Dr. Mohammed Abdalla

Egypt, Domiat G Hospital

Adenomyosis

definitionAdenomyosis is a benign disease

of the uterus characterized by ectopic endometrial glands and stroma within the myometrium

It is associated with myometrial hypertrophy and may be either diffuse or focal.

adenomyoma describes a focus of adenomyosis within a leiomyoma (fibroid).  Both conditions are common so it is not surprising that this overlap condition may occur.

definition

The gland tissue grows during the menstrual cycle and then at menses tries to slough, the old tissue and blood cannot escape

This trapping of the blood and tissue causes uterine pain in the form of monthly menstrual cramps.

It also produces abnormal uterine bleeding.

definition

Over 23% of patients requiring hysterectomy for control of chronic severe pelvic pain had adenomyosis, and almost half of these women had had a tubal ligation performed. The possible relationship of adenomyosis to a previous tubal ligation has been explored.

Associated factors

Women's Health Center of South Orange County

No relationship was found between age at surgery, age at menarche, indications for surgery, menopausal status at intervention, and presence of adenomyosis.But parity may be associated with an increased frequency of adenomyosis.

Clinica Ostetrica e Ginecologica Luigi Mangiagalli, Department of Obstetrics and Gynaecology, University of Milano, Italy

Associated factors

The typical symptoms include

• Pelvic pain,

• Dysmenorrhea,

• And menorrhagia unresponsive to hormonal therapy or uterine curettage.

• Subfertility.And pregnancy termination.

Cyclic, cramping uterine pain beginning later in reproductive life (generally after age 35) and often associated with prolonged and heavy menses

classic presentation

Pelvic pain

In studies of chronic pelvic pain in which women had hysterectomies, the incidence of adenomyosis is about 15% to 25%

111 specimens of uteri and cervices

17 with adenomyosis alone

19 with adenomyosis with leiomyomas

39 with leiomyomas

alone

36 with neither.

58.8% 47.4% 20.5% 22.2%

from patient records the pregnancy terminations rate was:

Levgur M, Abadi MA, Tucker A.2000 May

2,616 consecutive hysterectomy specimens examined during a 7-year period.

Adenomyosis was noted in 16%

Multiparas between the ages of 30 and 50 years were most commonly affected.

Abnormal uterine bleeding was the common symptom

Myohyperplasia and leiomyomas were the usual associated lesions.

Adenomyosis uteri was seen equally in women of African, Indian and mixed races in this West Indian population

Aust N Z J Obstet Gynaecol 1988 Feb

diagnosis

The diagnosis can only be proven by the pathologists

A good gynecologist may suspect adenomyosis based on the clinical factors, but the final diagnosis usually has to wait until hysterectomy is performed.

(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%);

pelvic exam

pelvic exam

• there may be uterine enlargement from about 6-10 weeks pregnancy size

• The uterus can feel soft and boggy on pelvic exam. Sometimes adenomyosis is associated with uterine fibroids (leiomyomata)

repeated bimanual examinations, over several months, just before and after menstruation have been recommended to detect fluctuating changes in contour, size and consistency of the uterus

Helen Bickerstaff

pelvic exam

The pathological confirmation of clinically suspected cases is also low (10% to 38%)

Azziz R. Adenomyosis: current perspectives. Obsetet Gynecol Clin North Am

Seidman JD, Kjerulff KH. Pathological findings from the Maryland Womens Health Study - practice patterns in the diagnosis of of adenomysis. International journal of Gynecolological Pathology 1996, 15:217-221

pelvic exam

Hysterography

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.

Marshak RH, Eliasoph J. The roentgen findings in adenomyosis. Radiology 1955; 64:846-51

Filling 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%.

Radiological Society of North America ,

Radiology, Vol 118, 581-586,1976

Hysterography

True adenomyomas (encapsulated) are uncommon tumors of the uterus. At hysterosalpingography, detection of a network of fine channels in a very well-circumscribed area of the myometrium, connected with the uterine cavity, allows a preoperative diagnosis

Obstet Gynecol 1989 May; 73:885-7

Hysterography

Myometrial biopsy laparoscopically or sonographically guided

Myometrial biopsy laparoscopically or sonographically guided

a 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;

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.

CA 125

CA 125 antigens present on adenomyotic epithelial cells have a different molecular mass from those present on eutopic endometrium; the antibody binding site is however the same

If an antibody unique to adenomyosis could be isolated and purified then a highly specific serum screening test could be developed.

Kobayashi H, Ida W, Terao T, Kawashima Y. Molecular characteristics of the CA125 antigen produced by human endometrial epithelial cellls: comparison between eutopic and heterotopic epithelial cells. Am J Obstet Gynecol 1993; 169: 725-30.

CA 125

TVUS

TVUS

The technique is strongly operator dependent

ULTRASOUND CHARACTERISTICS OF ADENOMYOSIS.

ill defined hypoechoic areas

hetrogeneous myometrial echotexture

small anechioc lakes

asymetrical uterine enlargement

indistinct endometrial-myometrial border

subendometrial halo thickening

areas of decreased signal intensity at (MR

bright foci are seen On T2-weighted MR within the myometrium

characterized by the presence of heterotopic endometrial glands and stroma in the myometrium

corresponds to areas of decreased echogenicity on TVS

with

small echogenic

islands on TVS

The ratio of heterotopic endometrial tissue to smooth muscle decreased echogenicity partly determines the imaging appearance

adjacent smooth muscle hyperplasia.

histopathologic ultrasonographic ,MRI correlation

normal myometrium (M), homogeneous echotexture

The subendometrial haloas a thin hypoechoic band (arrows).

The endometrium is uniformly echogenic

NORMAL

E = endometrium

myometrium is thickened ventrally and has a heterogeneous echotexture

myometrial cyst (curved arrow).

The echogenicity of the ventral myometrium is decreased relative to that of the dorsal myometrium

decreased uterine echogenicity without lobulations, contour abnormality, or mass effects,

excentric endometrial cavity

Adenomyosis

ULTRASOUND CHARACTERISTICS OF ADENOMYOSIS.

uterine dimensions

Symmetry of myometrium

echogenicity of the myometrium

Brosens and co-workers assessed ultrasonographic details such as:

They found that The most predictive is the ill-defined heterogeneous echotexture within the myometrium.

Accuracy of endovaginal ultrasonography in the diagnosis of diffuse adenomyosis .

2090508617/20 (85)

Asher et al. (1994)

7786755328/56 (50)

Brosens et al. (1995)

94718629/100 (29)

Reinhold et al. (1995)

9868.496.28615/175 (86)

Atzori et al. (1996)

9671898918/119 (24)

Reinhold et al. (1996)

NPV%

PPV%

Specificity%

Sensitivity%

Prevalence

%

86

Transvaginal ultrasonography in the differential diagnosis of adenomyoma versus

leiomyoma

Transvaginal ultrasonography is an effective, noninvasive, and relatively inexpensive procedure for the preoperative differential diagnosis of adenomyoma versus leiomyoma.

Fedele L, Bianchi S, Dorta M, Zanotti F, Brioschi D, Carinelli SAm J Obstet Gynecol 1992 Sep; 167:603-6

Transvaginal sonography is an effective procedure for the preoperative differentiation of adenomyoma from leiomyoma. If the status of the lesion's margins and the presence or absence of hypoechoic lacunae were selected for analysis, leiomyomas could be correctly diagnosed with transvaginal sonography in 95% of cases.

Transvaginal ultrasonography in the differential diagnosis of adenomyoma

versus leiomyoma

Botsis D, Kassanos D, Antoniou G, Pyrgiotis E, Karakitsos P, Kalogirou DJ Clin Ultrasound 1998 Jan; 26:21-5

MRI

MRI• MRI should be expected to be excellent in

recognizing uterine masses like fibroids, cysts, and adenomyomas if they reach 5 mm. or greater in size. MRI may be able to lead us to expect adenomyosis if the myometrial thickness is increased or the consistency of the myometrium is changed.

Magnetic 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.

MRI

Comparative study

MRI / TVUS

20 women with clinically suspected adenomyosis underwent MR imaging and transvaginal Sonography

Pathologic proof was obtained in all cases .

8/171/179/17TVUS

1/171/1715/17MRI

False

-ve

False +ve

Correct diag.

17 patients were proved to have adenomyosis.

Department of Radiology, Georgetown University Medical Center,

Comparative study

MRI / TVUS

studied 106 consecutive premenopausal women who underwent hysterectomy for benign reasons.

Transvaginal ultrasonography and MRI were compared with histopathologic examination as the golden standard

22 (21%) patients had adenomyosis.

sensitivityspecificity

MRI7086

TVUS6865

COMBINED8960

Department of Gynecology and Obstetrics, Aarhus University and Aarhus University Hospital, Aarhus, Denmark

On 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.

MRI

On 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

MRI

Sagittal T1-weighted MR image shows a mildly enlarged anteverted uterus. The junctional zone is isointense relative to the myometrium.

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

Extensive involvement of diffuse adenomyosis in a 42-year-old woman. Sagittal T2-weighted MR image demonstrates diffuse areas of low signal intensity involving most of the uterus (straight arrows) and punctate high-signal-intensity foci (arrowhead). A few small nabothian cysts (curved arrows) are seen in the uterine cervix.

MANEGMENT

MANEGMENT

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

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, Shanghai 200011

Zhonghua Fu Chan Ke Za Zhi 1999 Apr; 34:214-6

conservative surgery for adenomyosis

The 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 value

Zhongguo Yi Xue Ke Xue Yuan Xue Bao 1998 Dec; 20:440-4

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 alleviated in 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 flow imaging decreased immediately after UAE.

•Low-abdominal pain and slight fever were seen after treatment and recovered 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

UAE is an effective and safe method in the treatment of

adenomyosis.

BUT the recurrence rate is not yet evaluated.

Uterine arterial embolization in the treatment of adenomyosis

DR.MOHAMMED ABDALLA

EGYPT, DOMIAT G HOSPITAL