterine enlargement in the absence of leiomyomas• • Asymmetric enlargement of the anterior or posterior• myometrial wall• • Lack of contour abnormality or mass effects• • Heterogeneous, poorly circumscribed areas within the• myometrium• • Hyperechoic islands or nodules, finger-like projections or• linear striations, indistinct endometrial stripe• • Anechoic lacunae or cysts of varying size• Color flow low velocity low reisitance within the lesion
  22. 22. normal myometrium NORMAL(M), homogeneousechotextureThe subendometrial haloas athin hypoechoic band(arrows).The endometrium isuniformly echogenic
  23. 23. E = endometrium Adenomyosis myometrium is thickened ventrally and has a heterogeneous echotextureThe echogenicity of the ventral myometrium isdecreased relative to that of the dorsalmyometriummyometrial cyst (curved arrow).excentric endometrial cavitydecreased uterine echogenicity without lobulations, contourabnormality, or mass effects,
  24. 24. MRI
  25. 25. MRI CRITERIA• Focal or diffuse thickening of the junctional zone• • Low signal intensity uterine mass with ill-defined border• • Junctional zone thickness 12mm• • Poor definition of junctional zone border• • Localised high signal foci within an area of low signal• intensity• • Linear striations of increased signal radiating out from the• endometrium into the myometrium• • Bright foci in endometrium of similar intensity to the• myometrium (T1-weighted)• • Ratio of maximal junctional zone thickness to myometrium• thickness (ratiomax)
  26. 26. MRIMagnetic resonance imaging was superior to TVS for the diagnosis of adenomyosis.Magnetic resonance imaging had a higher specificity than TVS, but their sensitivities were in line.
  27. 27. MRIOn T2-weighted MRI, focal adenomyosis are seen in areas of abnormal low signal intensity within the myometrium in approximately 50% of patients. These foci correspond to islands of heterotopic endometrial tissue, cystic dilatation of heterotopic glands, or hemorrhagic foci.
  28. 28. MRIOn T2-weighted MRI, diffuse adenomyosis usually manifested as diffuse thickening of the junctional zone with homogeneous low signal intensity .T2-weighted imaging provided significantly better lesion detection than unenhanced or contrast material–enhanced T1- weighted imaging
  29. 29. A challenge……….• Adenomyosis poses a significant challenge in the management of infertile women• Hysterectomy is the only definitive treatment for women with adenomyosis but this is not an option for women who are infertile and keen to conserve the uterus
  30. 30. MANAGEMENT10 different options
  31. 31. Treatment• Advances in treatment have been limited by the difficulties in determining a clinical diagnosis and the lack of a specific intervention• Different surgical and medical modalities of treatment have been addressed in the literature but many of these have not been tested specifically for adenomyosis uteri.• In the absence of treatments directed at the disease itself, management is often directed at the symptoms.
  33. 33. Medical Approaches• As previously stated, a PROGESTERONES constant feature of medical CONTINOUS OCP therapy for adenomyosis is DANAZOL that, over the years, it has NSAID’S mimicked that which has been GnRh Analouges applied to endometriosis. At RU 486(MIFIPRISTONE) present, medical therapy of LNG-IUS adenomyosis can be attempted HIGH FREQ ULTRASOUND for symptomatic relief, especially in premenopausal women and in women who wish to become pregnant
  35. 35. MANAGEMENTThe only definitive treatment for adenomyosis is total hysterectomy, with or without ovarian conservation.
  36. 36. Is There Medical Treatment for Symptomatic Adenomyosis?• Frequently the moderately enlarged uterus is asymptomatic and no treatment is necessary. Temporary relief of very painful heavy periods can be achieved with GnRH agonists .• These medications cause a menopause-like state with complete cessation of ovarian function and menses, causing the abnormal tissue to shrink.• This temporary reversible state permits an anemic patient to restore a normal blood count, especially when iron supplements are prescribed.• However, GnRH agonists are not easy to tolerate, causing menopausal symptoms such as hot flashes.• Other consequences include weakening of the bones, alteration of the cholesterol profile (decrease in "good" cholesterol, HDL, and increase in "bad" cholesterol, LDL)• For these reasons, this type of medical treatment is usually limited to six months. Upon cessation of GnRH treatment, the painful heavy periods tend to resume.• GnRH agonists are also used to treat infertility associated with adenomyosis. There are a few anecdotal reports of successful pregnancies after a six to eight month course of GnRH agonists.• One should be aware that such treatment may be successful in mild cases of adenomyosis but may fail in more severe cases.• Progesterone is usually ineffective in the treatment of adenomyosis or, at best, is only temporarily and partially helpful.• Similarly, birth control pills are ineffective or only temporarily and partially helpful.• Levonorgestrel containing IUD helps relieve pain and heavy bleeding but only temporarily.
  37. 37. PAIN MANAGEMENT• (NSAID’s, or hormonal suppression with progesterone or GnRH agonists). Newer medical therapies such as mifepristone and the levorgestrel intrauterine system have been described but these are not compatible with ongoing fertility therapy.
  38. 38. Severe Pain and Heavy Menstrual Bleeding Due to Adenomyosis• B.B., a 40 year -old woman, was seen because of a history of ten years of severe menstrual pain and excessive bleeding lasting ten days of each month. She was obviously anemic. She had consulted many physicians, had several ultrasound studies and a laparoscopy. She was told that she had multiple fibroids and that a myomectomy was impossible; recently a physician had told her that any such attempt would be "a bloody mess" and inevitably result in hysterectomy.• On examination, her uterus was enlarged to the size of a 16 week pregnancy with a prominent swelling involving the upper uterus. On high resolution transvaginal ultrasound a nine centimeter "tumor" was identified, but its boundaries were ill- defined; the appearance suggested an adenomyoma more than a fibroid. The patient was told that if it was a fibroid it would be removed with an excellent chance that she would be able to conceive in the future. However, she was informed, if in fact surgery revealed an adenomyoma, resection would solve her medical problem but her uterus would be missing significant portion of its muscular wall, precluding future pregnancy. At surgery she was found to have adenomyosis, confirmed during surgery by a frozen section pathology evaluation. Therefore, an adenomyomectomy was performed with reconstruction of the remaining uterus. Blood loss was minimal and the postoperative recovery was smooth. One year later she reported that she has very light regular periods lasting three days. She has no pelvic pain.
  39. 39. Treating Adenomyosis with the Progesterone IUD LNG-IUS• Adenomyosis has been a frustrating disease to treat; medical treatment with oral progesterone or birth control pills often does not work and uterine artery embolization often fails. Hysterectomy is the only treatment known to be highly (100%) effective.• According to a recent study, the progesterone-containing IUD (Mirena) can help with menstrual cramping in about 70% of women.• The IUD probably works because it slowly gives off progesterone directly to the lining cells in the uterus and in the uterine muscle wall. Progesterone causes the cells to shrink and produce less prostaglandin, the protein that causes cramping.• The most common side effects from the IUD were weight gain (29%), benign ovarian cysts (22%) and lower abdominal pain (12%).If you have pain from adenomyosis, this IUD is probably worth considering.
  40. 40. Levonorgestrel-releasing intrauterine system In 1997, Fedele et al. utilized the levonorgestrel-releasing intrauterine system (LNG-IUS) for relief from adenomyosis-associated menorrhagia.In 23 women with recurrent menorrhagia and adenomyosis diagnosed with TVS, the insertion of the system induced amenorrhea in two, oligomenorrhea in three, spotting in two and regular flows in the remaining 16 women after 1 year. Significant increases in hemoglobin, hematocrit and serum ferritin were also observed. This small trial documented that the LNG-IUS produces the same positive effects on excessive bleeding also when adenomyosis is present.
  41. 41. Gonadotropin-releasing Hormone Analogues
  42. 42. • In 2002, Imaoka et al. investigated a possible role of gonadotropin-releasing hormone analogues for the treatment of diffuse adenomyosis, as evidenced by MRI. They administered the analogue over a 6-month period to 31 patients with MRI features suggestive of diffuse adenomyosis and concluded that use of gonadotropin-releasing hormone analogues is associated with a decrease in myometrium JZ width. Furthermore, asymmetric adenomyosis with high- signal intensity foci appears to be the most sensitive to hormonal therapy
  43. 43. • The medications GNRH agonists can cause cessation of the periods and associated menstrual cramping and even lead to shrinkage of the swelling associated with adenomyosis.• However, the effect is temporary-when the medication is discontinued, the symptoms return.• At the present time, the only treatment for adenomyosis is surgery.• In situations where the adenomyosis is confined to isolated areas in the muscle wall, an attempt may be made to surgically remove these areas and repair the rest of the uterus.• In situations where the majority of the uterus is affected, hysterectomy may be the only cure.
  44. 44. Fertility enhancement• As such, there are no specific procedures to enhance fertility specifically directed towards adenomyosis.• The therapeutic pathway for fertility management is not heavily influenced by the presence of adenomyosis.• Treatment protocols may need minor alterations.• If a woman requires assisted reproduction, one might consider downregulation with a GnRH agonist and using a long protocol (as opposed to daily GnRH agonist doses or antagonist protocols) to suppress disease activity before stimulation is begun.
  45. 45. Gonadotropin releasing hormone agonists in the treatment of adenomyosis with infertility (1) GnRH- agonists is efficient in reducing the adenomyotic uterine size, and may facilitate fertility. (2) For ademyomata associated with infertility, GnRH-alpha therapy may avoid the risk of rupture of uterus which may occur after adenomyomectomy pregnancy. (3) For infertility, GnRH-alpha treatment before laparoscopic surgery greatly decreases surgical difficulties and blood loss in certain cases.Obstetricts and Gynecology Hospital, Shanghai Medical University, Shanghai200011Zhonghua Fu Chan Ke Za Zhi 1999 Apr; 34:214-6
  46. 46. Can Uterine Artery Embolization Be Used to Treat Adenomyosis?• Only a small number of women with adenomyosis have been treated with uterine artery embolization (UAE),• and the results so far have been disappointing.• Symptoms appear to improve for a year or two, but most women then have recurrence of symptoms.
  47. 47. Uterine arterial embolization in the treatment of adenomyosis UAE is an effective and safe method inthe treatment of adenomyosis. BUT therecurrence rate is not yet evaluated.
  48. 48. Uterine arterial embolization in the treatment of adenomyosis UAE procedures were performed in 23 patients with adenomyosis. After treatment the symptoms and uterine volume of all patients were investigated.All clinical symptoms of 23 patients relieved.•Dysmenorrhea completely disappeared in 19 patients, significantly alleviatedin 2 patients. But in other 2 recurred.•The uterine volume shrunk significantly [(50 +/- 18)%] vs [(100 +/- 0)%].•The blood flow within the uterine and lesions detect by color doppler flowimaging decreased immediately after UAE.•Low-abdominal pain and slight fever were seen after treatment andrecovered within 1 - 2 weeks.Chen C, Liu P, Lu J, Yu L, Ma B, Wang J, Liu PZhonghua Fu Chan Ke Za Zhi 2002 Feb; 37:77-9
  49. 49. Uterine Artery Embolization• In 2001, Siskin et al. retrospectively evaluated the MRI appearance and clinical response of patients undergoing uterine artery embolization (UAE) for the treatment of menorrhagia due to adenomyosis. Of the 15 patients in the study, five had diffuse adenomyosis without evidence of uterine fibroids, one had focal adenomyosis without evidence of uterine fibroids and the remaining nine had adenomyosis with one or more fibroids. At 12 months follow-up, 92.3% patients reported significant improvement in symptomatology and quality of life. Postoperative MRI revealed significant reductions in median uterine and fibroid volume and mean JZ. Larger, prospective studies are needed to establish the safety and efficacy of this procedure in women with adenomyosis.
  50. 50. • Several reports followed, mostly from the Far East, which confirmed that UAE is an effective therapy for adenomyosis.• Worth mentioning is a South Korean study that investigated UAE in women with adenomyosis, but no fibroids.Several reports followed, mostly from the Far East, which confirmed that UAE is an effective therapy for adenomyosis.
  51. 51. Surgical Approaches• In a recent paper, Rabinovici and Stewart reviewed new interventional techniques that have been introduced over the last few years in order to find an adequate noninvasive therapy for adenomyosis.• They warn that there are no evidence-based data to guide us in using minimally invasive therapy, since most data regarding these evolving therapies come from the inadvertent treatment of adenomyosis in studies designed to treat uterine leiomyomata.• For this reason, all data are from case reports or small case series.• An additional problem is represented by the lack of an agreed imaging definition of adenomyosis, and so therapies that do not excise the uterus have no gold standard for comparison.
  52. 52. • New surgical procedures such as laparoscopic uterine artery ligation,• laparoscopic myometrial electrocoagulation,• high intensity focused ultrasound• and uterine artery embolization have all been proposed as therapies for adenomyosis.• These procedures are largely in the experimental phases.• Their impact on future fertility and the uterine integrity in case of electrocoagulation remains uncertain.• As such, they should not be considered as therapeutic approaches for women seeking fertility.
  53. 53. conservative surgery for adenomyosisThe conservative surgery for adenomyoma can reduce symptom and raise pregnancy rate significantly, it can be accepted by young women who want to preserve their reproductive capacity.Though the pregnancy rate of conservative surgery for diffused adenomyosis was low, it still has therapeutic valueZhongguo Yi Xue Ke Xue Yuan Xue Bao 1998 Dec; 20:440-4
  54. 54. Surgical resection
  55. 55. Surgical resection with GnRh tt• Microsurgical complete resection of the visible adenomyotic area followed by treatment of GnRH agonists has been described.• This surgical approach is also called an adenomyomecotmy.• Live births have resulted after it.• The rationale for medical adjuvant therapy is the assumption that surgical resection of the pathological area without damage to the uterine cavity is incomplete
  56. 56. Endometrial ablation for menorrhagia Endometrial ablation is unlikely to help women with symptomatic adenomyosis. This is simply because the destruction of the endometrium does not elminate the adenomyosis, which is located much deeper in the uterine wall. Uterine artery embolization in most cases also fails to resolve the symptoms of adenomyosis.
  57. 57. What is the Surgical Treatment for Adenomyosis? Hysterectomy is currently considered by most the only effective treatment for symptomatic adenomyosis.In recent years I have successfully treated many patients with adenomyosis by surgically removing only specific areas of the uterus containing the bulk of the disease (as carefully defined by transvaginal ultrasound). In addition, I have found it helpful to surgically remove the lining of the upper portion of the uterine cavity, since this is the source for regrowth of adenomyosis and this, in effect, prevents recurrence of adenomyosis. This is followed by reconstruction of the uterus, resulting in a near normal sized uterus. This results in resolution of the pain and normal to very light periods. The drawback of this surgical treatment is that pregnancy is no longer an option
  58. 58. Dilema & frustration remains ….. What Is the Treatment forAdenomyosis except Hystrectomy….
  59. 59. MRI-guided Focused Ultrasound Surgery
  60. 60. MRIgFUS represents a new, safe and effective method for theablation of adenomyotic tissue
  61. 61. MRIgFUS• significant improvements in dysmenorrhea and menorrhagia with a decrease in uterine size in most patients. In addition, MRI evaluation produced results suggestive of coagulation necrosis of adenomyosis in the majority of patients.• some reports suggest that there may be efficacy in techniques such as uterine artery embolization and MRI-guided focused ultrasound surgery (MRIgFUS).
  62. 62. MRIgFUS• Recently, Fukunishi et al. evaluated the thermal ablative effects of MRIgFUS on adenomyosis in improving clinical parameters in 20 premenopausal women; since adenomyosis symptoms are similar to those of uterine myomata, they used the symptom severity score questionnaire available for evaluating the effect of MRIgFUS on myoma.• They reported that most adenomyotic lesions could be satisfactorily ablated close to the serosal surface or the endometrium and, at 6 months, the mean uterine volume had decreased by 12.7%. Symptom severity score improved significantly during the 6 months of follow-up and no serious complications were observed.
  63. 63. Two other novel approaches
  64. 64. Inhibitors of AngiogenesisNew knowledge of a modified angiogenesis inheterotopic uterine mucosa in case of endometriosisand adenomyosis is opening the way for a newtreatment line. Starting from the observation thatdopamine and its agonists, such as cabergoline(Cb2), promote endocytosis of VEGF receptor(VEGFR)-2 in endothelial cells, thereby preventingVEGF–VEGFR-2 binding and reducingneoangiogenesis, the group of Pellicer et al. has nowevaluated in an animal model the antiangiogenicproperties of Cb2 on the growth of establishedendometriosis lesions. After treatment with Cb2, theyfound a significant decrease in the percentage ofactive endometriotic lesions and of cellularproliferation index, associated to a reducedneoangiogenesis, and a significant modification ofgene expression
  65. 65. • In women with suspected (nonhistological) diagnosis of adenomyosis, after insertion of a levonorgestrel-releasing intrauterine system, VEGF expression is substantially reduced in eutopic endometrial glands and stroma; however, it is not known whether the same occurs in the heterotopic glands.
  66. 66. • Another approach aimed at inhibiting angiogenesis has been studied by the group of Creatsas using pentoxiphylline, a phosphodiesterase inhibitor. In an animal model, they evaluated changes in morphology and in the expression of VEGF-C and of the receptor for tyrosine kinase, Flk-1 (a VEGF receptor) and observed a significant reduction in the mean volume of the endometriotic implants per animal when compared with the control group. Their conclusion was that pentoxiphylline may cause suppression of endometriotic lesions by suppressing angiogenesis through VEGF-C and Flk-1 expression.
  67. 67. Creus et al• In a prospective, randomized, controlled, blind trial, a group of patients was randomly assigned, immediately after laparoscopic surgery, to treatment with either oral pentoxiphylline (800 mg/day) or an oral placebo. These women were then observed for the occurrence of pregnancy for 6 months. In the approximate 100 patients who completed the study, the 6-month overall pregnancy rates were 28 and 14% in the pentoxiphylline and placebo groups, respectively (p = 0.1). These findings provide preliminary clinical evidence to suggest that new experimental treatment approaches toward endometriosis, that are based on immunomodulation deserve further attention. Well- designed multicenter trials are warranted to confirm or refute these results
  68. 68. In late 1980’s Steinleitner even suggestedthat, "the periovulatoryadministration of nonteratogenicimmunomodulatory agents mayprovide an alternative toconventional treatment forendometriosis."
  69. 69. A True Help for Adenomyosis
  70. 70. Can Adenomyosis be treated without surgery? Some studies have shown that there is a relationship between Adenomyosis and hormone imbalance, most commonly an excess of estrogen. Progesterone therapy, either in the natural or synthetic form has been known to help, but shows very little long term benefits.Danazol may be helpful in treating the pain and decreasing the size of the uterus but long term positive results are poor.
  71. 71. Xeno estrogensChemical estrogens known as xenoestrogens (xenomeans foreign) first came to widespread scientificattention in the early 1990’s. The cover story of TIMEmagazine October 30, 2000 told of young girls goingthrough early puberty. The famous 1997 Herman-Giddens study showed that out of 17,000 girls aged8, 15% of these girls aged 8 were sprouting breastbuds and pubic hair. TIME magazine blamedchemicals that act like estrogen or xenoestrogens forcausing the early puberty. These same chemicalestrogens, xenoestrogens, that are causing earlypuberty in girls are now being blamed as the cause ofadenomyosis as well as endometriosis, breast cancerand cervical cancer.
  72. 72. Natural Hormone Treatment of AdenomyosisNatural Progesterone opposes the effect of estradiol andxenoestrogens. Estrogen tells the cells to reproduce andproliferate. Natural Progesterone tells the cells to stopreproducing and grow up and mature. Excess estrogen orestrogen dominance encourages endometrial growth!Thus, excess estrogen in the form of estradiol and chemicalestrogens will cause adenomyosis and endometriosis to getworse.The solution for adenomyosis is to avoid xenoestrogens( chemical estrogens ) and then take Natural Progesterone. Bytaking Natural Progesterone, we are creating what is known inthe mainstream medicine as a "pseudo pregnancy" or false orfake pregnancy.
  73. 73. • Natural Progesterone is NOT the same as the synthetic prescription Progestin• These synthetic prescription Progestins are chemically modified from Natural Progesterone.• This is because any hormone found in nature, by law, cannot be patented.• Thus, if something cannot be patented, then there are 30 competitors.• The price goes down.• Patented Progestins are patented.
  74. 74. Plan of treatmentUsually, I recommend my patients to make a change to avoidxenoestrogens in their soaps, shampoos and laundry detergent, etc.for 1-2 months, and THEN take Natural Progesterone. This waitingtime allows the xenoestrogens to wash out of the body. Chronicexcess estrogen exposure makes the human body desensitized toestrogen. It is sort of like going to a rock concert. In thebeginning, the music is loud, but after half an hour, the music seemsnot so loud. The music loudness has NOT changed, your body has justtried to become less sensitive to the noise. Similarly, the bodybecomes less sensitive to estrogen because of the chronic excessestrogen exposure.Natural Progesterone resensitizes the estrogen receptors back tonormal. And it seems like you are getting more estrogen when youare really not.For most cases, cutting out the xenoestrogens for 1-2 months andTHEN taking Natural Progesterone works well for adenomyosis. Thisallows time for the xenoestrogens to wash out of the body. The rareexceptions to this rule are women with chronic levels of anxiety orfear that retain xenoestrogens and have an extreme "clogged toilet"syndrome
  75. 75. How can Female Alternative Surgery help Adenomyosis?• Most commonly, hysterectomy has been the mainstay of treatment. Traditional medicine states that since most women with Adenomyosis are beyond child-bearing age, the uterus is no longer relevant. At the Institute, we want to give women every opportunity to retain their female organs even if fertility is not a concern. Our surgical approach is first to make a diagnosis. For women who still wish to conceive, we try to remove the Adenomyosis using laser technology (CO2 Yag and Argon) which preserves the endometrial cavity but treats the remaining deep uterine muscle disease. In the case of women who are not concerned with fertility but want to preserve their organs, our approach is to remove as much of the affected tissue and, if necessary, decrease the size of the endometrial cavity. We treat the remaining uterine muscle with a deep tissue laser technique. Post surgical results have shown that pain almost always disappears and menstrual flow and volume decrease.
  76. 76. Remember: Every form oftreatment should be tried before a hysterectomy is ever considered.
  77. 77. Still after so many options……… the dilema & frustration of anideal treatment for adenomysosis persisits,specially in womenwhere uterus has to be conserved
  78. 78. thank you for hearing me out….. Invite you all for….. International Society ofUltrasound inObstetrics and Gynecology (ISUOG)8 International Symposium India 2012 thMay 31 - June 3, 2012 Taj Palace Hotel, New Delhi