{"paper_id":"4479ff19-3433-4901-8a8c-f8e3f18e4960","body_text":"Submit Manuscript | http://medcraveonline.com\nIntroduction\nThese days, the problem of endometriosis has become ever more \nrelevant.1–3 Environmental deterioration, increased emotional stress \nload in the society contribute to the formation of tension in the neuro \nhumoral regulatory systems predisposing to the emergence of various \nhyper proliferative pathologies, including endometriosis.4–6\nThe problem of endometriosis has long ceased to be purely medical \nbecause it is associated with reduced quality of life of the women of \nreproductive age - the most socially important category. 5,7 Currently, \nendometriosis is no longer associated with reproductive age only as \nthere is an increasing incidence of this condition being diagnosed \nin adolescence and at that time it accounts for 70% cases of chronic \npelvic pain.2,3 Numerous studies have proven that endometriosis may \noccur in adolescents girls. 2,8,7 The average age of disease onset is \n15.9 years. Therefore, timely diagnosis of endometriosis and choice \nof adequate therapeutic approach are of particular importance in \nthis patient population since they predetermine the possibility of \nsuccessful reproductive performance of such women in the future.2,7,9\nHaving regard to the above, the case history of adenomyosis \nfirst diagnosed in adolescence deserves close attention. On June \n6, 2013, patient M. aged 18 was admitted on an urgent basis to the \ngynecology department of Kyiv Municipal Hospital No.9. The patient \npresented with severe pain during menstruation, low-grade fever, \nnausea, vomiting. Referral diagnosis: nodular uterine leiomyoma \nwith impaired nodular delivery. From the medical history of the \npatient: menstruation first started at the age of 13 and regular cycle \nwas established within a year, periods were painful, sometimes \nleading to fainting. The patient also experienced loosed stool during \nthe first days of periods. The patient repeatedly applied to pediatric \ngynecology department where she was diagnosed with the following: \nDysmenorrhea. Adenomyosis? In 2011, she was examined by the \ngynecologist of the “Okhmatdyt” National Children’s Specialized \nHospital with subsequent pelvic ultrasound examination. Diagnosis: \nNodular adenomyosis (72x68 mm; endometrial nodule was identified \non the posterior uterine wall in the myometrium). The patient was \nprescribed 6 injections of Diphereline 3.62 mg. The reduction in the \nsize of nodule to 31x29 mm has been observed under the course of \nthe treatment. Diphereline was discontinued due to undesirable effects \nsuch as bone pain, hot flushes, fatigue, and tachycardia. Following \nwithdrawal of Diphereline, the periods resumed in 3 months and in 6 \nmonths menstrual pain developed again.\n The data of patient’s physical examination: the skin and visible \nmucous membranes are of pale pink color, the abdomen is soft, tender \non palpation, participates in the process of breathing. Peritoneal signs \nare weakly positive in the lower abdomen. Pasternatsky’s symptom \nis negative on both sides. Vaginal examination: uterus is enlarged as \nwith 8-9 weeks pregnancy, round-shaped, dense, tender on palpation, \ncervical tractions are painless. Uterine appendages on both sides are \nnot enlarged and painless on palpation. Ultrasound examination: \nuterus 69 x64x62mm. A hypoechoic mass is visible in the structure \nof myometrium on the posterior wall with hyperechoic dispersed \nparticulate matter 50 x 46 x 43mm (Figure 1).\nFigure 1 Patient M. Nodular adenomyosis (June 2013).\nDiagnosis: adenomyosis, nodular form. Secondary dysmenorrhea. \nContinuous treatment with Visanne over the period of 9 months \nhas been recommended. The patient was examined in 9 months, in \nMarch 2014. The general state of health was assessed by the patient \nas satisfactory. Pain disappeared in as little as 3 months of treatment \nwith Visanne. Findings of pelvic ultrasound: uterus 56x52x48mm. A \nhypoechoic mass is present in the structure of myometrium on the \nposterior wall with hyperechoic particulate matter 41x36x28mm \n(Figure 2).\nMOJ Womens Health. 2019;8(2):150‒152. 150\n© 2019 Zakharenko et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, \nwhich permits unrestricted use, distribution, and build upon your work non-commercially.\nClinical case report: conservative treatment of \nnodular adenomyosis\nVolume 8 Issue 2 - 2019\nZakharenko NF , Kovalenko NV, Manoliak IP\nDepartment of Gynecology, Kyiv Municipal Hospital No. 9, \nUkraine\nCorrespondence: Zakharenko NF , Department of Gynecology, \nKyiv Municipal Hospital No. 9, Ukraine, T el +380 (44) 455695, \nEmail \n \nReceived: March 15, 2018 | Published: April 02, 2019\nAbstract\nThis article describes a clinical case report of nodular adenomyosis first diagnosed in \nadolescent girl. It emphasizes the importance of early disease detection and correct \nchoice of therapeutic approach factors, directly relating to the future reproductive \nhealth of an adolescent girl. This case describes an example of successful long-term \nconservative treatment of adenomyosis with dienogest (Visanne) treatment for over \nthree years and subsequent realization of reproductive function by the patient.\nKeywords: nodular adenomyosis, adolescence, visanne, deterioration, problem, \nendometriosis\nMOJ W omen’s Health\nReview Article\n Open Access\n\n\nClinical case report: conservative treatment of nodular adenomyosis\n151\nCopyright:\n©2019 Zakharenko et al.\nCitation: Zakharenko NF , Kovalenko NV, Manoliak IP . Clinical case report: conservative treatment of nodular adenomyosis. MOJ Womens Health. \n2019;8(2):150‒152. DOI: 10.15406/mojwh.2019.08.00227\nFigure 2 Patient М. Nodular adenomyosis (March 2014).\nRecommended: continued treatment with Visanne for one year.\nIn March 2015, the patient visited the clinic for follow-up \nexamination. According to the patient, she decided to discontinue \ntreatment with Visanne three months ago due to the prolonged \ncomplaint-free period. At the time of examination, the patient reported \nreoccurrence of painful menstruation in February 2015. The pelvic \nultrasound has been performed. Findings: uterus 53×42.6×44mm. A \nhypoechoic mass is present in the structure of myometrium on the \nposterior wall with hyperechoic particulate matter 30x25.7x22.2mm–\nendometrioma. The patient was recommended to continue treatment \nwith Visanne.\n In January 2016 (in 11 months), the patient made follow-up \nvisit. The general state of health was assessed by the patient as good. \nFindings of pelvic ultrasound: uterus 44x38x36mm. A hypoechoic \nmass is present in the structure of myometrium on the posterior wall \nwith hyperechoic particulate matter 21x16.7x16.2mm (Figure 3). The \npatient was recommended to continue treatment with Visanne. In \nApril 2017, as the patient got married and started unprotected sexual \nlife, Visanne was discontinued and replaced by Epigalin (composition: \n200 mg indol-3-carbinol-200, 82 mg green tea extract). There were \nno complaints expressed by the patient at the time of examination. \nFindings of ultrasound: uterus 46x39x38mm. A hypoecho mass is \npresented in the structure of myometrium with hyperechoic particulate \nmatter 29.0x20.7x18.9mm. The patient was recommended to continue \ntreatment with Epigalin. In December 2017, the patient sought \nadvice of gynecologist because of 14-days delay of menstruation. \nUltrasound examination: uterus 56.2x50.8x49.4 mm. Gestational sac \n16.6x16.1mm is visible in the uterine cavity. A hypoechoic mass is \nvisible in the myometrium with hyperechoic particulate matter 18.1x \n11.1mm (Figure 4). \nPhysician’s statement: pregnancy 4 weeks. Nodular \nadenomyosis\nThe patient made scheduled visit on 02.02.2018. The general state \nof health was satisfactory. Normal course of pregnancy. Ultrasound \nfindings: uterine body: 139.0х74.0х103.0 mm; 113.0x44.0x57.0 mm \ngestational sac is visible in the uterine cavity; cervix: 37.0 mm. Internal \norifice of the uterus is closed; uterine walls: no abnormalities; uterine \ntonus: no abnormalities. Cervical canal: no abnormalities. Ultrasound \nreport: Pregnancy 13 weeks+05 days Progressing (Figure 5).\nOn 09.03.2018, the patient underwent the second scheduled \nultrasound. Conclusion: Pregnancy 18 weeks. Progressing (Figure 6).\nFigure 3 Patient М. Nodular adenomyosis (January 2016).\nFigure 4 Patient М. Pregnancy 4 weeks. Nodular adenomyosis (December \n2017).\nFigure 5 Patient М. Pregnancy 13 weeks Progressing.\nFigure 6 Patient М. Follow-up ultrasound examinations at pregnancy week \n18.\n\n\nClinical case report: conservative treatment of nodular adenomyosis\n152\nCopyright:\n©2019 Zakharenko et al.\nCitation: Zakharenko NF , Kovalenko NV, Manoliak IP . Clinical case report: conservative treatment of nodular adenomyosis. MOJ Womens Health. \n2019;8(2):150‒152. DOI: 10.15406/mojwh.2019.08.00227\nConclusion\nSecondary dysmenorrhea with underlying endometriosis is a \nhighly challenging issue in modern gynaecology. Unfortunately, \nstatistical data demonstrate that this condition is often diagnosed \nin 6-7 years after the appearance of complaints. Considering the \nfact that endometriosis is diagnosed in 30%-40% of patients with \nprimary infertility, the timely disease detection and correct choice of \ntherapeutic approach are of vital importance since they are directly \nrelated to the future reproductive health of an adolescent girl. The \nnodular adenomyosis, even with large nodules, can be successfully \ntreated conservatively with dienogest, and such long-term therapy (for \nover three years) is well-tolerated by the patients and contributes to \nthe effective implementation of their reproductive function.\nAcknowledgments\nNone. \nConflicts of interest\nThe author declares there no conflict of interest here.\nReferences\n1. Tatarchuk TF, Kalugina LV . On the issue of prevention and treatment \nof hormone–dependent hyper proliferative diseases in women. Women’ s \nHealth. 2013;7(1):51–57.\n2. Guideline of the European Society of Human Reproduction and \nEmbryology. Management of endometriosis. 2013. 97 p.\n3. Dunselman GA, Vermeulen N, Becker C, et al. ESHRE guideline: \nmanagement of women with endometriosis. Hum Reprod.  \n2014;29(3):400–412.\n4. V ovk IB, Zakharenko NF, Radysh TV . Status of activation of blood \nlymphocytes and serum levels of inflammatory mediators in different \nforms of endometriosis. Pediatrics, obstetrics and gynecology . \n2013;76(1):77–81.\n5. Zakharenko NF, Zadorozhnaia TD, Kalugina LV . Indol-3-carbinol in the \ntreatment of adenomyosis. F1000Res. 2013;2(15):22–24.\n6. Zakharenko NF, Tatarchuk TF, Kovalenko NV . The role of oxidative \nstress in the genesis of endometriosis. Reproductive endocrinology . \n2014;4(18):13–16.\n7. Stilley JA. Cellular and molecular basis for endometriosis–associated \ninfertility. Cell Tissue Res. 2012;349(3):849–862.\n8. Johnson NP. Consensus on current management of endometriosis. Hum \nReprod. 2013;28(6):1552–1568.\n9. Zotova OA, Artymuk NV . Adenomyosis: clinic, risk factors and problems \nof diagnosis and treatment. Gynecology. 2013;5(6):31–34.","source_license":"CC0","license_restricted":false}