Adenomyosis

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Adenomyosis

• By Jillian Moser

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Case Report

• 46 y/o P4G4 female presenting for annual exam
• CC Pelvic pain x 5 years
• HPI Pelvic pain described as a constant dull
  ache with severe cramping, most intense during
  menstruation. Also admits to menorrhagia and
  dyspareunia.
• Aleve PRN for pain with little relief
• OCP treatment in past with out improvement of
  symptoms

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Menstrual History

• Menarche at age 14
• 28 day cycles
• Increasingly heavy and painful over past several
  years

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• PHM No significant diagnoses
• PSH Tubal ligation- 2002
• Cholecystectomy- 2004
• Meds multi vitamin
• Allergies NKDA
• FH No family history of endometrial/uterine/ovari
  an cancer, endometriosis, adenomyosis or other
  gynecologic conditions

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Physical Exam

• T- 98.7, BP- 118/68, P- 64, R- 18
• Abd BS X4, resonant on percussion, soft,
  non-tender on light and deep palpation, no masses
  or organomegaly appreciable.
• Genital No bleeding, lesions, or discharge.
  Speculum inserted w/o difficulty and pap smear
  obtained.
• Bimanual exam produced extreme discomfort ,
  uterus enlarged and boggy. No uterine or ovarian
  masses palpable.

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Differential Diagnosis

• Adenomyosis
• Endometriosis
• Uterine Fibroids

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Work up

• Pelvic ultrasound ordered
• Revealed enlarged uterus
• 1cm fibroid
• (unlikely to be the source of pain due to small
  size)

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Assessment and Plan

• Based on the enlarged uterus and the presenting
  symptoms of menorrhagia and pelvic pain, patient
  diagnosed with Adenomyosis
• Patient opted to undergo a LAVH and BSO on
  11-28-08

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Discussion

• Adenomyosis is defined as the chronic disruption
  of the boundary between the basal layer of the
  endometrium and the myometrium, resulting in
  significant infiltration of the basal endometrial
  glands and stroma into the myometrium with
  myometrial cell hyperplasia around infiltrating
  glands.
• Abnormally located endometrial tissue acts like
  normal endometrial tissue--gt thickens during
  follicular phase--gt sheds during menstruation--gt
  causes blood and debris to accumulate in the
  glands--gt causes swelling of the uterus
• The endometrial invasion into the myometrium can
  occur focally, creating an adenomyoma, or
  diffusely, causing the uterus to become dense and
  bulky

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Discussion

• Cause is unknown
• May be due to uterine trauma (i.e. pregnancy,
  c-section, tubal ligation, etc.)
• May be linked to excess estrogen, since it is
  most often seen in women between the ages of 35
  and 50 and is rarely seen in postmenopausal women
• Not uncommon to have coexisting endometriosis
  and/or uterine fibroids

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Discussion

• Symptoms
• May be asymptomatic
• Pelvic pain that increases with menses
• Menorrhagia
• Dyspareunia
• Signs
• Enlarged, dense/boggy uterus
• Imaging
• Ultrasound- more cost effective
• MRI- better diagnostic capability
• Diagnosing
• Only definitive means of diagnosing Adenomyosis
  is by pathological specimen examination post
  hysterectomy

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Discussion

• Treatment
• Ranges from conservative attempts at pain
  management with NSAIDS, hormonal suppression via
  OCPs, through radical measures via hysterectomy

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References

• Kunz, G, Herbertz, M, Beil, D, Huppert, P,
  Leyendecker, G (2007). Adenomyosis as a disorder
  of the early and late human reproductive period.
  Reproductive BioMedicine Online, 15, Retrieved
  October 10, 2008,from http//navigator-lhup.passhe
  .edu/login?urlhttp//search.ebscohost.com/login.a
  spx?directtruedba9hAN27976412loginpagelogin
  .aspsiteehost-livescopesite.
• Tocci, A, Greco, E, Ubaldi, F (2008, August).
  Adenomyosis and 'endometrial--subendometrial
  myometrium unit disruption disease' are two
  different entities. Reproductive BioMedicine
  Online, 17, Retrieved October 10, 2008, from
  http//navigator-lhup.passhe.edu/login?urlhttp//
  search.ebscohost.com/login.aspx?directtruedba9h
  AN33947640loginpagelogin.aspsiteehost-lives
  copesite.
• http//www.mayoclinic.com/health/Adenomyosis/DS006
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• http//www.adenomyosis.org/