Adenomyosis

Question 1

What is adenomyosis

Answer 1

Presence of functional endometrial tissue within the myometrium of the uterus
Benign invasion of the middle layer of the uterine wall has been described as a variant of endometriosis

Question 2

What are the symptoms of adenomyosis

Answer 2

Menorrhagia
Dysmenorrhoea - progressive, beginning as cyclical pain but can worsen to daily pain
Deep dyspareunia
Irregular bleeding

Question 3

What does adenomyosis commonly occur with?

Answer 3

Fibroids

Question 4

When is adenomyosis thought to occur?

Answer 4

When the endometrial stroma (connective/supporting tissue) is allowed to communicate with the underlying myometrium after uterine damage

Pregnancy and childbirth
C-section
Uterine surgery
Surgical management of miscarriage or termination of pregnancy

Question 5

Where is adenomyosis more commonly found?

Answer 5

Focal/diffuse

Posterior wall of the uterus

Question 6

What is an adenomyoma

Answer 6

Collection of endometrial glands which form grossly visible nodules

Receptors found in the ectopic endometrial tissue - oestrogen, progesterone and androgen receptors

Question 7

What are the risk factors for adenomyosis

Answer 7

High parity
Uterine surgery
Previous c-section
Hereditary occurrence has been reported, suggesting a potential genetic predisposition

Question 8

What is seen on examination in adenomyosis

Answer 8

Symmetrically enlarged tender uterus on abdominal and bimanual palpation

Question 9

List the differential diagnosis for menorrhagia and dysmenorrhoea

Answer 9

Endometriosis
Fibroids
Endometrial hyperplasia/endometrial carcinoma
Endometrial polyps
Pelvic inflammatory disease
Hypothyroidism and coagulation disorders (menorrhagia)

Question 10

List some investigations for adenomyosis

Answer 10

TV USS - highly observer dependent, but there is agreement on the signs seen in adenomyosis - these include a globular uterine configuration, poor definition of the endometrial-myometrial interface, myometrial anterior posterior asymmetry, intamyometrial cysts and a heterogenous myometrial echo texture

MRI - endo-myometrial junctional zone that can be distinguished from the endometrium and outer myometrium. Irregular thickening of this zone

Histological diagnosis from hysteroscopic biopsy

Question 11

Describe the management of adenomyosis

Answer 11

Hysterectomy 
Hormone therapy - COCP, POP. GnrH agonists, aromatase inhibitors  (reduce proliferation of ectopic endometrial cells and reduce their mass and decrease uterine size and volume of blood lost) 
Uterine artery embolisation 
Endometrial ablation and resection
Laparoscopic excision
NSAIDs