ADENOMYOSIS

STUDENT PRESENTATION
CONTENT

• CASE STUDY EXAMPLE

• WHAT IS ADENOMYOSIS?
• SIGN AND SYMPTOMS
• INVESTIGATIONS
• DIAGNOSIS
• MANAGEMENT
 CASE 1

 A 35-year-old woman with a long history

of heavy menses and cramps presents
with progressively worsening symptoms
over the course of a few month. She has
also gained weight. During the interview,
she asked about the use of hormonal
contraception. On physical exam, the
uterus was enlarged, smooth, boggy, and
tender. She elected to treat with
hormonal contraceptives to preserve
fertility instead of undergoing
hysterectomy.
 Case 2

 A 43-year-old woman who is Gravida 3,

Para 2 and Aborta 1, presents with
increasing, worsening pain with
menses, along with progressively
heavier menstrual bleeding. Pelvic
examination reveals a diffusely
enlarged, tender, and boggy uterus.
Serum β-hCG is negative. Transvaginal
sonogram showed an enlarged uterus
with a thickened posterior myometrium
(arrows).
 Case 3

 A 38-year-old nulliparous female presented to an assisted conception

clinic with subfertility and a long-standing history of dysmenorrhoea.
Transvaginal ultrasound revealed two lesions in the body of the uterus,
which were presumed to be fibroids. A decision was made to remove
these lesions prior to attempting in vitro fertilisation (IVF). However, on
laparotomy, deeply penetrating adenomyosis was discovered, resulting
in an unexpected hysterectomy and significant blood loss.

 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4346970/
What is adenomyosis?

 the invasion of endometrial glands and

condition characterized by
stroma into myometrium with surrounding smooth muscle hyperplasia.
 It affects around 1% of women and until recently the diagnosis was most
commonly made only after histological assessment of tissue removed at
hysterectomy.
 It can be visualised with ultrasound but MRI is better at differentiating
adenomyosis from fibroids.
 Usually it affects women in the age group of 35-50. However there are few rare
cases involving the adolescent age group.
 Adenomyosis often coexist with other uterine condition such as leiomyoma and
endometriosis.
 The exact pathogenesis of adenomyosis remains debatable.
 Causes & Risk Factor

 There are no exact causes. But there are a few theories

 Fetal development? Maybe adenomyosis is present since before birth.
 Inflammation during uterine surgery.
 Invasive tissue. Healing of tissue inwards, from uterine injuries from C-sections, or
other surgery.

 Risk factors that may result in adenomyosis is

 Women in their 40’s to 50’s.
 Multiple Pregnancies
 History of uterine surgeries.
Symptoms

 Possible symptoms include ;

 Chronic pelvic pain
 Heavy menstrual bleeding
 Very painful periods
 pain during sex
 bleeding between periods
 worsening uterine cramps
 an enlarged and tender uterus
 general pain in the pelvic area
 a feeling that there is pressure on the bladder and rectum
 pain while having a bowel movement
 Signs

• Physical exam findings;

• Uterus is uniformly smooth,
• Large
• Soft
• Globular
• Boggy
• Tender

• Condition regresses after menopause? – is it due to the fact that

adenomyosis is estrogen dependent?
Investigations & Diagnosis

 Initial test to order in patient with enlarged uterus is β-hCG.

 Imaging
 Ultrasound- sensitivity of 72% and specificity of 81%
 MRI- ( GOLD STANDARD ) sensitivity of 77% and specificity of 89%, best used
when trying to exclude malignant neoplasia
 Both modalities show diffusely enlarged uterus with some cystic areas
within myometrium
 Adenomyosis is diagnosed on clinical history and examination.
 Definitive diagnosis if from hysterectomy and histology.
Endometrial glands and stroma found
invading the myometrium.
Differential diagnosis
 Leiomyoma
 Pregnancy
 Endometrial Polyp
 Fibroids
 Endometriosis
 Treatment- Medications
 NSAIDs (ibuprofen) given for pain management
 Hormonal therapy
 Levonorgestrel-releasing intrauterine devices
 Oral contraceptives
 Progesterone or Progestins
 Gonadotropin-releasing hormone (GnRH) agonists
 https://www.hindawi.com/journals/bmri/2018/6832685/
 https://emedicine.medscape.com/article/2500101-overview
Treatment –Surgical approach

 Uterine artery embolization (UAE) has long been used as conservative

treatment for women with symptomatic uterine fibroids. More recently, it has
been considered as a treatment for symptomatic adenomyosis for women who
are not candidates for surgical management. After UAE, patients with
adenomyosis have reported significant improvement in dysmenorrhea, pelvic
heaviness and urinary frequency.
 Other new techniques include high intensity focused ultrasound (HIFU) to
thermally ablate the adenomyotic foci.
 Hysterectomy is currently considered the only definitive management for
adenomyosis, and is still the recommended method if desired future fertility is
not a factor.
Prognosis & Prevention

 Good prognosis if patient seek treatment, the disease also regresses post
menopausal?
 There are no known cause identified directly to prevent the development
of adenomyosis. However, obesity has been identified as an independent risk
factor associated with adenomyosis, possibly due to exposure to elevated
estrogen levels and may be prevented with appropriate diet and physical activity.

 Controversial evidence linking adenomyosis with infertility

 Several mechanisms may be involved, including impairment of sperm transport [7],
aberrant uterine contractility [22], alterations of adhesion molecules, cell proliferation,
apoptosis, and free radical metabolism [15, 23]. Adenomyosis is also speculated to be a
cause of recurrent implantation failure during IVF treatment [24].
 https://www.hindawi.com/journals/bmri/2018/6832685/
Sources;

 https://www.hindawi.com/journals/bmri/2018/6832685/
 https://emedicine.medscape.com/article/2500101-overview
 Gynaecology illustrated (2011, Elsevier Churchill Livingstone) Catrina
Bain. Kevin Burton. C Jay McGavigan. D McK Hart
 https://www.medicalnewstoday.com/articles/321296#endometriosis