Adenomyosis Flashcards
What is adenomyosis?
The presence of functional endometrial tissue within the myometrium of the uterrus
Which layer of the uterine wall is invaded by endometrium in adenomyosis?
Middle layer
What is the relationships between adenomyosis and endometriosis?
Adenomyosis has been described as a variant of endometriosis, but although the conditions can occur together, they are distinct diagnoses
How common is adenomyosis in hysterectomy specimens?
It is found in up to 40% of hysterectomy specimens
What is the pathophysiology of adenomyosis?
It is thought to occur when the endometrial stroma is allowed to communicate with the underlying myometrium after uterine damage
What is the endometrial stroma?
Connective/supporting tissue
What might cause interaction between the underlying myometrium and the endometrial stroma?
- Pregnancy and childbirth
- C-section
- Uterine surgery
- Surgical management of miscarriage or termination of pregnancy
Give an example of a uterine surgery that might allow the interaction of myometrium and endometrial stroma
Endometrial curettage
Is the invasion of endometrium focal or diffusion in adenomyosis?
Can be either
Where is invasion of endometrium in adenomyosis most commonly found?
In the posterior wall of the uterus
How extensive is the invasion of endometrium in adenomyosis?
Variable
What can happen in severe cases of adenomyosis?
Pockets of menstrual blood can be seen in the myometrium of the hysterectomy specimens
What is an adenomyoma?
When a collection of endometrial glands form grossly visible nodules
What receptors are found in the ectopic endometrial tissue in adenomyosis?
Oestrogen, progesterone, and androgen receptors
What is the result of oestrogen, progesterone, and androgen receptors being found in the endometrial tissue in adenomyosis?
Makes it responsive to hormones
What are the risk factors for adenomyosis?
- High parity
- Uterine surgery
- Previous C-section
- Family history
Give 2 examples of uterine surgery that increase the risk of adenomyosis
- Endometrial curettage
- Endometrial ablation
What are the main presenting symptoms of adenomyosis?
- Menorrhagia
- Dysmenorrhoea
- Deep dyspareunia
- Irregular bleeding
Describe the dysmenorrhoea in adenomyosis
It is commonly progressive, beginning as cyclical pain but can worsen to daily pain
What may be found on examination in adenomyosis?
Symmetrically enlarged tender uterus
What are the differential diagnoses for adenomyosis?
- Endometriosis
- Fibroids
- Endometrial hyperplasia/endometrial carcinoma
- Endometrial polyps
- Pelvic inflammatory disease
- Hypothyroidism and coagulation disorders
How is the definitive diagnosis of adenomyosis made?
Histological diagnosis after hysterectomy
What recent advances have there been in the diagnosis of adenomyosis?
Advances in histological diagnosis from specimens obtained at hysteroscopic biopsy
What can assist the diagnosis of adenomyosis in clinically suspected cases?
Imaging
What imaging is used in adenomyosis?
- Transvaginal ultrasound
- MRI
What is the limitation of transvaginal ultrasound in adenomyosis?
Highly observer dependant
What are the signs of adenomyosis on transvaginal ultrasound?
- Globular uterine configuration
- Poor definition of the endometrial-myometrial interface
- Myometrial anterior-posterior asymmetry
- Intramyometrial cysts
- Heterogenous myometrial echo texture
What does MRI show in adenomyosis?
‘Endo-myometrial junctional zone’ that can be distinguished from the endometrium and outer myometrium
What is recognised as a hallmark of adenomyosis on MRI?
Irregular thickening of the endometrial junction
What is the main aim of the management of adenomyosis?
Control dysmenorrhoea and menorrhagia
What is the only curative therapy for adenomyosis at present?
Hysterectomy
What are the more conservative approaches aimed at symptom control in adenomyosis?
- Analgesia
- Hormone therapy
- Non-hormone treatments
What analgesics are used in adenomyosis?
NSAIDs
What hormone therapies are available for the management of adenomyosis?
- Combined oral contraceptives
- Progestogens
- Gonadotrophin releasing hormone agonists
- Aromatase inhibitors
How can progesterones be administered in adenomyosis?
- Oral
- intrauterine system. e.g. Mirena
What is the purpose of hormonal therapy in adenomyosis?
Reduction of bleeding and cycle control
How do hormonal therapies work in adenomyosis?
Proposed that hormones reduce the proliferation of the ectopic endometrial cells, therefore reducing their mass and subsequently decreasing uterine size and volume of blood lost
What can temporarily induce the regression of adenomyosis?
Continuous combined oral contraceptive and high dose progestins, e.g. SC depot medroxyprogesterone
What are the non-hormonal treatments available in adenomyosis?
- Hysterectomy
- Uterine artery embolism
- Endometrial ablation and resection
- Laparoscopic excision
- MR-guided focused ultrasound
Is uterine embolism a long or short term management option for adenomyosis?
Short and medium
Who is uterine artery embolism a good option for in adenomyosis?
Women who wish to avoid hysterectomy and/or preserve their fertility
What is the aim of uterine artery embolism in adenomyosis?
Block blood supply to the adenomyosis, causing it to shrink
