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    Adenomiosis Gyn Induction

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    Hari Sandi
    This document describes a case of a 32-year-old woman who presented with lower abdominal pain for the past two years. Physical examination and imaging revealed an enlarged uterus with a cystic mass in the posterior wall consistent with adenomyosis. The patient underwent an adenomyosis resection procedure where a 6x5cm mass was removed from the posterior uterine corpus. The document then provides definitions, risk factors, diagnostic criteria, treatment options, and pathological findings for adenomyosis. It summarizes that adenomyosis is a benign condition where endometrial tissue is found deep in the uterine wall, and total hysterectomy is the definitive treatment while conservative options aim to preserve fertility.

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    Adenomiosis Gyn Induction

    Uploaded by

    Hari Sandi
    84 views24 pages
    This document describes a case of a 32-year-old woman who presented with lower abdominal pain for the past two years. Physical examination and imaging revealed an enlarged uterus with a cystic mass in the posterior wall consistent with adenomyosis. The patient underwent an adenomyosis resection procedure where a 6x5cm mass was removed from the posterior uterine corpus. The document then provides definitions, risk factors, diagnostic criteria, treatment options, and pathological findings for adenomyosis. It summarizes that adenomyosis is a benign condition where endometrial tissue is found deep in the uterine wall, and total hysterectomy is the definitive treatment while conservative options aim to preserve fertility.

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    This document describes a case of a 32-year-old woman who presented with lower abdominal pain for the past two years. Physical examination and imaging revealed an enlarged uterus with a cystic mass in the posterior wall consistent with adenomyosis. The patient underwent an adenomyosis resection procedure where a 6x5cm mass was removed from the posterior uterine corpus. The document then provides definitions, risk factors, diagnostic criteria, treatment options, and pathological findings for adenomyosis. It summarizes that adenomyosis is a benign condition where endometrial tissue is found deep in the uterine wall, and total hysterectomy is the definitive treatment while conservative options aim to preserve fertility.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    84 views24 pages

    Adenomiosis Gyn Induction

    Uploaded by

    Hari Sandi
    This document describes a case of a 32-year-old woman who presented with lower abdominal pain for the past two years. Physical examination and imaging revealed an enlarged uterus with a cystic mass in the posterior wall consistent with adenomyosis. The patient underwent an adenomyosis resection procedure where a 6x5cm mass was removed from the posterior uterine corpus. The document then provides definitions, risk factors, diagnostic criteria, treatment options, and pathological findings for adenomyosis. It summarizes that adenomyosis is a benign condition where endometrial tissue is found deep in the uterine wall, and total hysterectomy is the definitive treatment while conservative options aim to preserve fertility.

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    ADENOMIOSIS

    GYN INDUCTION T2B


    DECEMBER 2012

    CASE ILUSTRATION (JUNE 1ST 2012)


    Mrs. D V, 32 yo (BC 352 35 99)

    Chief complained:
    Lower abdominal pain since 2 years
    Recent history since last 2 years patient
    complained lower abdominal pain during
    menstruation.
    Menorrhagia 10 pad/day, duration 14 days.
    Vaginal discharge (+) itchy (-) and
    odour(-)mass in abdomen (-).
    Previous
    history
    and
    family
    history:
    Hypertension (-), Asma (-), DM (-), Allergy (-)
    Obstetrical history : P0
    Menstrual story: Menarche 13yo,. Regular
    cycle 30 days, duration 6 days, pain (-), 3-4
    pads/day
    Marital history: 1x,
    Contraception: (-)

    Physical examination:
    BP : 120/80 PR 88x/mnt RR
    20x/mnt t:afebris
    General state wnl
    Gynecologic state:
    I : v/u wnl
    Io :smooth portio, ostium closed,
    Fluor (-),
    fluxus (-)
    RVT: uterine cavity
    size and
    shape enlarged, cystic mass
    with solid part fulfilled cavum
    douglas until 3 finger above
    the symphisis, with anal
    mucose cannot be assessed

    US FM
    Uterus anteflexed, enlarged,
    At posterior corpus hypoechoic
    mass with irregular edge size 61x40
    mm originated from adenomiosis.
    Stratum basale endometrium is
    reguler,
    thickness
    7
    mm.
    Endoserviks and portio normal
    HSG:
    Right Hydrosalphing with right tuba
    non patent and left tube is patent
    Spermaanalysis: normozoospermia
    A: Adenomiosis
    P: adenomyosis resection

    INTRAOPERATIVE
    Spinal- anesthesia, Pfanenstiel incision
    Exploration: uterus enlarged correspond
    to 12 wga
    Posterior wall of the uterus adhered to
    the rectum, right fallopian tube adhere to
    the rectum, both ovarian and left tube
    wnl
    Performed adhesiolisis.
    Performed chromotubation both tubes
    were patent
    Performed osada technique, the mass
    was 6x5 cm in the posterior corpus.
    Done hemostatic electrocauterization and
    stitches
    Bleeding was 800cc
    Ensure there were no bleeding,abdominal
    washing 500cc saline, and the gauze
    were complete
    Closed the abdominal wall, layer by layer

    DEFINITION

    A benign uterine condition in which endometrial glands


    and stroma are found deep in the myometrium
    A benign disease of the uterus characterized by ectopic
    endometrial glands and stroma within the myometrium
    It is associated with myometrial hypertrophy and may be
    either diffuse or focal
    = myometrial endometriosis

    PREVALENCES

    Occurs primarily in women in 25 45s


    Increase significantly
    Range from 1 50%
    General population 1 2 %
    Infertile women 30 50 %

    RISK FACTORS
    Multi-parous
    Previously history of
    Endometrial hyperplasia
    (OR 2.7; 1.3-5.8)
    Spontaneous abortion (OR 1.6; 1.0-2.4)
    Dilatation and curratage (OR 2.1; 1.1-3.8)

    Neither on the evidence of


    Caesarean section
    (OR 1.19; 0.95-1.50)
    Myomectomy
    (OR 1.12; 0.68-1.85)
    Endometrial ablation
    (OR 3.62; 0.71-14.83)

    1.
    2.

    Parazzini et al. Hum Reprod 1997;12:1275-1279


    Panganamamula et al. Obstet Gynecol 2004;104:1034-1038

    ETIOLOGY OF ADENOMYOSIS
    Four primary theories
    1. Heredity
    (transformation)
    2. Trauma (mechanical
    injuries)
    3. Hyper-estrogenemia
    (food, diseases, medical
    treatment
    4. Viral transmission

    DIAGNOSIS

    Medical History
    Pelvic examinations
    Serum markers CA-125
    Imaging Diagnostic
    Ultrasonography
    CT-scan
    MRI

    Biopsy of uterus(at diagnostic hysteroscopy or


    laparoscopy procedure)

    DIAGNOSTIC CRITERIA

    Asymptomatic adenomyosis occurs in 30-45% parous women

    in reproductive age

    Symptomatic adenomyosis
    Classic symptoms (secondary dysmenorrhea, abnormal uterine
    bleeding)
    Most common physical sign particularly tender during menstruation

    Diagnosis
    Laboratory diagnostic
    methods
    There has been a hope to find specific
    markers in blood with which the diagnosis
    endometriosis could be verified
    One such marker is CA-125 that is produced
    by cells from the celome epithelium. High
    concentrations of CA-125 have been seen
    together with ovarian cancer. Moderately
    high concentrations are seen together with
    inflammatory pelvic diseases and also
    together with endometriosis. This lack of
    specificity reduces the value of the
    determination of CA-125.

    THE DIAGNOSTIC CRITERIA FOR ADENOMYOSIS

    THE PRINCIPLES FOR IMAGING ANALYSIS


    Uterus enlargement
    Asymetrical of uterine shape to midline echo
    Hetero-echogenicity of myometrial
    imaging
    Diffuse junctional-zone thickened
    (not clearly discenible well defined
    margins from the myometrium layer)
    Increase vascular density of tumour
    in myometrium area (profused
    vascularization may be suggestive of
    malignancy)

    ULTRASOUND CHARACTERISTICS OF ADENOMYOSIS.

    Brosens and coworkers


    assessed
    ultrasonographi
    c details such
    as:

    uterine dimensions
    Symmetry of myometrium
    echogenicity of the
    myometrium

    They found that the most predictive is the illdefined heterogeneous echotexture within the
    myometrium.

    MRI
    On T2-weighted MRI, diffuse adenomyosis usually
    manifested as diffuse thickening of the junctional zone
    with homogeneous low signal intensity .T2-weighted
    imaging provided significantly better lesion detection than
    unenhanced or contrast materialenhanced T1-weighted
    imaging

    Sagittal T2-weighted MR image shows diffuse,


    even thickening of the junctional zone (arrows),
    a finding consistent with diffuse adenomyosis

    Diagnosis
    MRT, Magnetic
    Resonance
    Tomography
    Magnetic Resonance Tomography
    has hitherto been use very little but
    there is a hope that the technique
    might develop into a useful
    diagnostic method.
    Endometriomas esp. with blood
    under degradation give rise to a
    relatively characteristic picture,
    provided they are more than 0,5
    cm in diameter.

    PATHOLOGICAL FINDINGS OF

    ADENOMYOSIS

    Usually hyperemic with thickened walls


    The foci are frequently scattered diffusely throughout the myometrium.
    Occasionally may be more circumscribed with the formation of a distinct
    nodule an adenomyoma
    Basal endometrial hyperplasia invading a hyperplastic myometrial stroma

    TREATMENT CHOICES FOR


    ADENOMYOSIS
    CONSERVATIVE
    MEDICINE
    Hormonal (GnRHagonists)
    Enzymes
    (Aromatase
    inhibitots, anti
    Estrogen sulfatase)

    CONSERVATIVE
    RADICAL
    SURGERY
    SURGERY
    Wedge Resection Histerectomy
    Adenomyosis
    Operative
    Laparotomy
    Operative
    Laparoscopy
    Interventional
    imaging

    Laparoscopy
    Laparotomy

    MANAGEMENT
    The only definitive treatment for adenomyosis is
    total hysterectomy, with or without ovarian
    conservation.

    Gonadotropin Releasing Hormone Agonists In The Treatment Of


    Adenomyosis With Infertility

    1. GnRH- agonists is efficient in reducing the adenomyotic


    uterine size, and may facilitate fertility.
    2. For ademyomata associated with infertility, GnRHalpha therapy may avoid the risk of rupture of uterus
    which may occur after adenomyomectomy pregnancy.
    3. For
    infertility,
    GnRH-alpha
    treatment
    before
    laparoscopic surgery greatly decreases surgical
    difficulties and blood loss in certain cases.

    Obstetricts and Gynecology Hospital, Shanghai Medical


    University, Shanghai 2011
    Zhonghua Fu Chan Ke Za Zhi 1999 Apr; 34:214-6

    CONSERVATIVE SURGERY FOR ADENOMYOSIS

    The conservative surgery for adenomyoma can reduce


    symptom and raise pregnancy rate significantly, it can be
    accepted by young women who want to preserve their
    reproductive capacity.
    Though the pregnancy rate of conservative surgery for
    diffused adenomyosis was low, it still has therapeutic
    value

    Zhongguo Yi Xue Ke Xue Yuan Xue Bao 1998 Dec; 20:440-4

    ADENOMYOSIS

    CLINICAL MANAGEMENT
    DIAGNOSTIC PROCEDURES (Laboratory, Biopsy, Imaging)

    CONCERN FOR THE


    FUTURE REPRODUCTIVE
    FUNCTION
    CONSERVATIVE
    MANAGEMENT &
    INTERVENTION

    NOT-CONCERN FOR
    REPRODUCTIVE
    FUNCTION

    MEDICAL TREATMENT
    (HORMONES, ANTI-ENZYMES)

    RADICAL
    MANAGEMENT &
    INTERVENTION

    INTERVENTIONAL NON-SURGERY
    UTERINE ARTERY EMBOLIZATION
    (MRI MICROVIBRATION)

    LAPAROTOMY
    UTERINE WEDGE RESECTION &
    METROPLASTIC SURGERY

    LAPAROTOMY / LAPAROSCOPY
    TOTAL HYSTERECTOMY
    (VAGINAL/ ABDOMINAL/ LAPAROSCOPICALLY)

    Thank you
    FOR KIND ATTETION

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