Ob

1
Adenomyosis

• ObGy Dept. First Hospital,
• XiAn Jiao Tong University

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
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.

4
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.

5
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.

6
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.

7
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
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.
from patient records the pregnancy terminations
rate was
58.8
47.4
20.5
22.2
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
(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.
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
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
15
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,
15217-221
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 64846-51
18
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
19
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 73885-7
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
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 167481-6.
24
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.
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
histopathologic ultrasonographic ,MRI correlation
small echogenic islands on TVS
characterized by the presence of heterotopic
endometrial glands and stroma in the myometrium
bright foci are seen On T2-weighted MR within the
myometrium
with
corresponds to areas of decreased echogenicity on
TVS
adjacent smooth muscle hyperplasia.
areas of decreased signal intensity at (MR
The ratio of heterotopic endometrial tissue to
smooth muscle decreased echogenicity partly
determines the imaging appearance
29
normal myometrium (M), homogeneous echotexture
NORMAL
The subendometrial haloas a thin hypoechoic band
(arrows).
The endometrium is uniformly echogenic
30
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,
31
ULTRASOUND CHARACTERISTICS OF ADENOMYOSIS.
Brosens and co-workers assessed ultrasonographic
details such as
uterine dimensions
Symmetry of myometrium
echogenicity of the myometrium
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.
NPV
PPV
Specificity
Sensitivity
Prevalence
96
71
89
89
18/119 (24)
Reinhold et al. (1996)
98
68.4
96.2
86
15/175 (86)
Atzori et al. (1996)

94
71
86
29/100 (29)
Reinhold et al. (1995)
86
77
86
75
53
28/56 (50)
Brosens et al. (1995)
20
90
50
86
17/20 (85)
Asher et al. (1994)
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 SAm J Obstet Gynecol 1992 Sep
167603-6
34
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 DJ Clin Ultrasound 1998
Jan 2621-5
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
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.

38
Comparative study
MRI / TVUS
39
20 women with clinically suspected adenomyosis
underwent MR imaging and transvaginal Sonography
Pathologic proof was obtained in all cases.
17 patients were proved to have adenomyosis.
False -ve
False ve
Correct diag.
1/17
1/17
15/17
MRI
8/17
1/17
9/17
TVUS
40
Comparative study
MRI / TVUS
41
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.
specificity sensitivity
86 70 MRI
65 68 TVUS
60 89 COMBINED
42
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.

43
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 materialenhanced
  T1-weighted imaging

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 34214-6
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
20440-4
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
PZhonghua Fu Chan Ke Za Zhi 2002 Feb 3777-9
52
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.

53
THANK YOU
DR.MOHAMMED ABDALLA EGYPT, DOMIAT G HOSPITAL