Adenomyosis: Difference between revisions

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{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]


==Overview==
==[[Overview]]==


'''Adenomyosis''' is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus).<ref>Katz VL. Benign gynecologic lesions: vulva, vagina, cervix, uterus, oviduct, ovary. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007: Chapter 18.</ref> <ref>Speroff L, Fritz MA. Dysfunction uterine bleeding. In. Speroff L, Fritz MA, eds. Clinical Gynecologic Endocrinology and Infertility. 7th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2005: Chapter 15.</ref> The condition is typically found in women in the ages between 35 and 50.  Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50.  Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely.  With diffuse involvement, the uterus becomes bulky and heavier.
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely.  With diffuse involvement, the uterus becomes bulky and heavier.


==Historical Perspective<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887  }} </ref>==
==[[Historical Perspective]]==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'. <br>
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887  }} </ref>. <br>
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]].
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]]<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887  }} </ref>.
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].


==Classification==
==[[Classification]]==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
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*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912  }} </ref>.
*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912  }} </ref>.


==Pathophysiology==
==[[Pathophysiology]]==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847  }} </ref>:
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847  }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests.
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The basic Fibroblast Growth Factor (bFGF) receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364  }} </ref>.  
*The '''basic Fibroblast Growth Factor (bFGF)''' receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364  }} </ref>.  
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354  }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795  }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866  }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904  }} </ref> also contribute to the pathogenesis of the disease.  
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354  }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795  }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866  }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904  }} </ref> also contribute to the pathogenesis of the disease.  
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870  }} </ref>.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870  }} </ref>.
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==Causes==
==[[Causes]]==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[caesarean section]]
* [[Caesarean section]]
* [[Tubal ligation]]
* [[Tubal ligation]]
* [[Pregnancy termination]]
* [[Abortion]]
* [[pregnancy]]
* [[Pregnancy]]


==Differential Diagnosis of Adenomyosis==
==[[Differentiating adenomyosis from other Diseases]]==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.


{| class="wikitable"
For further information about the differential diagnosis, click [[Adenomyosis differential diagnosis|here]].
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]] 
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099  }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496  }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035  }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners 
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]] 
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge 
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549  }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing 
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}


==Epidemiology and Demographics==
==[[Epidemiology and Demographics]]==
* The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868  }} </ref>.
* In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue=  | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281  }} </ref>.
 
===Age===
===Age===  
*Patients of all age groups may develop [disease name].
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099  }} </ref>.
*[Disease name] is more commonly observed among patients aged [age range] years old.
*[Disease name] is more commonly observed among [elderly patients/young patients/children].
===Gender===
*[Disease name] affects men and women equally.
   
*[Gender 1] are more commonly affected with [disease name] than [gender 2].
* The [gender 1] to [Gender 2] ratio is approximately [number > 1] to 1.
   
   
===Race===
===Race===
*There is no racial predilection for [disease name].
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870  }} </ref>
*[Disease name] usually affects individuals of the [race 1] race.
*[Race 2] individuals are less likely to develop [disease name].


==Risk Factors==
==[[Risk Factors]]==
*Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].
*Similar to the [[epidemiology]], the risk factors of [[adenomyosis]] are unknown and difficult to be accurately determined as [[diagnosis]] is based on examining [[pathological]] specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue=  | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281  }} </ref>.
* [[Adenomyosis]] often coexists with other pelvic diseases namely [[endometriosis]] and [[leiomyoma]], so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099  }} </ref>.
* Prior [[uterine]] surgery has been shown to be a possible risk factor for the development of [[adenomyosis]]<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398  }} </ref>.


== Natural History, Complications and Prognosis==
==[[Adenomyosis natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
*The majority of patients with [disease name] remain asymptomatic for [duration/years].
*Early clinical features of adenomyosis include [[dysmenorrhea]], heavy [[menstrual bleeding]], and [[chronic pelvic pain]].
*Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
*Some reported [[complications]] of adenomyosis are [[preterm]] birth and [[miscarriage]] in young women diagnosed by pelvic imaging<ref name="pmid31318420">{{cite journal| author=Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y| title=Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. | journal=Hum Reprod Update | year= 2019 | volume= 25 | issue= 5 | pages= 592-632 | pmid=31318420 | doi=10.1093/humupd/dmz012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318420  }} </ref>. The relationship of adenomyosis to [[infertility]] is controversial<ref name="pmid22442261">{{cite journal| author=Maheshwari A, Gurunath S, Fatima F, Bhattacharya S| title=Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. | journal=Hum Reprod Update | year= 2012 | volume= 18 | issue= 4 | pages= 374-92 | pmid=22442261 | doi=10.1093/humupd/dms006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22442261  }} </ref>.
*If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
*[[Prognosis]] is generally good as [[surgical treatment]] by [[hysterectomy]] is often curable unless there is another associated [[uterine]] pathology that requires further attention. There is no increased risk for secondary development of [[endometrial carcinoma]].
*Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
*Prognosis is generally [excellent/good/poor], and the [1/5/10­year mortality/survival rate] of patients with [disease name] is approximately [#%].
There is no increased risk for cancer development. As the condition is estrogen-dependent, menopause presents a natural cure. Patients with adenomyosis often also have [[leiomyoma]]ta and/or [[endometriosis]].


==Diagnosis==
==[[Diagnosis]]==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI).  Transvaginal ultrasound is the most cost effective and most available.  Either modality will show an enlarged uterus.  On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].
[[Adenomyosis]] is a [[histopathological]] [[diagnosis]] that is made after [[hysterectomy]]. The preoperative [[diagnosis]] is suggested by pelvic [[imaging]] such as [[transvaginal ultrasound]] and [[MRI]] along with the classical presentation of heavy [[menstrual bleeding]], [[dysmenorrhea]], and [[uniformly enlarged globular uterus]].
   
===[[Symptoms]]===
*[[Symptoms]] of [[adenomyosis]] may include the following<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783  }} </ref>:
:*Heavy [[menstrual bleeding]]
:*[[Dysmenorrhea]]
:*Chronic [[pelvic pain]]


MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound).  In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (&lt;8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.
===[[Physical Examination]]===
*Bimanual [[pelvic examination]] may be remarkable for<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783  }} </ref>:
:*Diffusely enlarged [[uterus]] (Boggy soft uterus)
:*[[Uterus]] is mobile (not fixed as in endometriosis)
:*Uterine [[tenderness]] may be noted.


MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.
=== [[Pelvic Imaging]] ===


===Diagnostic Criteria===
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost-effective and most available.  Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]
   
=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of [disease name] may include the following:
:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]
=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Physical examination may be remarkable for:
:*[finding 1]
:*[finding 2]
:*[finding 3]
:*[finding 4]
:*[finding 5]
:*[finding 6]


===Ultrasonography===
====[[Ultrasonography]]====


*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.
*Typical appearances of [[adenomyosis]] at [[transvaginal ultrasound]] include poorly marginated [[hypoechoic]] and [[heterogeneous]] areas within the [[myometrium]], [[myometrial]] cysts, and a globular or enlarged [[uterus]] with asymmetry.


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===Computed Tomography===
====[[Computed Tomography]]====


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===Magnetic Resonance Imaging===
====[[Magnetic Resonance Imaging]]====
 
* [[MRI]] provides better diagnostic capability due to the increased spatial and contrast [[resolution]], and to not be limited by the presence of bowel gas or calcified [[uterine]] fibroids (as is [[ultrasound]]).  In particular, [[MRI]] is better able to differentiate [[adenomyosis]] from multiple small [[leiomyoma|uterine fibroids]].
 
* [[MRI]] can be used to classify [[adenomyosis]] based on the depth of penetration of the ectopic [[endometrium]] into the [[myometrium]].


*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.  
*[[Adenomyosis]] appears as either diffuse or focal thickening (greater than 12 mm )of the [[junctional zone]] forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on [[T2-weighted]] images.  
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.
 
*[[Histologically]], areas of low signal intensity correspond to [[smooth muscle]] [[hyperplasia]], and bright foci on [[T2-weighted]] images correspond to islands of ectopic [[endometrial]] tissue and cystic dilatation of [[glands]].


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== Treatment ==
== [[Treatment]] ==  
=== Medical Therapy ===
=== [[Surgery]] ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.
*[[Surgery]] is the mainstay of therapy for [[adenomyosis]]<ref name="pmid30918629">{{cite journal| author=Vannuccini S, Petraglia F| title=Recent advances in understanding and managing adenomyosis. | journal=F1000Res | year= 2019 | volume= 8 | issue=  | pages=  | pmid=30918629 | doi=10.12688/f1000research.17242.1 | pmc=6419978 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30918629 }} </ref>.
   
*[[Hysterectomy]] with preservation of the [[ovaries]] is the most common approach to the [[treatment]] of [[adenomyosis]], and it is done via [[abdominal]], [[transvaginal]], [[laparoscopic]] approach, or [[robotic surgery]]. <ref name="pmid30918629">{{cite journal| author=Vannuccini S, Petraglia F| title=Recent advances in understanding and managing adenomyosis. | journal=F1000Res | year= 2019 | volume= 8 | issue=  | pages=  | pmid=30918629 | doi=10.12688/f1000research.17242.1 | pmc=6419978 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30918629  }} </ref>.
*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*Unlike [[Leiomyoma]], there is no plane of cleavage to excise [[adenomyomas]] and preserve the [[uterus]]. [[Uterus]] sparing resection is an investigational approach especially for young women seeking future [[pregnancy]]<ref name="pmid9825848">{{cite journal| author=Wood C| title=Surgical and medical treatment of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 323-36 | pmid=9825848 | doi=10.1093/humupd/4.4.323 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825848  }} </ref>.
*[Medical therapy 1] acts by [mechanism of action 1].
 
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].
=== [[Medical Therapy]] ===
*[[Medical]] [[treatment]] for [[dysmenorrhea]] and [[menorrhagia]] can be prescribed as a temporary alternative for young women in the child-bearing period.
=== Surgery ===
*[[Hormonal]] therapy to control the symptoms includes [[levonorgestrel]]-releasing [[IUD]] (most preferred method), [[combined oral contraceptive pills]], [[GnRH]] analogs, and oral [[GnRH]] antagonists<ref name="pmid31971678">{{cite journal| author=Schlaff WD, Ackerman RT, Al-Hendy A, Archer DF, Barnhart KT, Bradley LD | display-authors=etal| title=Elagolix for Heavy Menstrual Bleeding in Women with Uterine Fibroids. | journal=N Engl J Med | year= 2020 | volume= 382 | issue= 4 | pages= 328-340 | pmid=31971678 | doi=10.1056/NEJMoa1904351 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31971678  }} </ref>.
*Surgery is the mainstay of therapy for [disease name].
*[[Levonorgestrel]]-[[IUD]] has a direct action on the [[uterus]]. It alleviates [[dysmenorrhea]] and [[menorrhagia]]<ref name="pmid17707716">{{cite journal| author=Bragheto AM, Caserta N, Bahamondes L, Petta CA| title=Effectiveness of the levonorgestrel-releasing intrauterine system in the treatment of adenomyosis diagnosed and monitored by magnetic resonance imaging. | journal=Contraception | year= 2007 | volume= 76 | issue= 3 | pages= 195-9 | pmid=17707716 | doi=10.1016/j.contraception.2007.05.091 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17707716  }} </ref>.
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*Once the [[hormonal]] [[therapy]] is stopped to conceive, [[symptoms]] recur within six months.
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].
=== Prevention ===
*There are no primary preventive measures available for [disease name].
   
   
*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].
=== [[Uterine artery embolization]] ===
 
*In women who decline [[hysterectomy]] or have [[contraindications]] for [[hysterectomy]] or women who failed [[hormonal]] [[therapy]], [[uterine artery embolization]] can be an alternative to control [[dysmenorrhea]] and heavy [[menstrual bleeding]].<ref name="pmid27806072">{{cite journal| author=Zhou J, He L, Liu P, Duan H, Zhang H, Li W | display-authors=etal| title=Outcomes in Adenomyosis Treated with Uterine Artery Embolization Are Associated with Lesion Vascularity: A Long-Term Follow-Up Study of 252 Cases. | journal=PLoS One | year= 2016 | volume= 11 | issue= 11 | pages= e0165610 | pmid=27806072 | doi=10.1371/journal.pone.0165610 | pmc=5091759 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27806072  }} </ref>.
*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].
* The outcomes of the [[procedure]] are significantly correlated with the lesion [[vascularity]].<ref name="pmid27806072">{{cite journal| author=Zhou J, He L, Liu P, Duan H, Zhang H, Li W | display-authors=etal| title=Outcomes in Adenomyosis Treated with Uterine Artery Embolization Are Associated with Lesion Vascularity: A Long-Term Follow-Up Study of 252 Cases. | journal=PLoS One | year= 2016 | volume= 11 | issue= 11 | pages= e0165610 | pmid=27806072 | doi=10.1371/journal.pone.0165610 | pmc=5091759 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27806072  }} </ref>.
 
 
Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.
 
Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.


==References==
==[[References]]==
{{Reflist|2}}
{{Reflist|2}}


==Additional Resources==
==[[Additional Resources]]==
{{refbegin|2}}
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.   
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.   

Latest revision as of 20:25, 25 May 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun M.D. PhD.[2], Dina Elantably, MD[3]

Overview

Adenomyosis is a medical condition characterized by the presence of ectopic endometrial tissue (the inner lining of the uterus) within the myometrium (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse menses (dysmenorrhea & menorrhagia, respectively). Adenomyosis may involve the uterus focally, creating an adenomyoma, or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

Historical Perspective

  • Adenomyosis was first discovered by Carl von Rokitansky, a German pathologist, in 1860 when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'[1].
  • In 1892 the first systematic investigation of adenomyosis was carried out by 'Thomas Stephen Cullen', a gynecologist. He distinguished 3 types of adenomyoma: intramural, subperitoneal and submucous adenomyoma[1].
  • In 1893, Kelly and Cullen described the pathogenesis of adenomyoma. The 'gradual ascendancy of Cullen’s mucosal theory' stated that endometrium invades the inner myometrium through the presence in it of ‘chinks’, or fissures.
  • In 1892, Cullen described that abdominal hysterectomy is indicated for treatment as the endometrial growths are interwoven with the normal muscle of the uterus.

Classification

  • Adenomyosis can be classified according to its histopathology into 2 groups:
  • Diffuse adenomyosis: Uniformly enlarged boggy uterus.
  • Focal adenomyosis (adenomyoma): Grossly it resembles fibroid but without a surrounding pseudocapsule.
  • Other variants of adenomyosis include juvenile cystic adenomyosis; which is the presence of endometrial cysts > 1cm in diameter within the myometrium. It is usually seen in young women <30 years old [2].

Pathophysiology

  1. Endomyometrial invagination of the endometrium; due to weakness of the uterine smooth muscles.
  2. De novo development of adenomyosis from mullerian rests due to metaplasia.

{{#ev:youtube|nOCtpIwCZ-Y}}

Causes

The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:

Differentiating adenomyosis from other Diseases

For further information about the differential diagnosis, click here.

Epidemiology and Demographics

  • It is generally estimated that adenomyosis is present in 20-35% of women[10].
  • The incidence and prevalence of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing hysterectomy, so the total population of women having the disease is not known[11].

Age

Race

  • There is no racial predilection for adenomyosis.
  • Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease[9]

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

Adenomyosis is a histopathological diagnosis that is made after hysterectomy. The preoperative diagnosis is suggested by pelvic imaging such as transvaginal ultrasound and MRI along with the classical presentation of heavy menstrual bleeding, dysmenorrhea, and uniformly enlarged globular uterus.

Symptoms

Physical Examination

  • Diffusely enlarged uterus (Boggy soft uterus)
  • Uterus is mobile (not fixed as in endometriosis)
  • Uterine tenderness may be noted.

Pelvic Imaging

The uterus may be imaged using ultrasound (US) or magnetic resonance imaging (MRI). Transvaginal ultrasound is the most cost-effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize uterine fibroids.

Ultrasonography

Image courtesy of RadsWiki

  • US: Adenomyosis

    US: Adenomyosis

  • US: Adenomyosis

    US: Adenomyosis

  • US: Adenomyosis

    US: Adenomyosis

Computed Tomography

Images courtesy of RadsWiki

  • CT: Adenomyosis

    CT: Adenomyosis

  • CT: Adenomyosis

    CT: Adenomyosis

Magnetic Resonance Imaging

  • Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.

Images courtesy of RadsWiki

  • T2: Adenomyosis

    T2: Adenomyosis

  • T2: Adenomyosis

    T2: Adenomyosis

  • T2: Adenomyosis

    T2: Adenomyosis

  • T1 fat sat contrast: Adenomyosis

    T1 fat sat contrast: Adenomyosis

Images courtesy of RadsWiki

MR: T2 image demonstrates adenomyosis


MR: T2 image demonstrates adenomyosis


Treatment

Surgery

Medical Therapy

Uterine artery embolization

References

  1. ↑ 1.0 1.1 Benagiano G, Brosens I (2006). "History of adenomyosis". Best Pract Res Clin Obstet Gynaecol. 20 (4): 449–63. doi:10.1016/j.bpobgyn.2006.01.007. PMID 16515887.
  2. ↑ Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M (2010). "Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases". Fertil Steril. 94 (3): 862–8. doi:10.1016/j.fertnstert.2009.05.010. PMID 19539912.
  3. ↑ Ferenczy A (1998). "Pathophysiology of adenomyosis". Hum Reprod Update. 4 (4): 312–22. doi:10.1093/humupd/4.4.312. PMID 9825847.
  4. ↑ Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA (2001). "Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium". Menopause. 8 (5): 368–71. doi:10.1097/00042192-200109000-00012. PMID 11528364.
  5. ↑ Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG; et al. (2005). "Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer". Exp Toxicol Pathol. 56 (4–5): 255–63. doi:10.1016/j.etp.2004.10.001. PMID 15816354.
  6. ↑ Guo SW, Mao X, Ma Q, Liu X (2013). "Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis". Fertil Steril. 99 (1): 231–240. doi:10.1016/j.fertnstert.2012.08.038. PMID 22999795.
  7. ↑ Stewart EA (2001). "Gonadotropins and the uterus: is there a gonad-independent pathway?". J Soc Gynecol Investig. 8 (6): 319–26. PMID 11750866.
  8. ↑ Mori T, Singtripop T, Kawashima S (1991). "Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice?". Am J Obstet Gynecol. 165 (1): 232–4. doi:10.1016/0002-9378(91)90258-s. PMID 1853904.
  9. ↑ 9.0 9.1 9.2 9.3 Bergeron C, Amant F, Ferenczy A (2006). "Pathology and physiopathology of adenomyosis". Best Pract Res Clin Obstet Gynaecol. 20 (4): 511–21. doi:10.1016/j.bpobgyn.2006.01.016. PMID 16563870.
  10. ↑ Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L (2006). "Adenomyosis: epidemiological factors". Best Pract Res Clin Obstet Gynaecol. 20 (4): 465–77. doi:10.1016/j.bpobgyn.2006.01.017. PMID 16563868.
  11. ↑ 11.0 11.1 Abbott JA (2017). "Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management". Best Pract Res Clin Obstet Gynaecol. 40: 68–81. doi:10.1016/j.bpobgyn.2016.09.006. PMID 27810281.
  12. ↑ 12.0 12.1 Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P (2006). "Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis". Fertil Steril. 86 (3): 711–5. doi:10.1016/j.fertnstert.2006.01.030. PMID 16782099.
  13. ↑ Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP (2004). "Is prior uterine surgery a risk factor for adenomyosis?". Obstet Gynecol. 104 (5 Pt 1): 1034–8. doi:10.1097/01.AOG.0000143264.59822.73. PMID 15516398.
  14. ↑ Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y (2019). "Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis". Hum Reprod Update. 25 (5): 592–632. doi:10.1093/humupd/dmz012. PMID 31318420.
  15. ↑ Maheshwari A, Gurunath S, Fatima F, Bhattacharya S (2012). "Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes". Hum Reprod Update. 18 (4): 374–92. doi:10.1093/humupd/dms006. PMID 22442261.
  16. ↑ 16.0 16.1 McElin TW, Bird CC (1974). "Adenomyosis of the uterus". Obstet Gynecol Annu. 3 (0): 425–41. PMID 4608783.
  17. ↑ 17.0 17.1 Vannuccini S, Petraglia F (2019). "Recent advances in understanding and managing adenomyosis". F1000Res. 8. doi:10.12688/f1000research.17242.1. PMC 6419978. PMID 30918629.
  18. ↑ Wood C (1998). "Surgical and medical treatment of adenomyosis". Hum Reprod Update. 4 (4): 323–36. doi:10.1093/humupd/4.4.323. PMID 9825848.
  19. ↑ Schlaff WD, Ackerman RT, Al-Hendy A, Archer DF, Barnhart KT, Bradley LD; et al. (2020). "Elagolix for Heavy Menstrual Bleeding in Women with Uterine Fibroids". N Engl J Med. 382 (4): 328–340. doi:10.1056/NEJMoa1904351. PMID 31971678.
  20. ↑ Bragheto AM, Caserta N, Bahamondes L, Petta CA (2007). "Effectiveness of the levonorgestrel-releasing intrauterine system in the treatment of adenomyosis diagnosed and monitored by magnetic resonance imaging". Contraception. 76 (3): 195–9. doi:10.1016/j.contraception.2007.05.091. PMID 17707716.
  21. ↑ 21.0 21.1 Zhou J, He L, Liu P, Duan H, Zhang H, Li W; et al. (2016). "Outcomes in Adenomyosis Treated with Uterine Artery Embolization Are Associated with Lesion Vascularity: A Long-Term Follow-Up Study of 252 Cases". PLoS One. 11 (11): e0165610. doi:10.1371/journal.pone.0165610. PMC 5091759. PMID 27806072.

Additional Resources

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  • Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
  • Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
  • Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
  • Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
  • Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
  • Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
  • Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
  • Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
  • Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
  • Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
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  • Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.

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