Adenomyosis presentation

ADENOMYOSIS

Magdy Abdelrahman Mohamed2014

DEFINITION• Adenomyosis is defined by the presence

of ectopic endometrial glands and stroma within the myometrium.

• The presence of ectopic endometrial glands and stroma induces a hypertrophic and hyperplastic reaction in the surrounding myometrial tissue.

• It usually occurs in 4th or 5th decade.

• Associated with high parity• usually associated with other

conditions, such as myoma, endometrial polyps and endo metriosis.

TYPES

• Diffuse

• Local

• adenomyoma describes a focus of adenomyosis within a leiomyoma. 

• Both conditions are common so it is not surprising that this overlap condition may occur

Presentation

• Menorrhagia.• Congestive dysmenorrhoea.• Dyspareunia.• Chronic pelvic pain.

Adenomyosis & subfertility

• It thought to be a condition of parous women, with the final diagnosis made after hysterectomy.

• Thus, an association between adenomyosis and subfertility has not been fully established.

• Some believe that adenomyosis is not common in subfertile women, while others think that adenomyosis plays a critical role in subfertility.

• The hypothesis of a possible link between adenomyosis and infertility is becoming more and more plausible.

• There is observation that adenomyosis is present even in younger women and can be associated with pelvic endometriosis and infertility.

• (Kissler et al., 2007; Kunz et al.,2005).

Possible mechanism

1-Altered uterine peristaltic activity.Kissler et al. (2006) placed into the posterior vaginal fornix radio-labelled macro-albumin aggregates (with a size of 5–20 um mimicking sperm size) and scanned with a gamma camera immediately after application and at various time intervals up to 30 min.

• Fertile women. Positive, uni- and ipsilateral transport of radionuclides to the side bearing the dominant follicle.

• Diffuse adenomysis & infertility.– 70% remain in uterus.– 22% transport to contralateral side.– 8% to ipsilateral side of dominant follicle.

2-Altered endometrial function and receptivity.

DIAGNOSIS

• The sure diagnosis of adenomyosis is made on a pathologic specimen.

• The pathologic diagnosis is dependent on the visualization of endometrial glands and stroma in more than 1 low-power field from the endometrial basalis layer.

• Katz VL. Benign gynecologic lesions. 5th Edition. 2007:419–471.

TVS• Operator dependent.• meta-analysis on the accuracy of

sonography in the diagnosis of adenomyosis showed that it had sensitivity of 82.5% (77.5–87.9) and specificity of 84.6% (79.8–89.8).

Meredith SM et al, 2009.

• Uterine enlargement.• Cystic anechoic spaces or lakes in

the myometrium.• Heterogeneous echo texture.• Obscure endometrial/myometrial

border.• Subendometrial halo thickening.

• Globular uterine enlargement with an obscure endometrial/myometrial border (arrow).

• Anechoic cystic lacunae in the posterior uterine wall (arrow) with a heterogeneous echo texture.

• Linear striations (arrows) in the presence of a heterogeneous echo texture

MRI• More accurate.• Findings

– Diffuse or local widening of junctional zones on T2 weighted images >12 mm.

– Low intensity lesion (ill-defined).– Uterine enlargement.– Small hypointense myometrial spots.

Sagittal T2-weighted MR image shows diffuse, even thickening of the junctional zone (arrows), a finding consistent with diffuse adenomyosis

• focal thickening of the JZ (short arrows).

OTHER TESTS

• Ca-125.• Hyserosalpingraphy.

MANEGMENT

The only definitive treatment for adenomyosis is hysterectomy, with or without ovarian conservation.

ALTERNATIVES• GNRH Analogues.• Levonorgestrel releasing IUD.• Uterine artery embolization.• Focused U/S……….. For localized

adenomyosis.• Endometrial ablation.• Conservative surgery.

MANAGEMENT OF INFERTILITY.

• Data available on treatment of infertility associated with adenomyosis are still fairly limited and mostly confined to case reports or uncontrolled small series.

CONSERVATIVE SURGERIES

Nishida. Conservative surgery for adenomyosis.

• Of 44 patient results were.

Triple flap (Osada) method.

Other options

A- GnRH analogue: Few case reports (Silva et al.,1994) published the first term pregnancy in a patient with a 10-year history of secondary infertility, after 5 months of therapy with GnRHa.

B- IUD containing danazol.• a Japanese group (Igarashi et al.,

2000) have published results of 14 women with symptomatic adenomyosis that had relapsed after previous medical therapy.

• There was good relief of the symptoms.

• Three of the four infertile women conceived after removal.

C- Uterine artery embolization. few case seriesD- MRI-assisted high-intensity focused

ultrasound (HIFU). Only one case of successful treatment of adenomyosis associated infertility with HIFU has been published. (Rabinovici et al., 2006b)