Adenomyosis

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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'.
  
• 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 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 .

Pathophysiology

• The pathogenesis of Adenomyosis is poorly understood. There two theories that explain the possible pathogenesis:

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.

• The basic Fibroblast Growth Factor (bFGF) receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal uterine bleeding and menorrhagia.
• Estrogen and progesterone hormones play a role in the pathogenesis of adenomyosis. Other hormones such as oxytocin , FSH, and prolactin 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.
• On microscopic histopathological analysis, there are endometrial glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the myometrium.

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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:

• Caesarean section
• Tubal ligation
• Abortion
• Pregnancy

Differential Diagnosis of Adenomyosis

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.

	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 serum cancer antigen-125  Nodules of the recto vaginal septum and hypoechoic, vascular mass on MRI Laproscopic visualization confirms the diagnosis
Adenomyosis	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 leiomyomas	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
Pelvic Inflammatory disease	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, uterine, and adnexal tenderness Visualization of purulent endocervical discharge	Positive Nucleic acid amplification tests for Chlamydia trachomatis and N. gonorrhoeae Gram negative diplococci on gram stain
Pelvic congestion Syndrome	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

• It is generally estimated that adenomyosis is present in 20-35% of women.
• 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.

Age

• Adenomyosis is more commonly observed among women aged 40-50 years in those undergoing hysterectomy for diagnosis.
• Adenomyosis is less commonly diagnosed in adolescents who undergo pelvic imaging by transvaginal ultrasound or MRI rather than a hysterectomy for diagnosis.

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

Risk Factors

• 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.
• Adenomyosis often coexists with other pelvic diseases namely endometriosis and leiomyoma, so it is unknown whether it exhibits specific risk factors.
• Prior uterine surgery has been shown to be a possible risk factor for the development of adenomyosis.

Natural History, Complications and Prognosis

• Early clinical features of adenomyosis include dysmenorrhea, heavy menstrual bleeding, and chronic pelvic pain.
• Some reported complications of adenomyosis are preterm birth and miscarriage in young women diagnosed by pelvic imaging. The relationship of adenomyosis to infertility is controversial.
• 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.

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

• Symptoms of adenomyosis may include the following:

• Heavy menstrual bleeding
• Dysmenorrhea
• Chronic pelvic pain

Physical Examination

• Bimanual pelvic examination may be remarkable for:

• 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

• 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.

Image courtesy of RadsWiki

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  US: Adenomyosis

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  US: Adenomyosis

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  US: Adenomyosis

Computed Tomography

Images courtesy of RadsWiki

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  CT: Adenomyosis

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  CT: Adenomyosis

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 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.

• 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.

Images courtesy of RadsWiki

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  T2: Adenomyosis

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  T2: Adenomyosis

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  T2: Adenomyosis

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  T1 fat sat contrast: Adenomyosis

Images courtesy of RadsWiki

MR: T2 image demonstrates adenomyosis

MR: T2 image demonstrates adenomyosis

Treatment

Surgery

• Surgery is the mainstay of therapy for adenomyosis.
• 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. .
• 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.

Medical Therapy

• Medical treatment for dysmenorrhea and menorrhagia can be prescribed as a temporary alternative for young women in the child-bearing period.
• Hormonal therapy to control the symptoms includes levonorgestrel-releasing IUD (most preferred method), combined oral contraceptive pills, GnRH analogs, and oral GnRH antagonists.
• Levonorgestrel-IUD has a direct action on the uterus. It alleviates dysmenorrhea and menorrhagia.
• Once the hormonal therapy is stopped to conceive, symptoms recur within six months.

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..
• The outcomes of the procedure are significantly correlated with the lesion vascularity..

Additional Resources

• Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
• 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.
• Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
• Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
• Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
• Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
• Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
• Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
• Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
• Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
• 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.