Adenomyosis

Dr. Mohammed Abdalla

Egypt, Domiat G Hospital
 definition
Adenomyosis 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.
 definition
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.
 Associated factors
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.

Women's Health Center of South Orange County

 Associated factors
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
 The typical symptoms include

• Pelvic pain,

• Dysmenorrhea,

• And menorrhagia unresponsive to hormonal therapy or uterine

curettage.

• Subfertility.And pregnancy termination.

classic presentation

Cyclic, cramping uterine pain beginning later in reproductive life

(generally after age 35) and often associated with prolonged and
heavy menses
 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 19 with 39 with
adenomyosis adenomyosis with
36 with
leiomyomas
alone leiomyomas alone neither.

from patient records the pregnancy terminations rate was:

58.8% 47.4% 20.5% 22.2%

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
(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 adenomyosis

based on the clinical factors, but the final diagnosis
usually has to wait until hysterectomy is performed.
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)
 pelvic exam
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
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
 Hysterography
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

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
 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.
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

histopathologic ultrasonographic ,MRI
correlation
small echogenic
characterized by the presence islands on TVS
of heterotopic endometrial bright foci are seen On
glands and stroma in the T2-weighted MR within the
myometrium
myometrium

with corresponds to areas of

decreased echogenicity on
adjacent smooth muscle TVS

hyperplasia. areas of decreased signal

intensity at (MR

The ratio of heterotopic endometrial tissue to smooth muscle

decreased echogenicity partly determines the imaging appearance
normal myometrium (M), NORMAL
homogeneous echotexture

The subendometrial haloas a

thin hypoechoic band
(arrows).

The endometrium is
uniformly echogenic
 E = endometrium Adenomyosis

myometrium is thickened
ventrally and has a
heterogeneous echotexture

The echogenicity of the ventral

myometrium is decreased relative
to that of the dorsal myometrium

myometrial cyst (curved arrow).

excentric endometrial cavity

decreased uterine echogenicity without lobulations, contour

abnormality, or mass effects,
 ULTRASOUND CHARACTERISTICS OF
.ADENOMYOSIS

Brosens and co- uterine dimensions

workers assessed
ultrasonographic Symmetry of myometrium
:details such as
echogenicity of the
myometrium

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

Prevalence Sensitivity Specificity P N

% % % PV%
PV
%
Reinhold et al. 18/119
(1996) (24)
89 89 71 96

Atzori et al. 15/175 96.2 68.4

(86)
86 98
(1996)
Reinhold et al. 29/100 86 71 94
86
(1995) (29)
Brosens et al. 28/56 53 75 86 77
(1995) (50)
Asher et al. 17/20 86 50 90 20
(1994) (85)
 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 S
Am J Obstet Gynecol 1992 Sep; 167:603-6
 Transvaginal ultrasonography in the
differential diagnosis of adenomyoma
versus leiomyoma
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.

Botsis D, Kassanos D, Antoniou G, Pyrgiotis E,

Karakitsos P, Kalogirou D
J 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.
 MRI
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.
Comparative study

MRI / TVUS
Department of Radiology, Georgetown University Medical Center,
women with clinically suspected adenomyosis 20
underwent MR imaging and transvaginal Sonography
.Pathologic proof was obtained in all cases
17 patients were proved to have adenomyosis.

Correct False False

diag. +ve -ve

MRI 15/17 1/17 1/17

TVUS 9/17 1/17 8/17

Comparative study

MRI / TVUS
Department of Gynecology and Obstetrics, Aarhus University and Aarhus
University Hospital, Aarhus, Denmark

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.

sensitivity specificity
MRI 70 86
TVUS 68 65
COMBINED 89 60
 MRI
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
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

• 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 P

Zhonghua Fu Chan Ke Za Zhi 2002 Feb; 37:77-9
 Uterine arterial embolization in the
treatment of adenomyosis

UAE is an effective and safe

method in the treatment of
adenomyosis.
BUT the recurrence rate is not
yet evaluated.
 DR.MOHAMMED ABDALLA
EGYPT, DOMIAT G HOSPITAL