Adenomyosis

Adenomyosis
Jamie A. M. Massie MD
Ruth B. Lathi MD
Lynn M. Westphal MD
Basics
Description
The presence of endometrial glands and stroma within the uterine musculature.
Age-Related Factors
Primarily occurs in women 3050 years old
Epidemiology
Incidence difficult to determine as diagnosis based on microscopic
examination of uterus and many patients are asymptomatic
Possibly affects up to 1520% of women
Less common in nulliparous women
Risk Factors
Age >30 years
History of uterine surgery
History of childbearing, although increasing parity not associated with

increased risk of disease
Pathophysiology
Unknown, but theories include:
Endomyometrial invagination of the endometrium
Activation of mllerian rests within uterine musculature
Associated Conditions
Leiomyomas
Endometriosis
Endometrial polyps
Diagnosis
Signs and Symptoms
History
Pelvic pain
Excessively heavy or prolonged menstrual bleeding
Secondary dysmenorrhea: Pain that begins after the start of menstrual flow
~1/3 of affected women are asymptomatic.
Review of Systems
Lightheadedness/Dizziness
Primary complaint not GI related
Denies fever/chills
Denies anorexia or nausea/vomiting
Absence of urinary frequency or dysuria
Absence of purulent vaginal discharge
Physical Exam
Symmetrically enlarged and boggy uterus
Uterus soft and tender
Uterus is freely mobile
No uterosacral nodularity
No adnexal masses
Tests
Confirmation of clinical diagnosis can only be made by pathologic evaluation

of uterus at time of hysterectomy.
Gross appearance:
o
Diffusely enlarged uterus with thickened myometrium
Areas of focal involvement may appear as circumscribed

adenomyomas.
Histologic appearance:
o
Endometrial tissue within the myometrium, at least 1 low-power field

from the endomyometrial junction
Zone of endometrial hyperplasia surrounds the adenomatous tissue
Labs
Hysterectomy specimen to pathology
Imaging
TVS shows generally enlarged uterus:
o Diffusely enlarged uterus with thickened uterine wall
MRI is diagnostic modality of choice:

o
Areas of decreased signal intensity in affected areas
Can usually distinguish between uterine fibroids and adenomyomas

(focal areas of adenomyosis)
Differential Diagnosis
Uterine leiomyomata
Endometrial polyps
Uterine malignancy
Primary dysmenorrhea
Endometriosis
Interstitial cystitis
Pelvic adhesive disease
PID
Ovarian torsion
Ectopic pregnancy
Management
General Measures
Only definitive treatment for adenomyosis is total hysterectomy, however, treatment is
based on patient age and desire for future fertility.
Medication (Drugs)
In women who choose to maintain their fertility or have other
contraindications to surgical management, medical treatments can be utilized.
NSAIDs
OCPs
Medroxyprogesterone acetate (Depo Provera)
GnRH agonist:
o
Duration of therapy should be limited to 6 months if used alone.
Add-back therapy with progestins or low-dose OCPs may be utilized to

minimize bone loss and limit vasomotor symptoms.
Surgery
Total hysterectomy, with ovarian conservation:
o Abdominal or laparoscopic-assisted approach
o
Vaginal hysterectomy indicated if the uterus is not significantly

enlarged
Uterine artery embolization:

o
Endomyometrial ablation is useful in patients who desire conservative

surgical management.
Laparoscopic myometrial electrocoagulation
Excision of adenomyomas
Followup
Disposition
Issues for Referral
Suspicion of uterine malignancy prior to surgical intervention or at time of
planned hysterectomy necessitates referral to a gynecologic oncologist.
Patients with adenomyosis and infertility should be referred to reproductive

endocrinologist or gynecologist with expertise in infertility.
P.65
Prognosis
Hysterectomy provides definitive resolution of symptoms.
Medical therapies result in short-term improvement, but symptoms often recur
after discontinuation of therapy.
Conservative surgical interventions, such as endomyometrial ablation or

uterine artery embolization, may have benefit in patients with bleeding as
primary complaint.
Patient Monitoring
Patients with severe menorrhagia are at risk of developing anemia:
Preoperative CBC
Treatment with a GnRH agonist for 3 months preoperatively can improve
hematocrit and decrease need for blood transfusions intraoperatively.
Routine CBC in symptomatic patients or those reporting persistent heavy

bleeding is warranted.
Bibliography
Duehold M, et al. Magnetic resonance imaging and transvaginal ultrasonography for
the diagnosis of adenomyosis. Fertil Steril. 2001;76:588594.
McElin TW, et al. Adenomyosis of the uterus. Obstet Gynecol Annu. 1974;3:425441.
Vercellini P, et al. Adenomyosis at hysterectomy: A study on frequency distribution
and patient characteristics. Human Reprod. 1995;10:11601162.
Wood C. Surgical and medical treatment of adenomyosis. Hum Reprod Update.
1998;4(4):323336.
Miscellaneous
Abbreviations
GnRHGonadotropin-releasing hormone
OCPOral contraceptive pill
PIDPelvic inflammatory disease
TVSTransvaginal ultrasound
Codes
ICD9-CM
617.0:
Adenomyosis
Endometriosis:
Cervix
Internal
Myometrium
Patient Teaching
Pelvic Pain Patient Education Pamphlet, American College of Obstetricians and
Gynecologists, January 2006

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Adenomyosis

Less common in nulliparous women

History of childbearing, although increasing parity not associated with

~1/3 of affected women are asymptomatic.

Denies anorexia or nausea/vomiting

Absence of urinary frequency or dysuria

Absence of purulent vaginal discharge

Uterus is freely mobile

Confirmation of clinical diagnosis can only be made by pathologic evaluation

Diffusely enlarged uterus with thickened myometrium

Areas of focal involvement may appear as circumscribed

Endometrial tissue within the myometrium, at least 1 low-power field

Zone of endometrial hyperplasia surrounds the adenomatous tissue

MRI is diagnostic modality of choice:

Areas of decreased signal intensity in affected areas

Can usually distinguish between uterine fibroids and adenomyomas

Pelvic adhesive disease

Medroxyprogesterone acetate (Depo Provera)

Duration of therapy should be limited to 6 months if used alone.

Add-back therapy with progestins or low-dose OCPs may be utilized to

Vaginal hysterectomy indicated if the uterus is not significantly

Uterine artery embolization:

Endomyometrial ablation is useful in patients who desire conservative

Laparoscopic myometrial electrocoagulation

Patients with adenomyosis and infertility should be referred to reproductive

Conservative surgical interventions, such as endomyometrial ablation or

Routine CBC in symptomatic patients or those reporting persistent heavy

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