Adenomyosis

Adenomyosis refers to the extension of endometrial tissue and stroma into the uterine myometrium. It is described as "endometriosis interna" in older texts although this term is rarely used today. About 15% of women are affected. Most are in their late 30's and 40's. Endometriosis is present in 15% of cases.

Pathologically, the uterus is diffusely enlarged with a thickened myometrium containing characteristic glandular irregularities. The endometrial cavity tends also to be enlarged. There is no distinct capsular margin between the adenomyoma and surrounding myometrium unlike the picture in a uterine myoma.

Presentation is with dysmenorrhoea, dyspareunia and menorrhagia. Patients may have associated infertility. It should be noted that many women with adenomyosis are asymptomatic (1). On examination, the uterus is symmetrically enlarged and tender. It is generally softer than a uterine myoma.

The condition must be distinguished from uterine myoma, pelvic inflammatory disease, endometrial carcinoma and endometrial polyps.

Investigations:

• most accurate modality for the diagnosis of adenomyosis is probably magnetic resonance imaging (1)
  • sensitivity and specificity ranging from 86% to 100%
• diagnosis is, however, often confirmed only at histology after hysterectomy (2)

Treatment depends on the severity of the disease:

• options include palliative GnRH analogues, the levonorgestrel-releasing intrauterine system (1), and total abdominal or vaginal hysterectomy with in general, removal of both ovaries only if the patient is older than 45 years of age
  • suppression of gonadotrophins with GnRH agonists may relieve the symptoms, and although this may not provide a long-term cure, it may allow surgery to be deferred or the menopause to be reached (2)
• when a more conservative line is adopted, D+C is necessary to exclude endometrial carcinoma

Reference:

1. Farquhar C et al. Medical and surgical management of adenomyosis. Best Pract Res Clin Obstet Gynaecol. 2006;20(4):603-16.
2. Cheong Y, Stones W. Investigations for chronic pelvic pain. Revs in Gynaecol Pract 2005; 5 (4): 227-236.
3. Kroon N, Reginald P. Medical management of chronic pelvic pain. Curr. Obs. & Gynae. 2005; 15 (5): 285-290.