adenomyosis

1. Dr. Mohammed Abdalla
Egypt, Domiat G Hospital
Adenomyosis

2. 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.

3. 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

4. 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

5. 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

6. 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

7. 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

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

9. 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

10. 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

11. 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%);

12. pelvic exam

13. 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)

14. 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

15. 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

16. Hysterography

17. 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

18. 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

19. 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

20. Myometrial biopsy laparoscopically
or sonographically guided

21. 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;

22. CA 125

23. 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

24. 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

25. TVUS

26. TVUS
The technique is strongly operator
dependent

27. ULTRASOUND CHARACTERISTICS OF
.ADENOMYOSIS
ill defined hypoechoic areas
hetrogeneous myometrial echotexture
small anechioc lakes
asymetrical uterine enlargement
indistinct endometrial-myometrial border
subendometrial halo thickening

28. 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

29. normal myometrium (M),
homogeneous echotexture
The subendometrial haloas a
thin hypoechoic band
(arrows).
The endometrium is
uniformly echogenic
NORMAL

30. 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

31. 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.

32. Accuracy of endovaginal ultrasonography in the
.diagnosis of diffuse adenomyosis
2090508617/20
(85)
Asher et al.
(1994)
7786755328/56
(50)
Brosens et al.
(1995)
947186
29/100
(29)
Reinhold et al.
(1995)
9868.496.286
15/175
(86)
Atzori et al.
(1996)
96718989
18/119
(24)
Reinhold et al.
(1996)
NPV
%
PPV
%
Specificity
%
Sensitivit
y%
Prevalence
%
86

33. 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

34. 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 D
J Clin Ultrasound 1998 Jan; 26:21-5

35. MRI

36. 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.

37. 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

38. Comparative study
MRI / TVUS

39. 20women 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,

40. Comparative study
MRI / TVUS

41. 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.
6089COMBINED
6568TVUS
8670MRI
specificitysensitivity
Department of Gynecology and Obstetrics, Aarhus University and Aarhus
University Hospital, Aarhus, Denmark

42. 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

43. 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

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

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

46. 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.

47. MANEGMENT

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

49. 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

50. 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

51. 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

52. 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

53. DR.MOHAMMED ABDALLA
EGYPT, DOMIAT G HOSPITAL