Title of the report

Prepared by

Sixth grade student

Supervised by

2020 1441
1
 Acknowledgments
I would like to express my appreciation and gratitude to my supervisor
DR. Najmah Mahmood for her support and efforts that she made for us.

Contents Page

Introduction 3
Etiology 3
Pathophysiology 3
Clinical presentation 4
Diagnosis 4
Deferential diagnosis 5
Treatment 5
References 6

2
 Introduction
The presence of endometrial tissue, including endometrial glands and stroma, in
the myometrium in association with smooth muscle proliferation in the inner
myometrium defined as adenomyosis. (Figure-1) It is either focal or diffuse,
typically results in an irregular endo‐myometrial border or junctional zone with
uterine enlargement. Histologically defined by a depth of penetration between
2.5 and 5 mm. Often it is an incidental finding during a pathologic examination
seen in up to 60% of women in their 40s. Approximately 15% of patients with
adenomyosis have associated endometriosis. Islands of adenomyosis do not
participate in the proliferative and secretory cycles induced by the ovary. (1,2)

Figure 1 – Normal uterus versus uterus with adenomyosis shown in the wall

Etiology
Adenomyosis associated most strongly with multiparous, middle age,
gynecological surgery history, and multiple curettage procedures. Adenomyosis
often coexists with other uterine diseases, like uterine leiomyomas and
endometriosis. It is responsive to cyclical hormonal changes that result in
bleeding within the myometrium, leading to increasingly severe secondary
dysmenorrhea, uterine enlargement and menorrhagia. (3–5)

Pathophysiology
The pathophysiology of adenomyosis development still poorly understood. The
origin is thought to be an abnormal invagination of the basalis layer of the
endometrium into the adjacent myometrial layer.
The endometrial-myometrial region is composed of the basalis endometria and
the sub-endometrial myometrium, which is also known as the myometrial
junctional zone. Mechanical disruption of the endometrial-myometrial region,
3
hormonal imbalance, and impaired immunity are thought to be the causal factors.
Also, elevated levels of estrogen are necessary for development and maintenance
of adenomyosis. (4)
Generally, gross features of the uterus include diffuse enlargement associated
with a thickened myometrium containing characteristic glandular irregularities,
with implants containing both stroma and glandular tissue. Enlargement of the
endometrial cavity also. The distinction may not always be clear between
adenomyosis and a uterine fibroid on ultrasonic examination. (1)
Adenomyosis is of two types, focal collections of glandular tissue and diffuse,
scattered individual glands. (3)
• Focal adenomyosis: Known also as adenomyoma, can resemble a fibroid
on gross inspection, but without the pseudocapsule.
• Diffuse adenomyosis: The uterus with diffuse adenomyosis is uniformly
enlarged and boggy on gross inspection, in contrast to the fibroid uterus
which is irregular and firm appearance, although fibroids and adenomyosis
can occur concurrently.
The myometrial wall appears thickened with small hemorrhagic or
chocolate-colored areas representing islands of endometrial bleeding.

Clinical presentation
The women are usually aged 40, parous, one third of the patients are
asymptomatic, others on pelvic examination reveals symmetrically enlarged
mobile uterus and if the examination is conducted premenstrually, it will be
boggy and tender. In contrast to endometriosis, where dyspareunia is not a
symptom can be found, menorrhagia, progressively dysmenorrhea, and
dyspareunia are the typical symptoms, other symptoms like, backache and
chronic pelvic pain may also be found. Rarely, the uterine enlargement exceeds
3-months pregnancy. The consistency of the enlarged adenomyomatous uterus
is generally softer than that of a fibroid uterus. An evidence suggests that there
is relation between menstrual blood loss and the overexpression of inflammatory
mediators in adenomyotic tissue samples. Finally, an associated with increased
pregnancy complications was found, including preterm birth and miscarriage.
(1,3,6)

Diagnosis
The diagnosis is made on histological examination of the uterus after
hysterectomy but the preoperative diagnosis may be suggested on ultrasound
examination and magnetic resonance imaging (MRI).

4
 - Ultrasonography: The primary investigation is transvaginal ultrasound,
asymmetrical thickening of the myometrium or a globular uterus found in the
ultrasound with myometrial cysts and heterogeneous echogenic islands, sub-
endometrial echogenic lines and buds, fan‐shaped shadowing, trans-lesional
vascularity and an irregular or interrupted junctional zone. (2,6)

- Magnetic resonance imaging (MRI): Is the investigation of choice, as it

provides excellent images of the myometrium, endometrium and areas of
adenomyosis. MRI is reserved for which it is important to distinguish diffuse
and focal adenomyosis from leiomyomas. With MRI, measurement of the
thickening of the junctional zone is possible, with >12 mm diagnostic of the
disease and <8 mm excluding it. (3,5)

- Histology: Diagnostic hysteroscopy, myometrial biopsy, and endometrial

biopsy, have occasionally been found to be useful in identifying suspected
adenomyosis. Biopsy can demonstrate features may include, irregular
endometrium with superficial openings, Irregular sub-endometrial
myometrium (junctional zone), and Intramural endometriomas. (3,4)

Deferential diagnosis (4)

- Leiomyoma
- Endometriosis
- Uterine Cancer
- Pelvic Adhesive disease
- Isthmocele

Treatment (1–3,5)
▪ Drugs: Non‐steroidal anti‐inflammatory drugs NSAIDs, GnRH analogs,
progestins, oral contraceptive pill and antifibrinolytics may be considered as
first‐line methods of treatment.
▪ The levonorgestrel‐releasing intrauterine system (LNG‐IUS): It has been
shown to be effective for reducing uterine volume and relief of adenomyosis‐
related symptoms at 1 year, but the efficacy declines with time.
▪ Hysterectomy: It is the definitive treatment for adenomyosis for old age
women, who have completed her family.
▪ Uterine artery embolization (UAE): It is for women who have completed
her family, may be effective for reducing symptoms related to adenomyosis.
It is also an option for women who decline, or have contraindications to, a
hysterectomy or have failed hormonal treatment.

5
 References

1. Hacker NF, Gambone JC, Hobel CJ. Hacker & Moore’s Essential of
Obstetrics & Gynecology. 6th ed. elsevier. 2016. 323–324 p.

2. D. Keith Edmonds M, Christoph Lees M, Tom Bourne P. Dewhurst’s

Textbook of Obstetrics & Gynaecology. 9th ed. 2018. 1609–1611 p.

3. Elizabeth A Stewart M, Robert L Barbieri M, Deborah Levine M, Alana

Chakrabarti M. Uterine adenomyosis. UpToDate Inc. 2020.

4. Lisa Kirsten Ely M, Nicole W Karjane M. Adenomyosis. 2018;

5. Biskerstaff H, Kenny LC. Gynecology by Ten Teachers. 20th ed. 2017.

6. Sunesh Kumar M, VG Padubidri M, Shirish N Daftary M. Howkins &

Bourne Shaw’s Textbook of Gynecology. 17th ed. 2018. 196–197 p.