wikidoc - User contributions [en]

User:Dina

2021-07-27T19:35:53Z

Dina: /* June 2020 - Present: Associate Editor-in-Chief at Wikidoc.org, Remote contributor */

__NOTOC__
==Dina Elantably, MD==

Email:[mailto:dina.antably@gmail.com dina.antably@gmail.com] 
[mailto:dina_elantably@pg.cu.edu.eg dina_elantably@pg.cu.edu.eg] 

==Current Position==
'''June 2020 - Present:''' Associate Editor-in-Chief at Wikidoc.org, Remote contributor

==Education==
* 2020-ECFMG certification
* 2016-MBBCh Degree, Cairo University Faculty of Medicine, Cairo, Egypt

== Honors and Awards ==
* Graduated valedictorian of class 2016-Cairo University Faculty of Medicine.
* 2018-World Congress Fund scholarship award, Milano, Italy
* 2020-Strauss and Katz World Congress Fund scholarship award, SF, USA

== Pages Contributed ==
* [[Cardiorenal syndrome]]
* [[Vasculitis resident survival guide]]
* [[Adenomyosis]]
* [[Adenomyosis differential diagnosis]]
* [[Precocious puberty]]

== Publications ==

* A Elantably, D Elantably. Cardiac tamponade in the setting of a pyogenic liver abscess: A rare but serious complication.. Journal of the American College of Cardiology. 2020, Mar; 75(11 Supplement 1): 2519.

* Abdel Aal AK, Massoud MO, Elantably DM. Does the type and size of Amplatzer vascular plug affect the occlusion time of pulmonary arteriovenous malformations?. Diagn Interv Radiol. 2017, Jan; 23(1): 61. Cited in PubMed; PMID: 27856403.

* El-Enany G, Nagui NA, Nada HR, Elantably D. Multiple recurrent subcutaneous and joint swellings. Int J Dermatol. 2020, Mar; 59(7): 799-800. Cited in PubMed; PMID: 32141077.

* Elantably D, El-Komy MHM, El-Nabarawy EA, Abdelkader HA, Naggar RE.. Enoxaparin induced eruptive angiokeratoma, an extremely rare side effect. J Thromb Thrombolysis. 2020, May; 49(4): 687-689. Cited in PubMed; PMID: 31925666.

* Elantably D, Mourad A, Elantably A, Effat M. Warfarin induced leukocytoclastic vasculitis: an extraordinary side effect. J Thromb Thrombolysis. 2020, Jan; 49(1): 149-152. Cited in PubMed; PMID: 31375992.

* Nada HR, Rashed LA, Elantably DMM, El Sharkawy DA.. Expression of retinoid receptors in hand eczema. Int J Dermatol. 2020, May; 59(5): 576-581. Cited in PubMed; PMID: 32129477.

* Elantably D, Nada H, Sharkawy D, Rashed L.. (March 2021). Decreased expression of retinoid receptors (RAR and RXR) in hand eczema, a case-control study Poster presented at: American Academy of Dermatology; San Francisco, Ca, USA.

* Elantably D., Elenany G., and Mogawer R.. (June, 2019). Blue Rubber Bleb Nevus Syndrome associated with angiokeratomas, an extraordinary association. Poster presented at: 24th World Congress of Dermatology; Milano, ITA.

User:Dina

2021-07-18T20:32:16Z

Dina:

__NOTOC__
==Dina Elantably, MD==

Email:[mailto:dina.antably@gmail.com dina.antably@gmail.com] 
[mailto:dina_elantably@pg.cu.edu.eg dina_elantably@pg.cu.edu.eg] 

==Current Position==
=== June 2020 - Present: Associate Editor-in-Chief at Wikidoc.org, Remote contributor ===

==Education==
* 2020-ECFMG certification
* 2016-MBBCh Degree, Cairo University Faculty of Medicine, Cairo, Egypt

== Honors and Awards ==
* Graduated valedictorian of class 2016-Cairo University Faculty of Medicine.
* 2018-World Congress Fund scholarship award, Milano, Italy
* 2020-Strauss and Katz World Congress Fund scholarship award, SF, USA

== Pages Contributed ==
* [[Cardiorenal syndrome]]
* [[Vasculitis resident survival guide]]
* [[Adenomyosis]]
* [[Adenomyosis differential diagnosis]]
* [[Precocious puberty]]

== Publications ==

* A Elantably, D Elantably. Cardiac tamponade in the setting of a pyogenic liver abscess: A rare but serious complication.. Journal of the American College of Cardiology. 2020, Mar; 75(11 Supplement 1): 2519.

* Abdel Aal AK, Massoud MO, Elantably DM. Does the type and size of Amplatzer vascular plug affect the occlusion time of pulmonary arteriovenous malformations?. Diagn Interv Radiol. 2017, Jan; 23(1): 61. Cited in PubMed; PMID: 27856403.

* El-Enany G, Nagui NA, Nada HR, Elantably D. Multiple recurrent subcutaneous and joint swellings. Int J Dermatol. 2020, Mar; 59(7): 799-800. Cited in PubMed; PMID: 32141077.

* Elantably D, El-Komy MHM, El-Nabarawy EA, Abdelkader HA, Naggar RE.. Enoxaparin induced eruptive angiokeratoma, an extremely rare side effect. J Thromb Thrombolysis. 2020, May; 49(4): 687-689. Cited in PubMed; PMID: 31925666.

* Elantably D, Mourad A, Elantably A, Effat M. Warfarin induced leukocytoclastic vasculitis: an extraordinary side effect. J Thromb Thrombolysis. 2020, Jan; 49(1): 149-152. Cited in PubMed; PMID: 31375992.

* Nada HR, Rashed LA, Elantably DMM, El Sharkawy DA.. Expression of retinoid receptors in hand eczema. Int J Dermatol. 2020, May; 59(5): 576-581. Cited in PubMed; PMID: 32129477.

* Elantably D, Nada H, Sharkawy D, Rashed L.. (March 2021). Decreased expression of retinoid receptors (RAR and RXR) in hand eczema, a case-control study Poster presented at: American Academy of Dermatology; San Francisco, Ca, USA.

* Elantably D., Elenany G., and Mogawer R.. (June, 2019). Blue Rubber Bleb Nevus Syndrome associated with angiokeratomas, an extraordinary association. Poster presented at: 24th World Congress of Dermatology; Milano, ITA.

Precocious puberty

2021-05-27T20:30:04Z

Dina: /* Overview */

__NOTOC__
{{Precocious puberty}}
'''For patient information click [[{{PAGENAME}} (patient information)|here]]'''

{{CMG}} Associate Editor (s)-In-Chief: [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

{{SK}}
pubertas praecox, sexual precocity

==[[Precocious puberty overview|Overview]]==
[[Precocious puberty]] is defined as the development of secondary [[sexual]] characters before the age of eight in [[females]] and nine in [[males]]. The causes of [[precocious puberty]] are numerous and it can range from being a variant of normal development to severe [[life-threatening]] cause (eg; [[germ cell tumor]]). Physicians should differentiate central and peripheral causes of [[precocious puberty]] and determine the need for [[treatment]].

==[[Precocious puberty historical perspective|Historical Perspective]]==
==[[Precocious puberty classification|Classification]]==
 
==[[Precocious puberty pathophysiology|Pathophysiology]]==

==[[Precocious puberty causes|Causes]]==

==[[Differentiating Precocious puberty from other diseases|Differentiating Precocious puberty from other Diseases]]==

==[[Precocious puberty epidemiology and demographics|Epidemiology and Demographics]]==
 

==[[Precocious puberty risk factors|Risk Factors]]==

==[[Precocious puberty screening|Screening]]==
 
==[[Precocious puberty natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
 

==[[Diagnosis]]==
'''History and Symptoms:'''

 

==[[Treatment]]==
'''Central precocious puberty'''

[[Precocious puberty medical therapy|Medical Therapy]] | [[Precocious puberty surgery|Surgery]] | [[Precocious puberty primary prevention|Primary Prevention]] | [[Precocious puberty secondary prevention|Secondary Prevention]] | [[Precocious puberty cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Precocious puberty future or investigational therapies|Future or Investigational Therapies]]

==Case Studies==
 

==Related Chapters==

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

==References==
[[Category:Pediatrics]]
[[Category:Endocrinology]]

 
<references />

Precocious puberty

2021-05-27T20:29:44Z

Dina: /* Overview */

__NOTOC__
{{Precocious puberty}}
'''For patient information click [[{{PAGENAME}} (patient information)|here]]'''

{{CMG}} Associate Editor (s)-In-Chief: [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

{{SK}}
pubertas praecox, sexual precocity

==[[Precocious puberty overview|Overview]]==
 
[[Precocious puberty]] is defined as the development of secondary [[sexual]] characters before the age of eight in [[females]] and nine in [[males]]. The causes of [[precocious puberty]] are numerous and it can range from being a variant of normal development to severe [[life-threatening]] cause (eg; [[germ cell tumor]]). Physicians should differentiate central and peripheral causes of [[precocious puberty]] and determine the need for [[treatment]].

==[[Precocious puberty historical perspective|Historical Perspective]]==
==[[Precocious puberty classification|Classification]]==
 
==[[Precocious puberty pathophysiology|Pathophysiology]]==

==[[Precocious puberty causes|Causes]]==

==[[Differentiating Precocious puberty from other diseases|Differentiating Precocious puberty from other Diseases]]==

==[[Precocious puberty epidemiology and demographics|Epidemiology and Demographics]]==
 

==[[Precocious puberty risk factors|Risk Factors]]==

==[[Precocious puberty screening|Screening]]==
 
==[[Precocious puberty natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
 

==[[Diagnosis]]==
'''History and Symptoms:'''

 

==[[Treatment]]==
'''Central precocious puberty'''

[[Precocious puberty medical therapy|Medical Therapy]] | [[Precocious puberty surgery|Surgery]] | [[Precocious puberty primary prevention|Primary Prevention]] | [[Precocious puberty secondary prevention|Secondary Prevention]] | [[Precocious puberty cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Precocious puberty future or investigational therapies|Future or Investigational Therapies]]

==Case Studies==
 

==Related Chapters==

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

==References==
[[Category:Pediatrics]]
[[Category:Endocrinology]]

 
<references />

Precocious puberty

2021-05-27T15:09:21Z

Dina:

__NOTOC__
{{Precocious puberty}}
'''For patient information click [[{{PAGENAME}} (patient information)|here]]'''

{{CMG}} Associate Editor (s)-In-Chief: [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

{{SK}}
pubertas praecox, sexual precocity

==[[Precocious puberty overview|Overview]]==
 

==[[Precocious puberty historical perspective|Historical Perspective]]==
==[[Precocious puberty classification|Classification]]==
 
==[[Precocious puberty pathophysiology|Pathophysiology]]==

==[[Precocious puberty causes|Causes]]==

==[[Differentiating Precocious puberty from other diseases|Differentiating Precocious puberty from other Diseases]]==

==[[Precocious puberty epidemiology and demographics|Epidemiology and Demographics]]==
 

==[[Precocious puberty risk factors|Risk Factors]]==

==[[Precocious puberty screening|Screening]]==
 
==[[Precocious puberty natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
 

==[[Diagnosis]]==
'''History and Symptoms:'''

 

==[[Treatment]]==
'''Central precocious puberty'''

[[Precocious puberty medical therapy|Medical Therapy]] | [[Precocious puberty surgery|Surgery]] | [[Precocious puberty primary prevention|Primary Prevention]] | [[Precocious puberty secondary prevention|Secondary Prevention]] | [[Precocious puberty cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Precocious puberty future or investigational therapies|Future or Investigational Therapies]]

==Case Studies==
 

==Related Chapters==

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

==References==
[[Category:Pediatrics]]
[[Category:Endocrinology]]

 
<references />

Precocious puberty

2021-05-25T21:47:18Z

Dina: /* Treatment */

__NOTOC__
{{Precocious puberty}}
'''For patient information click [[{{PAGENAME}} (patient information)|here]]'''

{{CMG}} Associate Editor (s)-In-Chief: [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

{{SK}}

==[[Precocious puberty overview|Overview]]==
 

==[[Precocious puberty historical perspective|Historical Perspective]]==
==[[Precocious puberty classification|Classification]]==
 
==[[Precocious puberty pathophysiology|Pathophysiology]]==

==[[Precocious puberty causes|Causes]]==

==[[Differentiating Precocious puberty from other diseases|Differentiating Precocious puberty from other Diseases]]==

==[[Precocious puberty epidemiology and demographics|Epidemiology and Demographics]]==
 

==[[Precocious puberty risk factors|Risk Factors]]==

==[[Precocious puberty screening|Screening]]==
 
==[[Precocious puberty natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
 

==[[Diagnosis]]==
'''History and Symptoms:'''

 

==[[Treatment]]==
'''Central precocious puberty'''

[[Precocious puberty medical therapy|Medical Therapy]] | [[Precocious puberty surgery|Surgery]] | [[Precocious puberty primary prevention|Primary Prevention]] | [[Precocious puberty secondary prevention|Secondary Prevention]] | [[Precocious puberty cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Precocious puberty future or investigational therapies|Future or Investigational Therapies]]

==Case Studies==
 

==Related Chapters==

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

==References==
[[Category:Pediatrics]]
[[Category:Endocrinology]]

 
<references />

Precocious puberty

2021-05-25T20:27:20Z

Dina: /* Diagnosis */

__NOTOC__
{{Precocious puberty}}
'''For patient information click [[{{PAGENAME}} (patient information)|here]]'''

{{CMG}} Associate Editor (s)-In-Chief: [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

{{SK}}

==[[Precocious puberty overview|Overview]]==
 

==[[Precocious puberty historical perspective|Historical Perspective]]==
==[[Precocious puberty classification|Classification]]==
 
==[[Precocious puberty pathophysiology|Pathophysiology]]==

==[[Precocious puberty causes|Causes]]==

==[[Differentiating Precocious puberty from other diseases|Differentiating Precocious puberty from other Diseases]]==

==[[Precocious puberty epidemiology and demographics|Epidemiology and Demographics]]==
 

==[[Precocious puberty risk factors|Risk Factors]]==

==[[Precocious puberty screening|Screening]]==
 
==[[Precocious puberty natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
 

==[[Diagnosis]]==
'''History and Symptoms:'''

 

===Treatment===
'''Central precocious puberty'''

[[Precocious puberty medical therapy|Medical Therapy]] | [[Precocious puberty surgery|Surgery]] | [[Precocious puberty primary prevention|Primary Prevention]] | [[Precocious puberty secondary prevention|Secondary Prevention]] | [[Precocious puberty cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Precocious puberty future or investigational therapies|Future or Investigational Therapies]]

==Case Studies==
 

==Related Chapters==

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

==References==
[[Category:Pediatrics]]
[[Category:Endocrinology]]

 
<references />

Adenomyosis

2021-05-25T20:25:26Z

Dina: /* Natural History, Complications and Prognosis */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==[[Overview]]==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==[[Historical Perspective]]==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]]<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>.
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==[[Classification]]==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==[[Pathophysiology]]==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The '''basic Fibroblast Growth Factor (bFGF)''' receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==[[Causes]]==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[Caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[Pregnancy]]

==[[Differentiating adenomyosis from other Diseases]]==

For further information about the differential diagnosis, click [[Adenomyosis differential diagnosis|here]].

==[[Epidemiology and Demographics]]==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==[[Risk Factors]]==
*Similar to the [[epidemiology]], the risk factors of [[adenomyosis]] are unknown and difficult to be accurately determined as [[diagnosis]] is based on examining [[pathological]] specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.
* [[Adenomyosis]] often coexists with other pelvic diseases namely [[endometriosis]] and [[leiomyoma]], so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.
* Prior [[uterine]] surgery has been shown to be a possible risk factor for the development of [[adenomyosis]]<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398 }} </ref>.

==[[Adenomyosis natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
*Early clinical features of adenomyosis include [[dysmenorrhea]], heavy [[menstrual bleeding]], and [[chronic pelvic pain]].
*Some reported [[complications]] of adenomyosis are [[preterm]] birth and [[miscarriage]] in young women diagnosed by pelvic imaging<ref name="pmid31318420">{{cite journal| author=Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y| title=Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. | journal=Hum Reprod Update | year= 2019 | volume= 25 | issue= 5 | pages= 592-632 | pmid=31318420 | doi=10.1093/humupd/dmz012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318420 }} </ref>. The relationship of adenomyosis to [[infertility]] is controversial<ref name="pmid22442261">{{cite journal| author=Maheshwari A, Gurunath S, Fatima F, Bhattacharya S| title=Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. | journal=Hum Reprod Update | year= 2012 | volume= 18 | issue= 4 | pages= 374-92 | pmid=22442261 | doi=10.1093/humupd/dms006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22442261 }} </ref>.
*[[Prognosis]] is generally good as [[surgical treatment]] by [[hysterectomy]] is often curable unless there is another associated [[uterine]] pathology that requires further attention. There is no increased risk for secondary development of [[endometrial carcinoma]].

==[[Diagnosis]]==
[[Adenomyosis]] is a [[histopathological]] [[diagnosis]] that is made after [[hysterectomy]]. The preoperative [[diagnosis]] is suggested by pelvic [[imaging]] such as [[transvaginal ultrasound]] and [[MRI]] along with the classical presentation of heavy [[menstrual bleeding]], [[dysmenorrhea]], and [[uniformly enlarged globular uterus]].

===[[Symptoms]]===
*[[Symptoms]] of [[adenomyosis]] may include the following<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Heavy [[menstrual bleeding]]
:*[[Dysmenorrhea]]
:*Chronic [[pelvic pain]]

===[[Physical Examination]]===
*Bimanual [[pelvic examination]] may be remarkable for<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Diffusely enlarged [[uterus]] (Boggy soft uterus)
:*[[Uterus]] is mobile (not fixed as in endometriosis)
:*Uterine [[tenderness]] may be noted.

=== [[Pelvic Imaging]] ===

The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost-effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

====[[Ultrasonography]]====

*Typical appearances of [[adenomyosis]] at [[transvaginal ultrasound]] include poorly marginated [[hypoechoic]] and [[heterogeneous]] areas within the [[myometrium]], [[myometrial]] cysts, and a globular or enlarged [[uterus]] with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

====[[Computed Tomography]]====

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

====[[Magnetic Resonance Imaging]]====

* [[MRI]] provides better diagnostic capability due to the increased spatial and contrast [[resolution]], and to not be limited by the presence of bowel gas or calcified [[uterine]] fibroids (as is [[ultrasound]]). In particular, [[MRI]] is better able to differentiate [[adenomyosis]] from multiple small [[leiomyoma|uterine fibroids]].

* [[MRI]] can be used to classify [[adenomyosis]] based on the depth of penetration of the ectopic [[endometrium]] into the [[myometrium]].

*[[Adenomyosis]] appears as either diffuse or focal thickening (greater than 12 mm )of the [[junctional zone]] forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on [[T2-weighted]] images.

*[[Histologically]], areas of low signal intensity correspond to [[smooth muscle]] [[hyperplasia]], and bright foci on [[T2-weighted]] images correspond to islands of ectopic [[endometrial]] tissue and cystic dilatation of [[glands]].

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== [[Treatment]] ==
=== [[Surgery]] ===
*[[Surgery]] is the mainstay of therapy for [[adenomyosis]]<ref name="pmid30918629">{{cite journal| author=Vannuccini S, Petraglia F| title=Recent advances in understanding and managing adenomyosis. | journal=F1000Res | year= 2019 | volume= 8 | issue= | pages= | pmid=30918629 | doi=10.12688/f1000research.17242.1 | pmc=6419978 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30918629 }} </ref>.
*[[Hysterectomy]] with preservation of the [[ovaries]] is the most common approach to the [[treatment]] of [[adenomyosis]], and it is done via [[abdominal]], [[transvaginal]], [[laparoscopic]] approach, or [[robotic surgery]]. <ref name="pmid30918629">{{cite journal| author=Vannuccini S, Petraglia F| title=Recent advances in understanding and managing adenomyosis. | journal=F1000Res | year= 2019 | volume= 8 | issue= | pages= | pmid=30918629 | doi=10.12688/f1000research.17242.1 | pmc=6419978 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30918629 }} </ref>.
*Unlike [[Leiomyoma]], there is no plane of cleavage to excise [[adenomyomas]] and preserve the [[uterus]]. [[Uterus]] sparing resection is an investigational approach especially for young women seeking future [[pregnancy]]<ref name="pmid9825848">{{cite journal| author=Wood C| title=Surgical and medical treatment of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 323-36 | pmid=9825848 | doi=10.1093/humupd/4.4.323 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825848 }} </ref>.

=== [[Medical Therapy]] ===
*[[Medical]] [[treatment]] for [[dysmenorrhea]] and [[menorrhagia]] can be prescribed as a temporary alternative for young women in the child-bearing period.
*[[Hormonal]] therapy to control the symptoms includes [[levonorgestrel]]-releasing [[IUD]] (most preferred method), [[combined oral contraceptive pills]], [[GnRH]] analogs, and oral [[GnRH]] antagonists<ref name="pmid31971678">{{cite journal| author=Schlaff WD, Ackerman RT, Al-Hendy A, Archer DF, Barnhart KT, Bradley LD | display-authors=etal| title=Elagolix for Heavy Menstrual Bleeding in Women with Uterine Fibroids. | journal=N Engl J Med | year= 2020 | volume= 382 | issue= 4 | pages= 328-340 | pmid=31971678 | doi=10.1056/NEJMoa1904351 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31971678 }} </ref>.
*[[Levonorgestrel]]-[[IUD]] has a direct action on the [[uterus]]. It alleviates [[dysmenorrhea]] and [[menorrhagia]]<ref name="pmid17707716">{{cite journal| author=Bragheto AM, Caserta N, Bahamondes L, Petta CA| title=Effectiveness of the levonorgestrel-releasing intrauterine system in the treatment of adenomyosis diagnosed and monitored by magnetic resonance imaging. | journal=Contraception | year= 2007 | volume= 76 | issue= 3 | pages= 195-9 | pmid=17707716 | doi=10.1016/j.contraception.2007.05.091 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17707716 }} </ref>.
*Once the [[hormonal]] [[therapy]] is stopped to conceive, [[symptoms]] recur within six months.

=== [[Uterine artery embolization]] ===
*In women who decline [[hysterectomy]] or have [[contraindications]] for [[hysterectomy]] or women who failed [[hormonal]] [[therapy]], [[uterine artery embolization]] can be an alternative to control [[dysmenorrhea]] and heavy [[menstrual bleeding]].<ref name="pmid27806072">{{cite journal| author=Zhou J, He L, Liu P, Duan H, Zhang H, Li W | display-authors=etal| title=Outcomes in Adenomyosis Treated with Uterine Artery Embolization Are Associated with Lesion Vascularity: A Long-Term Follow-Up Study of 252 Cases. | journal=PLoS One | year= 2016 | volume= 11 | issue= 11 | pages= e0165610 | pmid=27806072 | doi=10.1371/journal.pone.0165610 | pmc=5091759 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27806072 }} </ref>.
* The outcomes of the [[procedure]] are significantly correlated with the lesion [[vascularity]].<ref name="pmid27806072">{{cite journal| author=Zhou J, He L, Liu P, Duan H, Zhang H, Li W | display-authors=etal| title=Outcomes in Adenomyosis Treated with Uterine Artery Embolization Are Associated with Lesion Vascularity: A Long-Term Follow-Up Study of 252 Cases. | journal=PLoS One | year= 2016 | volume= 11 | issue= 11 | pages= e0165610 | pmid=27806072 | doi=10.1371/journal.pone.0165610 | pmc=5091759 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27806072 }} </ref>.

==[[References]]==
{{Reflist|2}}

==[[Additional Resources]]==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-25T19:56:03Z

Dina:

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==[[Overview]]==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==[[Historical Perspective]]==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]]<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>.
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==[[Classification]]==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==[[Pathophysiology]]==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The '''basic Fibroblast Growth Factor (bFGF)''' receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==[[Causes]]==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[Caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[Pregnancy]]

==[[Differentiating adenomyosis from other Diseases]]==

For further information about the differential diagnosis, click [[Adenomyosis differential diagnosis|here]].

==[[Epidemiology and Demographics]]==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==[[Risk Factors]]==
*Similar to the [[epidemiology]], the risk factors of [[adenomyosis]] are unknown and difficult to be accurately determined as [[diagnosis]] is based on examining [[pathological]] specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.
* [[Adenomyosis]] often coexists with other pelvic diseases namely [[endometriosis]] and [[leiomyoma]], so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.
* Prior [[uterine]] surgery has been shown to be a possible risk factor for the development of [[adenomyosis]]<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398 }} </ref>.

==[[Natural History, Complications and Prognosis]]==
*Early clinical features of adenomyosis include [[dysmenorrhea]], heavy [[menstrual bleeding]], and [[chronic pelvic pain]].
*Some reported [[complications]] of adenomyosis are [[preterm]] birth and [[miscarriage]] in young women diagnosed by pelvic imaging<ref name="pmid31318420">{{cite journal| author=Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y| title=Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. | journal=Hum Reprod Update | year= 2019 | volume= 25 | issue= 5 | pages= 592-632 | pmid=31318420 | doi=10.1093/humupd/dmz012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318420 }} </ref>. The relationship of adenomyosis to [[infertility]] is controversial<ref name="pmid22442261">{{cite journal| author=Maheshwari A, Gurunath S, Fatima F, Bhattacharya S| title=Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. | journal=Hum Reprod Update | year= 2012 | volume= 18 | issue= 4 | pages= 374-92 | pmid=22442261 | doi=10.1093/humupd/dms006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22442261 }} </ref>.
*[[Prognosis]] is generally good as [[surgical treatment]] by [[hysterectomy]] is often curable unless there is another associated [[uterine]] pathology that requires further attention. There is no increased risk for secondary development of [[endometrial carcinoma]].

==[[Diagnosis]]==
[[Adenomyosis]] is a [[histopathological]] [[diagnosis]] that is made after [[hysterectomy]]. The preoperative [[diagnosis]] is suggested by pelvic [[imaging]] such as [[transvaginal ultrasound]] and [[MRI]] along with the classical presentation of heavy [[menstrual bleeding]], [[dysmenorrhea]], and [[uniformly enlarged globular uterus]].

===[[Symptoms]]===
*[[Symptoms]] of [[adenomyosis]] may include the following<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Heavy [[menstrual bleeding]]
:*[[Dysmenorrhea]]
:*Chronic [[pelvic pain]]

===[[Physical Examination]]===
*Bimanual [[pelvic examination]] may be remarkable for<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Diffusely enlarged [[uterus]] (Boggy soft uterus)
:*[[Uterus]] is mobile (not fixed as in endometriosis)
:*Uterine [[tenderness]] may be noted.

=== [[Pelvic Imaging]] ===

The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost-effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

====[[Ultrasonography]]====

*Typical appearances of [[adenomyosis]] at [[transvaginal ultrasound]] include poorly marginated [[hypoechoic]] and [[heterogeneous]] areas within the [[myometrium]], [[myometrial]] cysts, and a globular or enlarged [[uterus]] with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

====[[Computed Tomography]]====

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

====[[Magnetic Resonance Imaging]]====

* [[MRI]] provides better diagnostic capability due to the increased spatial and contrast [[resolution]], and to not be limited by the presence of bowel gas or calcified [[uterine]] fibroids (as is [[ultrasound]]). In particular, [[MRI]] is better able to differentiate [[adenomyosis]] from multiple small [[leiomyoma|uterine fibroids]].

* [[MRI]] can be used to classify [[adenomyosis]] based on the depth of penetration of the ectopic [[endometrium]] into the [[myometrium]].

*[[Adenomyosis]] appears as either diffuse or focal thickening (greater than 12 mm )of the [[junctional zone]] forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on [[T2-weighted]] images.

*[[Histologically]], areas of low signal intensity correspond to [[smooth muscle]] [[hyperplasia]], and bright foci on [[T2-weighted]] images correspond to islands of ectopic [[endometrial]] tissue and cystic dilatation of [[glands]].

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== [[Treatment]] ==
=== [[Surgery]] ===
*[[Surgery]] is the mainstay of therapy for [[adenomyosis]]<ref name="pmid30918629">{{cite journal| author=Vannuccini S, Petraglia F| title=Recent advances in understanding and managing adenomyosis. | journal=F1000Res | year= 2019 | volume= 8 | issue= | pages= | pmid=30918629 | doi=10.12688/f1000research.17242.1 | pmc=6419978 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30918629 }} </ref>.
*[[Hysterectomy]] with preservation of the [[ovaries]] is the most common approach to the [[treatment]] of [[adenomyosis]], and it is done via [[abdominal]], [[transvaginal]], [[laparoscopic]] approach, or [[robotic surgery]]. <ref name="pmid30918629">{{cite journal| author=Vannuccini S, Petraglia F| title=Recent advances in understanding and managing adenomyosis. | journal=F1000Res | year= 2019 | volume= 8 | issue= | pages= | pmid=30918629 | doi=10.12688/f1000research.17242.1 | pmc=6419978 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30918629 }} </ref>.
*Unlike [[Leiomyoma]], there is no plane of cleavage to excise [[adenomyomas]] and preserve the [[uterus]]. [[Uterus]] sparing resection is an investigational approach especially for young women seeking future [[pregnancy]]<ref name="pmid9825848">{{cite journal| author=Wood C| title=Surgical and medical treatment of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 323-36 | pmid=9825848 | doi=10.1093/humupd/4.4.323 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825848 }} </ref>.

=== [[Medical Therapy]] ===
*[[Medical]] [[treatment]] for [[dysmenorrhea]] and [[menorrhagia]] can be prescribed as a temporary alternative for young women in the child-bearing period.
*[[Hormonal]] therapy to control the symptoms includes [[levonorgestrel]]-releasing [[IUD]] (most preferred method), [[combined oral contraceptive pills]], [[GnRH]] analogs, and oral [[GnRH]] antagonists<ref name="pmid31971678">{{cite journal| author=Schlaff WD, Ackerman RT, Al-Hendy A, Archer DF, Barnhart KT, Bradley LD | display-authors=etal| title=Elagolix for Heavy Menstrual Bleeding in Women with Uterine Fibroids. | journal=N Engl J Med | year= 2020 | volume= 382 | issue= 4 | pages= 328-340 | pmid=31971678 | doi=10.1056/NEJMoa1904351 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31971678 }} </ref>.
*[[Levonorgestrel]]-[[IUD]] has a direct action on the [[uterus]]. It alleviates [[dysmenorrhea]] and [[menorrhagia]]<ref name="pmid17707716">{{cite journal| author=Bragheto AM, Caserta N, Bahamondes L, Petta CA| title=Effectiveness of the levonorgestrel-releasing intrauterine system in the treatment of adenomyosis diagnosed and monitored by magnetic resonance imaging. | journal=Contraception | year= 2007 | volume= 76 | issue= 3 | pages= 195-9 | pmid=17707716 | doi=10.1016/j.contraception.2007.05.091 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17707716 }} </ref>.
*Once the [[hormonal]] [[therapy]] is stopped to conceive, [[symptoms]] recur within six months.

=== [[Uterine artery embolization]] ===
*In women who decline [[hysterectomy]] or have [[contraindications]] for [[hysterectomy]] or women who failed [[hormonal]] [[therapy]], [[uterine artery embolization]] can be an alternative to control [[dysmenorrhea]] and heavy [[menstrual bleeding]].<ref name="pmid27806072">{{cite journal| author=Zhou J, He L, Liu P, Duan H, Zhang H, Li W | display-authors=etal| title=Outcomes in Adenomyosis Treated with Uterine Artery Embolization Are Associated with Lesion Vascularity: A Long-Term Follow-Up Study of 252 Cases. | journal=PLoS One | year= 2016 | volume= 11 | issue= 11 | pages= e0165610 | pmid=27806072 | doi=10.1371/journal.pone.0165610 | pmc=5091759 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27806072 }} </ref>.
* The outcomes of the [[procedure]] are significantly correlated with the lesion [[vascularity]].<ref name="pmid27806072">{{cite journal| author=Zhou J, He L, Liu P, Duan H, Zhang H, Li W | display-authors=etal| title=Outcomes in Adenomyosis Treated with Uterine Artery Embolization Are Associated with Lesion Vascularity: A Long-Term Follow-Up Study of 252 Cases. | journal=PLoS One | year= 2016 | volume= 11 | issue= 11 | pages= e0165610 | pmid=27806072 | doi=10.1371/journal.pone.0165610 | pmc=5091759 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27806072 }} </ref>.

==[[References]]==
{{Reflist|2}}

==[[Additional Resources]]==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

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Precocious puberty

2021-05-25T19:51:35Z

Dina:

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{{Precocious puberty}}
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{{CMG}} Associate Editor (s)-In-Chief: [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

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==[[Precocious puberty overview|Overview]]==
 

==[[Precocious puberty historical perspective|Historical Perspective]]==
==[[Precocious puberty classification|Classification]]==
 
==[[Precocious puberty pathophysiology|Pathophysiology]]==

==[[Precocious puberty causes|Causes]]==

==[[Differentiating Precocious puberty from other diseases|Differentiating Precocious puberty from other Diseases]]==

==[[Precocious puberty epidemiology and demographics|Epidemiology and Demographics]]==
 

==[[Precocious puberty risk factors|Risk Factors]]==

==[[Precocious puberty screening|Screening]]==
 
==[[Precocious puberty natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
 

==Diagnosis==
'''History and Symptoms:'''

 

===Treatment===
'''Central precocious puberty'''

[[Precocious puberty medical therapy|Medical Therapy]] | [[Precocious puberty surgery|Surgery]] | [[Precocious puberty primary prevention|Primary Prevention]] | [[Precocious puberty secondary prevention|Secondary Prevention]] | [[Precocious puberty cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Precocious puberty future or investigational therapies|Future or Investigational Therapies]]

==Case Studies==
 

==Related Chapters==

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

==References==
[[Category:Pediatrics]]
[[Category:Endocrinology]]

 
<references />

Precocious puberty

2021-05-25T19:51:11Z

Dina:

__NOTOC__
{{Precocious puberty}}
'''For patient information click [[{{PAGENAME}} (patient information)|here]]'''

{{CMG}}Associate Editor (s)-In-Chief: [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

{{SK}}

==[[Precocious puberty overview|Overview]]==
 

==[[Precocious puberty historical perspective|Historical Perspective]]==
==[[Precocious puberty classification|Classification]]==
 
==[[Precocious puberty pathophysiology|Pathophysiology]]==

==[[Precocious puberty causes|Causes]]==

==[[Differentiating Precocious puberty from other diseases|Differentiating Precocious puberty from other Diseases]]==

==[[Precocious puberty epidemiology and demographics|Epidemiology and Demographics]]==
 

==[[Precocious puberty risk factors|Risk Factors]]==

==[[Precocious puberty screening|Screening]]==
 
==[[Precocious puberty natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
 

==Diagnosis==
'''History and Symptoms:'''

 

===Treatment===
'''Central precocious puberty'''

[[Precocious puberty medical therapy|Medical Therapy]] | [[Precocious puberty surgery|Surgery]] | [[Precocious puberty primary prevention|Primary Prevention]] | [[Precocious puberty secondary prevention|Secondary Prevention]] | [[Precocious puberty cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Precocious puberty future or investigational therapies|Future or Investigational Therapies]]

==Case Studies==
 

==Related Chapters==

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

==References==
[[Category:Pediatrics]]
[[Category:Endocrinology]]

 
<references />

Precocious puberty

2021-05-25T19:43:03Z

Dina:

__NOTOC__
{{Precocious puberty}}
'''For patient information click [[{{PAGENAME}} (patient information)|here]]'''

{{CMG}}Associate Editor (s)-In-Chief:[[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

{{SK}}

==[[Precocious puberty overview|Overview]]==
 

==[[Precocious puberty historical perspective|Historical Perspective]]==
==[[Precocious puberty classification|Classification]]==
 
==[[Precocious puberty pathophysiology|Pathophysiology]]==

==[[Precocious puberty causes|Causes]]==

==[[Differentiating Precocious puberty from other diseases|Differentiating Precocious puberty from other Diseases]]==

==[[Precocious puberty epidemiology and demographics|Epidemiology and Demographics]]==
 

==[[Precocious puberty risk factors|Risk Factors]]==

==[[Precocious puberty screening|Screening]]==
 
==[[Precocious puberty natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
 

==Diagnosis==
'''History and Symptoms:'''

 

===Treatment===
'''Central precocious puberty'''

[[Precocious puberty medical therapy|Medical Therapy]] | [[Precocious puberty surgery|Surgery]] | [[Precocious puberty primary prevention|Primary Prevention]] | [[Precocious puberty secondary prevention|Secondary Prevention]] | [[Precocious puberty cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Precocious puberty future or investigational therapies|Future or Investigational Therapies]]

==Case Studies==
 

==Related Chapters==

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

==References==
[[Category:Pediatrics]]
[[Category:Endocrinology]]

 
<references />

User:Dina

2021-05-25T19:41:37Z

Dina: /* Pages Contributed */

__NOTOC__
==Dina Elantably, MD==

Email:[mailto:dina.antably@gmail.com dina.antably@gmail.com] [[Image:dina.jpg|right|250px]]
[mailto:dina_elantably@pg.cu.edu.eg dina_elantably@pg.cu.edu.eg] 

==Current Position==
=== June 2020 - Present: Associate Editor-in-Chief at Wikidoc.org, Remote contributor ===

==Education==
* 2020-ECFMG certification
* 2016-MBBCh Degree, Cairo University Faculty of Medicine, Cairo, Egypt

== Honors and Awards ==
* Graduated valedictorian of class 2016-Cairo University Faculty of Medicine.
* 2018-World Congress Fund scholarship award, Milano, Italy
* 2020-Strauss and Katz World Congress Fund scholarship award, SF, USA

== Pages Contributed ==
* [[Cardiorenal syndrome]]
* [[Vasculitis resident survival guide]]
* [[Adenomyosis]]
* [[Adenomyosis differential diagnosis]]
* [[Precocious puberty]]

== Publications ==

* A Elantably, D Elantably. Cardiac tamponade in the setting of a pyogenic liver abscess: A rare but serious complication.. Journal of the American College of Cardiology. 2020, Mar; 75(11 Supplement 1): 2519.

* Abdel Aal AK, Massoud MO, Elantably DM. Does the type and size of Amplatzer vascular plug affect the occlusion time of pulmonary arteriovenous malformations?. Diagn Interv Radiol. 2017, Jan; 23(1): 61. Cited in PubMed; PMID: 27856403.

* El-Enany G, Nagui NA, Nada HR, Elantably D. Multiple recurrent subcutaneous and joint swellings. Int J Dermatol. 2020, Mar; 59(7): 799-800. Cited in PubMed; PMID: 32141077.

* Elantably D, El-Komy MHM, El-Nabarawy EA, Abdelkader HA, Naggar RE.. Enoxaparin induced eruptive angiokeratoma, an extremely rare side effect. J Thromb Thrombolysis. 2020, May; 49(4): 687-689. Cited in PubMed; PMID: 31925666.

* Elantably D, Mourad A, Elantably A, Effat M. Warfarin induced leukocytoclastic vasculitis: an extraordinary side effect. J Thromb Thrombolysis. 2020, Jan; 49(1): 149-152. Cited in PubMed; PMID: 31375992.

* Nada HR, Rashed LA, Elantably DMM, El Sharkawy DA.. Expression of retinoid receptors in hand eczema. Int J Dermatol. 2020, May; 59(5): 576-581. Cited in PubMed; PMID: 32129477.

* Elantably D, Nada H, Sharkawy D, Rashed L.. (March 2021). Decreased expression of retinoid receptors (RAR and RXR) in hand eczema, a case-control study Poster presented at: American Academy of Dermatology; San Francisco, Ca, USA.

* Elantably D., Elenany G., and Mogawer R.. (June, 2019). Blue Rubber Bleb Nevus Syndrome associated with angiokeratomas, an extraordinary association. Poster presented at: 24th World Congress of Dermatology; Milano, ITA.

Adenomyosis

2021-05-25T19:40:20Z

Dina: /* Differentiating adenomyosis from other Diseases */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]]<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>.
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The '''basic Fibroblast Growth Factor (bFGF)''' receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[Caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[Pregnancy]]

==Differentiating adenomyosis from other Diseases==

For further information about the differential diagnosis, click [[Adenomyosis differential diagnosis|here]].

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==Risk Factors==
*Similar to the [[epidemiology]], the risk factors of [[adenomyosis]] are unknown and difficult to be accurately determined as [[diagnosis]] is based on examining [[pathological]] specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.
* [[Adenomyosis]] often coexists with other pelvic diseases namely [[endometriosis]] and [[leiomyoma]], so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.
* Prior [[uterine]] surgery has been shown to be a possible risk factor for the development of [[adenomyosis]]<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398 }} </ref>.

== Natural History, Complications and Prognosis==
*Early clinical features of adenomyosis include [[dysmenorrhea]], heavy [[menstrual bleeding]], and [[chronic pelvic pain]].
*Some reported [[complications]] of adenomyosis are [[preterm]] birth and [[miscarriage]] in young women diagnosed by pelvic imaging<ref name="pmid31318420">{{cite journal| author=Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y| title=Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. | journal=Hum Reprod Update | year= 2019 | volume= 25 | issue= 5 | pages= 592-632 | pmid=31318420 | doi=10.1093/humupd/dmz012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318420 }} </ref>. The relationship of adenomyosis to [[infertility]] is controversial<ref name="pmid22442261">{{cite journal| author=Maheshwari A, Gurunath S, Fatima F, Bhattacharya S| title=Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. | journal=Hum Reprod Update | year= 2012 | volume= 18 | issue= 4 | pages= 374-92 | pmid=22442261 | doi=10.1093/humupd/dms006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22442261 }} </ref>.
*[[Prognosis]] is generally good as [[surgical treatment]] by [[hysterectomy]] is often curable unless there is another associated [[uterine]] pathology that requires further attention. There is no increased risk for secondary development of [[endometrial carcinoma]].

==Diagnosis==
[[Adenomyosis]] is a [[histopathological]] [[diagnosis]] that is made after [[hysterectomy]]. The preoperative [[diagnosis]] is suggested by pelvic [[imaging]] such as [[transvaginal ultrasound]] and [[MRI]] along with the classical presentation of heavy [[menstrual bleeding]], [[dysmenorrhea]], and [[uniformly enlarged globular uterus]].

=== Symptoms ===
*[[Symptoms]] of [[adenomyosis]] may include the following<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Heavy [[menstrual bleeding]]
:*[[Dysmenorrhea]]
:*Chronic [[pelvic pain]]

=== Physical Examination ===
*Bimanual [[pelvic examination]] may be remarkable for<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Diffusely enlarged [[uterus]] (Boggy soft uterus)
:*[[Uterus]] is mobile (not fixed as in endometriosis)
:*Uterine [[tenderness]] may be noted.

=== Pelvic Imaging ===

The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost-effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

====Ultrasonography====

*Typical appearances of [[adenomyosis]] at [[transvaginal ultrasound]] include poorly marginated [[hypoechoic]] and [[heterogeneous]] areas within the [[myometrium]], [[myometrial]] cysts, and a globular or enlarged [[uterus]] with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

====Computed Tomography====

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

====Magnetic Resonance Imaging====

* [[MRI]] provides better diagnostic capability due to the increased spatial and contrast [[resolution]], and to not be limited by the presence of bowel gas or calcified [[uterine]] fibroids (as is [[ultrasound]]). In particular, [[MRI]] is better able to differentiate [[adenomyosis]] from multiple small [[leiomyoma|uterine fibroids]].

* [[MRI]] can be used to classify [[adenomyosis]] based on the depth of penetration of the ectopic [[endometrium]] into the [[myometrium]].

*[[Adenomyosis]] appears as either diffuse or focal thickening (greater than 12 mm )of the [[junctional zone]] forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on [[T2-weighted]] images.

*[[Histologically]], areas of low signal intensity correspond to [[smooth muscle]] [[hyperplasia]], and bright foci on [[T2-weighted]] images correspond to islands of ectopic [[endometrial]] tissue and cystic dilatation of [[glands]].

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Surgery ===
*[[Surgery]] is the mainstay of therapy for [[adenomyosis]]<ref name="pmid30918629">{{cite journal| author=Vannuccini S, Petraglia F| title=Recent advances in understanding and managing adenomyosis. | journal=F1000Res | year= 2019 | volume= 8 | issue= | pages= | pmid=30918629 | doi=10.12688/f1000research.17242.1 | pmc=6419978 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30918629 }} </ref>.
*[[Hysterectomy]] with preservation of the [[ovaries]] is the most common approach to the [[treatment]] of [[adenomyosis]], and it is done via [[abdominal]], [[transvaginal]], [[laparoscopic]] approach, or [[robotic surgery]]. <ref name="pmid30918629">{{cite journal| author=Vannuccini S, Petraglia F| title=Recent advances in understanding and managing adenomyosis. | journal=F1000Res | year= 2019 | volume= 8 | issue= | pages= | pmid=30918629 | doi=10.12688/f1000research.17242.1 | pmc=6419978 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30918629 }} </ref>.
*Unlike [[Leiomyoma]], there is no plane of cleavage to excise [[adenomyomas]] and preserve the [[uterus]]. [[Uterus]] sparing resection is an investigational approach especially for young women seeking future [[pregnancy]]<ref name="pmid9825848">{{cite journal| author=Wood C| title=Surgical and medical treatment of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 323-36 | pmid=9825848 | doi=10.1093/humupd/4.4.323 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825848 }} </ref>.

=== Medical Therapy ===
*[[Medical]] [[treatment]] for [[dysmenorrhea]] and [[menorrhagia]] can be prescribed as a temporary alternative for young women in the child-bearing period.
*[[Hormonal]] therapy to control the symptoms includes [[levonorgestrel]]-releasing [[IUD]] (most preferred method), [[combined oral contraceptive pills]], [[GnRH]] analogs, and oral [[GnRH]] antagonists<ref name="pmid31971678">{{cite journal| author=Schlaff WD, Ackerman RT, Al-Hendy A, Archer DF, Barnhart KT, Bradley LD | display-authors=etal| title=Elagolix for Heavy Menstrual Bleeding in Women with Uterine Fibroids. | journal=N Engl J Med | year= 2020 | volume= 382 | issue= 4 | pages= 328-340 | pmid=31971678 | doi=10.1056/NEJMoa1904351 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31971678 }} </ref>.
*[[Levonorgestrel]]-[[IUD]] has a direct action on the [[uterus]]. It alleviates [[dysmenorrhea]] and [[menorrhagia]]<ref name="pmid17707716">{{cite journal| author=Bragheto AM, Caserta N, Bahamondes L, Petta CA| title=Effectiveness of the levonorgestrel-releasing intrauterine system in the treatment of adenomyosis diagnosed and monitored by magnetic resonance imaging. | journal=Contraception | year= 2007 | volume= 76 | issue= 3 | pages= 195-9 | pmid=17707716 | doi=10.1016/j.contraception.2007.05.091 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17707716 }} </ref>.
*Once the [[hormonal]] [[therapy]] is stopped to conceive, [[symptoms]] recur within six months.

=== Uterine artery embolization ===
*In women who decline [[hysterectomy]] or have [[contraindications]] for [[hysterectomy]] or women who failed [[hormonal]] [[therapy]], [[uterine artery embolization]] can be an alternative to control [[dysmenorrhea]] and heavy [[menstrual bleeding]].<ref name="pmid27806072">{{cite journal| author=Zhou J, He L, Liu P, Duan H, Zhang H, Li W | display-authors=etal| title=Outcomes in Adenomyosis Treated with Uterine Artery Embolization Are Associated with Lesion Vascularity: A Long-Term Follow-Up Study of 252 Cases. | journal=PLoS One | year= 2016 | volume= 11 | issue= 11 | pages= e0165610 | pmid=27806072 | doi=10.1371/journal.pone.0165610 | pmc=5091759 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27806072 }} </ref>.
* The outcomes of the [[procedure]] are significantly correlated with the lesion [[vascularity]].<ref name="pmid27806072">{{cite journal| author=Zhou J, He L, Liu P, Duan H, Zhang H, Li W | display-authors=etal| title=Outcomes in Adenomyosis Treated with Uterine Artery Embolization Are Associated with Lesion Vascularity: A Long-Term Follow-Up Study of 252 Cases. | journal=PLoS One | year= 2016 | volume= 11 | issue= 11 | pages= e0165610 | pmid=27806072 | doi=10.1371/journal.pone.0165610 | pmc=5091759 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27806072 }} </ref>.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-25T19:39:26Z

Dina:

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]]<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>.
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The '''basic Fibroblast Growth Factor (bFGF)''' receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[Caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[Pregnancy]]

==Differentiating adenomyosis from other Diseases==

For further information about the differential diagnosis, click [[Adenomyosis differential diagnosis|here]].

Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases that can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==Risk Factors==
*Similar to the [[epidemiology]], the risk factors of [[adenomyosis]] are unknown and difficult to be accurately determined as [[diagnosis]] is based on examining [[pathological]] specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.
* [[Adenomyosis]] often coexists with other pelvic diseases namely [[endometriosis]] and [[leiomyoma]], so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.
* Prior [[uterine]] surgery has been shown to be a possible risk factor for the development of [[adenomyosis]]<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398 }} </ref>.

== Natural History, Complications and Prognosis==
*Early clinical features of adenomyosis include [[dysmenorrhea]], heavy [[menstrual bleeding]], and [[chronic pelvic pain]].
*Some reported [[complications]] of adenomyosis are [[preterm]] birth and [[miscarriage]] in young women diagnosed by pelvic imaging<ref name="pmid31318420">{{cite journal| author=Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y| title=Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. | journal=Hum Reprod Update | year= 2019 | volume= 25 | issue= 5 | pages= 592-632 | pmid=31318420 | doi=10.1093/humupd/dmz012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318420 }} </ref>. The relationship of adenomyosis to [[infertility]] is controversial<ref name="pmid22442261">{{cite journal| author=Maheshwari A, Gurunath S, Fatima F, Bhattacharya S| title=Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. | journal=Hum Reprod Update | year= 2012 | volume= 18 | issue= 4 | pages= 374-92 | pmid=22442261 | doi=10.1093/humupd/dms006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22442261 }} </ref>.
*[[Prognosis]] is generally good as [[surgical treatment]] by [[hysterectomy]] is often curable unless there is another associated [[uterine]] pathology that requires further attention. There is no increased risk for secondary development of [[endometrial carcinoma]].

==Diagnosis==
[[Adenomyosis]] is a [[histopathological]] [[diagnosis]] that is made after [[hysterectomy]]. The preoperative [[diagnosis]] is suggested by pelvic [[imaging]] such as [[transvaginal ultrasound]] and [[MRI]] along with the classical presentation of heavy [[menstrual bleeding]], [[dysmenorrhea]], and [[uniformly enlarged globular uterus]].

=== Symptoms ===
*[[Symptoms]] of [[adenomyosis]] may include the following<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Heavy [[menstrual bleeding]]
:*[[Dysmenorrhea]]
:*Chronic [[pelvic pain]]

=== Physical Examination ===
*Bimanual [[pelvic examination]] may be remarkable for<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Diffusely enlarged [[uterus]] (Boggy soft uterus)
:*[[Uterus]] is mobile (not fixed as in endometriosis)
:*Uterine [[tenderness]] may be noted.

=== Pelvic Imaging ===

The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost-effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

====Ultrasonography====

*Typical appearances of [[adenomyosis]] at [[transvaginal ultrasound]] include poorly marginated [[hypoechoic]] and [[heterogeneous]] areas within the [[myometrium]], [[myometrial]] cysts, and a globular or enlarged [[uterus]] with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

====Computed Tomography====

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

====Magnetic Resonance Imaging====

* [[MRI]] provides better diagnostic capability due to the increased spatial and contrast [[resolution]], and to not be limited by the presence of bowel gas or calcified [[uterine]] fibroids (as is [[ultrasound]]). In particular, [[MRI]] is better able to differentiate [[adenomyosis]] from multiple small [[leiomyoma|uterine fibroids]].

* [[MRI]] can be used to classify [[adenomyosis]] based on the depth of penetration of the ectopic [[endometrium]] into the [[myometrium]].

*[[Adenomyosis]] appears as either diffuse or focal thickening (greater than 12 mm )of the [[junctional zone]] forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on [[T2-weighted]] images.

*[[Histologically]], areas of low signal intensity correspond to [[smooth muscle]] [[hyperplasia]], and bright foci on [[T2-weighted]] images correspond to islands of ectopic [[endometrial]] tissue and cystic dilatation of [[glands]].

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Surgery ===
*[[Surgery]] is the mainstay of therapy for [[adenomyosis]]<ref name="pmid30918629">{{cite journal| author=Vannuccini S, Petraglia F| title=Recent advances in understanding and managing adenomyosis. | journal=F1000Res | year= 2019 | volume= 8 | issue= | pages= | pmid=30918629 | doi=10.12688/f1000research.17242.1 | pmc=6419978 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30918629 }} </ref>.
*[[Hysterectomy]] with preservation of the [[ovaries]] is the most common approach to the [[treatment]] of [[adenomyosis]], and it is done via [[abdominal]], [[transvaginal]], [[laparoscopic]] approach, or [[robotic surgery]]. <ref name="pmid30918629">{{cite journal| author=Vannuccini S, Petraglia F| title=Recent advances in understanding and managing adenomyosis. | journal=F1000Res | year= 2019 | volume= 8 | issue= | pages= | pmid=30918629 | doi=10.12688/f1000research.17242.1 | pmc=6419978 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30918629 }} </ref>.
*Unlike [[Leiomyoma]], there is no plane of cleavage to excise [[adenomyomas]] and preserve the [[uterus]]. [[Uterus]] sparing resection is an investigational approach especially for young women seeking future [[pregnancy]]<ref name="pmid9825848">{{cite journal| author=Wood C| title=Surgical and medical treatment of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 323-36 | pmid=9825848 | doi=10.1093/humupd/4.4.323 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825848 }} </ref>.

=== Medical Therapy ===
*[[Medical]] [[treatment]] for [[dysmenorrhea]] and [[menorrhagia]] can be prescribed as a temporary alternative for young women in the child-bearing period.
*[[Hormonal]] therapy to control the symptoms includes [[levonorgestrel]]-releasing [[IUD]] (most preferred method), [[combined oral contraceptive pills]], [[GnRH]] analogs, and oral [[GnRH]] antagonists<ref name="pmid31971678">{{cite journal| author=Schlaff WD, Ackerman RT, Al-Hendy A, Archer DF, Barnhart KT, Bradley LD | display-authors=etal| title=Elagolix for Heavy Menstrual Bleeding in Women with Uterine Fibroids. | journal=N Engl J Med | year= 2020 | volume= 382 | issue= 4 | pages= 328-340 | pmid=31971678 | doi=10.1056/NEJMoa1904351 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31971678 }} </ref>.
*[[Levonorgestrel]]-[[IUD]] has a direct action on the [[uterus]]. It alleviates [[dysmenorrhea]] and [[menorrhagia]]<ref name="pmid17707716">{{cite journal| author=Bragheto AM, Caserta N, Bahamondes L, Petta CA| title=Effectiveness of the levonorgestrel-releasing intrauterine system in the treatment of adenomyosis diagnosed and monitored by magnetic resonance imaging. | journal=Contraception | year= 2007 | volume= 76 | issue= 3 | pages= 195-9 | pmid=17707716 | doi=10.1016/j.contraception.2007.05.091 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17707716 }} </ref>.
*Once the [[hormonal]] [[therapy]] is stopped to conceive, [[symptoms]] recur within six months.

=== Uterine artery embolization ===
*In women who decline [[hysterectomy]] or have [[contraindications]] for [[hysterectomy]] or women who failed [[hormonal]] [[therapy]], [[uterine artery embolization]] can be an alternative to control [[dysmenorrhea]] and heavy [[menstrual bleeding]].<ref name="pmid27806072">{{cite journal| author=Zhou J, He L, Liu P, Duan H, Zhang H, Li W | display-authors=etal| title=Outcomes in Adenomyosis Treated with Uterine Artery Embolization Are Associated with Lesion Vascularity: A Long-Term Follow-Up Study of 252 Cases. | journal=PLoS One | year= 2016 | volume= 11 | issue= 11 | pages= e0165610 | pmid=27806072 | doi=10.1371/journal.pone.0165610 | pmc=5091759 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27806072 }} </ref>.
* The outcomes of the [[procedure]] are significantly correlated with the lesion [[vascularity]].<ref name="pmid27806072">{{cite journal| author=Zhou J, He L, Liu P, Duan H, Zhang H, Li W | display-authors=etal| title=Outcomes in Adenomyosis Treated with Uterine Artery Embolization Are Associated with Lesion Vascularity: A Long-Term Follow-Up Study of 252 Cases. | journal=PLoS One | year= 2016 | volume= 11 | issue= 11 | pages= e0165610 | pmid=27806072 | doi=10.1371/journal.pone.0165610 | pmc=5091759 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27806072 }} </ref>.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

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Adenomyosis differential diagnosis

2021-05-25T19:37:36Z

Dina:

__NOTOC__

{{CMG}}; {{AE}} [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases that can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

Adenomyosis differential diagnosis

2021-05-25T19:34:42Z

Dina: Created page with "__NOTOC__ {{CMG}}; {{AE}} {{MMT}} Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases that can result in excessive..."

__NOTOC__

{{CMG}}; {{AE}} {{MMT}}

Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases that can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

Adenomyosis

2021-05-24T18:44:47Z

Dina: /* Differential Diagnosis of Adenomyosis */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]]<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>.
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The '''basic Fibroblast Growth Factor (bFGF)''' receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[Caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[Pregnancy]]

==Differential Diagnosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases that can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==Risk Factors==
*Similar to the [[epidemiology]], the risk factors of [[adenomyosis]] are unknown and difficult to be accurately determined as [[diagnosis]] is based on examining [[pathological]] specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.
* [[Adenomyosis]] often coexists with other pelvic diseases namely [[endometriosis]] and [[leiomyoma]], so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.
* Prior [[uterine]] surgery has been shown to be a possible risk factor for the development of [[adenomyosis]]<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398 }} </ref>.

== Natural History, Complications and Prognosis==
*Early clinical features of adenomyosis include [[dysmenorrhea]], heavy [[menstrual bleeding]], and [[chronic pelvic pain]].
*Some reported [[complications]] of adenomyosis are [[preterm]] birth and [[miscarriage]] in young women diagnosed by pelvic imaging<ref name="pmid31318420">{{cite journal| author=Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y| title=Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. | journal=Hum Reprod Update | year= 2019 | volume= 25 | issue= 5 | pages= 592-632 | pmid=31318420 | doi=10.1093/humupd/dmz012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318420 }} </ref>. The relationship of adenomyosis to [[infertility]] is controversial<ref name="pmid22442261">{{cite journal| author=Maheshwari A, Gurunath S, Fatima F, Bhattacharya S| title=Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. | journal=Hum Reprod Update | year= 2012 | volume= 18 | issue= 4 | pages= 374-92 | pmid=22442261 | doi=10.1093/humupd/dms006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22442261 }} </ref>.
*[[Prognosis]] is generally good as [[surgical treatment]] by [[hysterectomy]] is often curable unless there is another associated [[uterine]] pathology that requires further attention. There is no increased risk for secondary development of [[endometrial carcinoma]].

==Diagnosis==
[[Adenomyosis]] is a [[histopathological]] [[diagnosis]] that is made after [[hysterectomy]]. The preoperative [[diagnosis]] is suggested by pelvic [[imaging]] such as [[transvaginal ultrasound]] and [[MRI]] along with the classical presentation of heavy [[menstrual bleeding]], [[dysmenorrhea]], and [[uniformly enlarged globular uterus]].

=== Symptoms ===
*[[Symptoms]] of [[adenomyosis]] may include the following<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Heavy [[menstrual bleeding]]
:*[[Dysmenorrhea]]
:*Chronic [[pelvic pain]]

=== Physical Examination ===
*Bimanual [[pelvic examination]] may be remarkable for<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Diffusely enlarged [[uterus]] (Boggy soft uterus)
:*[[Uterus]] is mobile (not fixed as in endometriosis)
:*Uterine [[tenderness]] may be noted.

=== Pelvic Imaging ===

The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost-effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

====Ultrasonography====

*Typical appearances of [[adenomyosis]] at [[transvaginal ultrasound]] include poorly marginated [[hypoechoic]] and [[heterogeneous]] areas within the [[myometrium]], [[myometrial]] cysts, and a globular or enlarged [[uterus]] with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

====Computed Tomography====

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

====Magnetic Resonance Imaging====

* [[MRI]] provides better diagnostic capability due to the increased spatial and contrast [[resolution]], and to not be limited by the presence of bowel gas or calcified [[uterine]] fibroids (as is [[ultrasound]]). In particular, [[MRI]] is better able to differentiate [[adenomyosis]] from multiple small [[leiomyoma|uterine fibroids]].

* [[MRI]] can be used to classify [[adenomyosis]] based on the depth of penetration of the ectopic [[endometrium]] into the [[myometrium]].

*[[Adenomyosis]] appears as either diffuse or focal thickening (greater than 12 mm )of the [[junctional zone]] forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on [[T2-weighted]] images.

*[[Histologically]], areas of low signal intensity correspond to [[smooth muscle]] [[hyperplasia]], and bright foci on [[T2-weighted]] images correspond to islands of ectopic [[endometrial]] tissue and cystic dilatation of [[glands]].

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Surgery ===
*[[Surgery]] is the mainstay of therapy for [[adenomyosis]]<ref name="pmid30918629">{{cite journal| author=Vannuccini S, Petraglia F| title=Recent advances in understanding and managing adenomyosis. | journal=F1000Res | year= 2019 | volume= 8 | issue= | pages= | pmid=30918629 | doi=10.12688/f1000research.17242.1 | pmc=6419978 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30918629 }} </ref>.
*[[Hysterectomy]] with preservation of the [[ovaries]] is the most common approach to the [[treatment]] of [[adenomyosis]], and it is done via [[abdominal]], [[transvaginal]], [[laparoscopic]] approach, or [[robotic surgery]]. <ref name="pmid30918629">{{cite journal| author=Vannuccini S, Petraglia F| title=Recent advances in understanding and managing adenomyosis. | journal=F1000Res | year= 2019 | volume= 8 | issue= | pages= | pmid=30918629 | doi=10.12688/f1000research.17242.1 | pmc=6419978 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30918629 }} </ref>.
*Unlike [[Leiomyoma]], there is no plane of cleavage to excise [[adenomyomas]] and preserve the [[uterus]]. [[Uterus]] sparing resection is an investigational approach especially for young women seeking future [[pregnancy]]<ref name="pmid9825848">{{cite journal| author=Wood C| title=Surgical and medical treatment of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 323-36 | pmid=9825848 | doi=10.1093/humupd/4.4.323 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825848 }} </ref>.

=== Medical Therapy ===
*[[Medical]] [[treatment]] for [[dysmenorrhea]] and [[menorrhagia]] can be prescribed as a temporary alternative for young women in the child-bearing period.
*[[Hormonal]] therapy to control the symptoms includes [[levonorgestrel]]-releasing [[IUD]] (most preferred method), [[combined oral contraceptive pills]], [[GnRH]] analogs, and oral [[GnRH]] antagonists<ref name="pmid31971678">{{cite journal| author=Schlaff WD, Ackerman RT, Al-Hendy A, Archer DF, Barnhart KT, Bradley LD | display-authors=etal| title=Elagolix for Heavy Menstrual Bleeding in Women with Uterine Fibroids. | journal=N Engl J Med | year= 2020 | volume= 382 | issue= 4 | pages= 328-340 | pmid=31971678 | doi=10.1056/NEJMoa1904351 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31971678 }} </ref>.
*[[Levonorgestrel]]-[[IUD]] has a direct action on the [[uterus]]. It alleviates [[dysmenorrhea]] and [[menorrhagia]]<ref name="pmid17707716">{{cite journal| author=Bragheto AM, Caserta N, Bahamondes L, Petta CA| title=Effectiveness of the levonorgestrel-releasing intrauterine system in the treatment of adenomyosis diagnosed and monitored by magnetic resonance imaging. | journal=Contraception | year= 2007 | volume= 76 | issue= 3 | pages= 195-9 | pmid=17707716 | doi=10.1016/j.contraception.2007.05.091 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17707716 }} </ref>.
*Once the [[hormonal]] [[therapy]] is stopped to conceive, [[symptoms]] recur within six months.

=== Uterine artery embolization ===
*In women who decline [[hysterectomy]] or have [[contraindications]] for [[hysterectomy]] or women who failed [[hormonal]] [[therapy]], [[uterine artery embolization]] can be an alternative to control [[dysmenorrhea]] and heavy [[menstrual bleeding]].<ref name="pmid27806072">{{cite journal| author=Zhou J, He L, Liu P, Duan H, Zhang H, Li W | display-authors=etal| title=Outcomes in Adenomyosis Treated with Uterine Artery Embolization Are Associated with Lesion Vascularity: A Long-Term Follow-Up Study of 252 Cases. | journal=PLoS One | year= 2016 | volume= 11 | issue= 11 | pages= e0165610 | pmid=27806072 | doi=10.1371/journal.pone.0165610 | pmc=5091759 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27806072 }} </ref>.
* The outcomes of the [[procedure]] are significantly correlated with the lesion [[vascularity]].<ref name="pmid27806072">{{cite journal| author=Zhou J, He L, Liu P, Duan H, Zhang H, Li W | display-authors=etal| title=Outcomes in Adenomyosis Treated with Uterine Artery Embolization Are Associated with Lesion Vascularity: A Long-Term Follow-Up Study of 252 Cases. | journal=PLoS One | year= 2016 | volume= 11 | issue= 11 | pages= e0165610 | pmid=27806072 | doi=10.1371/journal.pone.0165610 | pmc=5091759 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27806072 }} </ref>.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-24T18:42:06Z

Dina: /* Treatment */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]]<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>.
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The '''basic Fibroblast Growth Factor (bFGF)''' receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[Caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[Pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==Risk Factors==
*Similar to the [[epidemiology]], the risk factors of [[adenomyosis]] are unknown and difficult to be accurately determined as [[diagnosis]] is based on examining [[pathological]] specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.
* [[Adenomyosis]] often coexists with other pelvic diseases namely [[endometriosis]] and [[leiomyoma]], so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.
* Prior [[uterine]] surgery has been shown to be a possible risk factor for the development of [[adenomyosis]]<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398 }} </ref>.

== Natural History, Complications and Prognosis==
*Early clinical features of adenomyosis include [[dysmenorrhea]], heavy [[menstrual bleeding]], and [[chronic pelvic pain]].
*Some reported [[complications]] of adenomyosis are [[preterm]] birth and [[miscarriage]] in young women diagnosed by pelvic imaging<ref name="pmid31318420">{{cite journal| author=Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y| title=Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. | journal=Hum Reprod Update | year= 2019 | volume= 25 | issue= 5 | pages= 592-632 | pmid=31318420 | doi=10.1093/humupd/dmz012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318420 }} </ref>. The relationship of adenomyosis to [[infertility]] is controversial<ref name="pmid22442261">{{cite journal| author=Maheshwari A, Gurunath S, Fatima F, Bhattacharya S| title=Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. | journal=Hum Reprod Update | year= 2012 | volume= 18 | issue= 4 | pages= 374-92 | pmid=22442261 | doi=10.1093/humupd/dms006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22442261 }} </ref>.
*[[Prognosis]] is generally good as [[surgical treatment]] by [[hysterectomy]] is often curable unless there is another associated [[uterine]] pathology that requires further attention. There is no increased risk for secondary development of [[endometrial carcinoma]].

==Diagnosis==
[[Adenomyosis]] is a [[histopathological]] [[diagnosis]] that is made after [[hysterectomy]]. The preoperative [[diagnosis]] is suggested by pelvic [[imaging]] such as [[transvaginal ultrasound]] and [[MRI]] along with the classical presentation of heavy [[menstrual bleeding]], [[dysmenorrhea]], and [[uniformly enlarged globular uterus]].

=== Symptoms ===
*[[Symptoms]] of [[adenomyosis]] may include the following<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Heavy [[menstrual bleeding]]
:*[[Dysmenorrhea]]
:*Chronic [[pelvic pain]]

=== Physical Examination ===
*Bimanual [[pelvic examination]] may be remarkable for<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Diffusely enlarged [[uterus]] (Boggy soft uterus)
:*[[Uterus]] is mobile (not fixed as in endometriosis)
:*Uterine [[tenderness]] may be noted.

=== Pelvic Imaging ===

The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost-effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

====Ultrasonography====

*Typical appearances of [[adenomyosis]] at [[transvaginal ultrasound]] include poorly marginated [[hypoechoic]] and [[heterogeneous]] areas within the [[myometrium]], [[myometrial]] cysts, and a globular or enlarged [[uterus]] with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

====Computed Tomography====

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

====Magnetic Resonance Imaging====

* [[MRI]] provides better diagnostic capability due to the increased spatial and contrast [[resolution]], and to not be limited by the presence of bowel gas or calcified [[uterine]] fibroids (as is [[ultrasound]]). In particular, [[MRI]] is better able to differentiate [[adenomyosis]] from multiple small [[leiomyoma|uterine fibroids]].

* [[MRI]] can be used to classify [[adenomyosis]] based on the depth of penetration of the ectopic [[endometrium]] into the [[myometrium]].

*[[Adenomyosis]] appears as either diffuse or focal thickening (greater than 12 mm )of the [[junctional zone]] forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on [[T2-weighted]] images.

*[[Histologically]], areas of low signal intensity correspond to [[smooth muscle]] [[hyperplasia]], and bright foci on [[T2-weighted]] images correspond to islands of ectopic [[endometrial]] tissue and cystic dilatation of [[glands]].

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Surgery ===
*[[Surgery]] is the mainstay of therapy for [[adenomyosis]]<ref name="pmid30918629">{{cite journal| author=Vannuccini S, Petraglia F| title=Recent advances in understanding and managing adenomyosis. | journal=F1000Res | year= 2019 | volume= 8 | issue= | pages= | pmid=30918629 | doi=10.12688/f1000research.17242.1 | pmc=6419978 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30918629 }} </ref>.
*[[Hysterectomy]] with preservation of the [[ovaries]] is the most common approach to the [[treatment]] of [[adenomyosis]], and it is done via [[abdominal]], [[transvaginal]], [[laparoscopic]] approach, or [[robotic surgery]]. <ref name="pmid30918629">{{cite journal| author=Vannuccini S, Petraglia F| title=Recent advances in understanding and managing adenomyosis. | journal=F1000Res | year= 2019 | volume= 8 | issue= | pages= | pmid=30918629 | doi=10.12688/f1000research.17242.1 | pmc=6419978 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30918629 }} </ref>.
*Unlike [[Leiomyoma]], there is no plane of cleavage to excise [[adenomyomas]] and preserve the [[uterus]]. [[Uterus]] sparing resection is an investigational approach especially for young women seeking future [[pregnancy]]<ref name="pmid9825848">{{cite journal| author=Wood C| title=Surgical and medical treatment of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 323-36 | pmid=9825848 | doi=10.1093/humupd/4.4.323 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825848 }} </ref>.

=== Medical Therapy ===
*[[Medical]] [[treatment]] for [[dysmenorrhea]] and [[menorrhagia]] can be prescribed as a temporary alternative for young women in the child-bearing period.
*[[Hormonal]] therapy to control the symptoms includes [[levonorgestrel]]-releasing [[IUD]] (most preferred method), [[combined oral contraceptive pills]], [[GnRH]] analogs, and oral [[GnRH]] antagonists<ref name="pmid31971678">{{cite journal| author=Schlaff WD, Ackerman RT, Al-Hendy A, Archer DF, Barnhart KT, Bradley LD | display-authors=etal| title=Elagolix for Heavy Menstrual Bleeding in Women with Uterine Fibroids. | journal=N Engl J Med | year= 2020 | volume= 382 | issue= 4 | pages= 328-340 | pmid=31971678 | doi=10.1056/NEJMoa1904351 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31971678 }} </ref>.
*[[Levonorgestrel]]-[[IUD]] has a direct action on the [[uterus]]. It alleviates [[dysmenorrhea]] and [[menorrhagia]]<ref name="pmid17707716">{{cite journal| author=Bragheto AM, Caserta N, Bahamondes L, Petta CA| title=Effectiveness of the levonorgestrel-releasing intrauterine system in the treatment of adenomyosis diagnosed and monitored by magnetic resonance imaging. | journal=Contraception | year= 2007 | volume= 76 | issue= 3 | pages= 195-9 | pmid=17707716 | doi=10.1016/j.contraception.2007.05.091 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17707716 }} </ref>.
*Once the [[hormonal]] [[therapy]] is stopped to conceive, [[symptoms]] recur within six months.

=== Uterine artery embolization ===
*In women who decline [[hysterectomy]] or have [[contraindications]] for [[hysterectomy]] or women who failed [[hormonal]] [[therapy]], [[uterine artery embolization]] can be an alternative to control [[dysmenorrhea]] and heavy [[menstrual bleeding]].<ref name="pmid27806072">{{cite journal| author=Zhou J, He L, Liu P, Duan H, Zhang H, Li W | display-authors=etal| title=Outcomes in Adenomyosis Treated with Uterine Artery Embolization Are Associated with Lesion Vascularity: A Long-Term Follow-Up Study of 252 Cases. | journal=PLoS One | year= 2016 | volume= 11 | issue= 11 | pages= e0165610 | pmid=27806072 | doi=10.1371/journal.pone.0165610 | pmc=5091759 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27806072 }} </ref>.
* The outcomes of the [[procedure]] are significantly correlated with the lesion [[vascularity]].<ref name="pmid27806072">{{cite journal| author=Zhou J, He L, Liu P, Duan H, Zhang H, Li W | display-authors=etal| title=Outcomes in Adenomyosis Treated with Uterine Artery Embolization Are Associated with Lesion Vascularity: A Long-Term Follow-Up Study of 252 Cases. | journal=PLoS One | year= 2016 | volume= 11 | issue= 11 | pages= e0165610 | pmid=27806072 | doi=10.1371/journal.pone.0165610 | pmc=5091759 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27806072 }} </ref>.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-24T08:59:08Z

Dina: /* Symptoms */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]]<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>.
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The '''basic Fibroblast Growth Factor (bFGF)''' receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[Caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[Pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==Risk Factors==
*Similar to the [[epidemiology]], the risk factors of [[adenomyosis]] are unknown and difficult to be accurately determined as [[diagnosis]] is based on examining [[pathological]] specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.
* [[Adenomyosis]] often coexists with other pelvic diseases namely [[endometriosis]] and [[leiomyoma]], so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.
* Prior [[uterine]] surgery has been shown to be a possible risk factor for the development of [[adenomyosis]]<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398 }} </ref>.

== Natural History, Complications and Prognosis==
*Early clinical features of adenomyosis include [[dysmenorrhea]], heavy [[menstrual bleeding]], and [[chronic pelvic pain]].
*Some reported [[complications]] of adenomyosis are [[preterm]] birth and [[miscarriage]] in young women diagnosed by pelvic imaging<ref name="pmid31318420">{{cite journal| author=Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y| title=Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. | journal=Hum Reprod Update | year= 2019 | volume= 25 | issue= 5 | pages= 592-632 | pmid=31318420 | doi=10.1093/humupd/dmz012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318420 }} </ref>. The relationship of adenomyosis to [[infertility]] is controversial<ref name="pmid22442261">{{cite journal| author=Maheshwari A, Gurunath S, Fatima F, Bhattacharya S| title=Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. | journal=Hum Reprod Update | year= 2012 | volume= 18 | issue= 4 | pages= 374-92 | pmid=22442261 | doi=10.1093/humupd/dms006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22442261 }} </ref>.
*[[Prognosis]] is generally good as [[surgical treatment]] by [[hysterectomy]] is often curable unless there is another associated [[uterine]] pathology that requires further attention. There is no increased risk for secondary development of [[endometrial carcinoma]].

==Diagnosis==
[[Adenomyosis]] is a [[histopathological]] [[diagnosis]] that is made after [[hysterectomy]]. The preoperative [[diagnosis]] is suggested by pelvic [[imaging]] such as [[transvaginal ultrasound]] and [[MRI]] along with the classical presentation of heavy [[menstrual bleeding]], [[dysmenorrhea]], and [[uniformly enlarged globular uterus]].

=== Symptoms ===
*[[Symptoms]] of [[adenomyosis]] may include the following<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Heavy [[menstrual bleeding]]
:*[[Dysmenorrhea]]
:*Chronic [[pelvic pain]]

=== Physical Examination ===
*Bimanual [[pelvic examination]] may be remarkable for<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Diffusely enlarged [[uterus]] (Boggy soft uterus)
:*[[Uterus]] is mobile (not fixed as in endometriosis)
:*Uterine [[tenderness]] may be noted.

=== Pelvic Imaging ===

The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost-effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

====Ultrasonography====

*Typical appearances of [[adenomyosis]] at [[transvaginal ultrasound]] include poorly marginated [[hypoechoic]] and [[heterogeneous]] areas within the [[myometrium]], [[myometrial]] cysts, and a globular or enlarged [[uterus]] with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

====Computed Tomography====

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

====Magnetic Resonance Imaging====

* [[MRI]] provides better diagnostic capability due to the increased spatial and contrast [[resolution]], and to not be limited by the presence of bowel gas or calcified [[uterine]] fibroids (as is [[ultrasound]]). In particular, [[MRI]] is better able to differentiate [[adenomyosis]] from multiple small [[leiomyoma|uterine fibroids]].

* [[MRI]] can be used to classify [[adenomyosis]] based on the depth of penetration of the ectopic [[endometrium]] into the [[myometrium]].

*[[Adenomyosis]] appears as either diffuse or focal thickening (greater than 12 mm )of the [[junctional zone]] forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on [[T2-weighted]] images.

*[[Histologically]], areas of low signal intensity correspond to [[smooth muscle]] [[hyperplasia]], and bright foci on [[T2-weighted]] images correspond to islands of ectopic [[endometrial]] tissue and cystic dilatation of [[glands]].

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

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[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-23T17:19:18Z

Dina:

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]]<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>.
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The '''basic Fibroblast Growth Factor (bFGF)''' receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[Caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[Pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==Risk Factors==
*Similar to the [[epidemiology]], the risk factors of [[adenomyosis]] are unknown and difficult to be accurately determined as [[diagnosis]] is based on examining [[pathological]] specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.
* [[Adenomyosis]] often coexists with other pelvic diseases namely [[endometriosis]] and [[leiomyoma]], so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.
* Prior [[uterine]] surgery has been shown to be a possible risk factor for the development of [[adenomyosis]]<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398 }} </ref>.

== Natural History, Complications and Prognosis==
*Early clinical features of adenomyosis include [[dysmenorrhea]], heavy [[menstrual bleeding]], and [[chronic pelvic pain]].
*Some reported [[complications]] of adenomyosis are [[preterm]] birth and [[miscarriage]] in young women diagnosed by pelvic imaging<ref name="pmid31318420">{{cite journal| author=Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y| title=Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. | journal=Hum Reprod Update | year= 2019 | volume= 25 | issue= 5 | pages= 592-632 | pmid=31318420 | doi=10.1093/humupd/dmz012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318420 }} </ref>. The relationship of adenomyosis to [[infertility]] is controversial<ref name="pmid22442261">{{cite journal| author=Maheshwari A, Gurunath S, Fatima F, Bhattacharya S| title=Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. | journal=Hum Reprod Update | year= 2012 | volume= 18 | issue= 4 | pages= 374-92 | pmid=22442261 | doi=10.1093/humupd/dms006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22442261 }} </ref>.
*[[Prognosis]] is generally good as [[surgical treatment]] by [[hysterectomy]] is often curable unless there is another associated [[uterine]] pathology that requires further attention. There is no increased risk for secondary development of [[endometrial carcinoma]].

==Diagnosis==
[[Adenomyosis]] is a [[histopathological]] [[diagnosis]] that is made after [[hysterectomy]]. The preoperative [[diagnosis]] is suggested by pelvic [[imaging]] such as [[transvaginal ultrasound]] and [[MRI]] along with the classical presentation of heavy [[menstrual bleeding]], [[dysmenorrhea]], and [[uniformly enlarged globular uterus]].

=== Symptoms ===
*[[Symptoms]] of [[adenomyosis]] may include the following<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Heavy [[menstrual bleeding]]
:*[[Dysmenorrhea]]
:*Chronic [[pelvic pain]]]

=== Physical Examination ===
*Bimanual [[pelvic examination]] may be remarkable for<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Diffusely enlarged [[uterus]] (Boggy soft uterus)
:*[[Uterus]] is mobile (not fixed as in endometriosis)
:*Uterine [[tenderness]] may be noted.

=== Pelvic Imaging ===

The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost-effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

====Ultrasonography====

*Typical appearances of [[adenomyosis]] at [[transvaginal ultrasound]] include poorly marginated [[hypoechoic]] and [[heterogeneous]] areas within the [[myometrium]], [[myometrial]] cysts, and a globular or enlarged [[uterus]] with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

====Computed Tomography====

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

====Magnetic Resonance Imaging====

* [[MRI]] provides better diagnostic capability due to the increased spatial and contrast [[resolution]], and to not be limited by the presence of bowel gas or calcified [[uterine]] fibroids (as is [[ultrasound]]). In particular, [[MRI]] is better able to differentiate [[adenomyosis]] from multiple small [[leiomyoma|uterine fibroids]].

* [[MRI]] can be used to classify [[adenomyosis]] based on the depth of penetration of the ectopic [[endometrium]] into the [[myometrium]].

*[[Adenomyosis]] appears as either diffuse or focal thickening (greater than 12 mm )of the [[junctional zone]] forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on [[T2-weighted]] images.

*[[Histologically]], areas of low signal intensity correspond to [[smooth muscle]] [[hyperplasia]], and bright foci on [[T2-weighted]] images correspond to islands of ectopic [[endometrial]] tissue and cystic dilatation of [[glands]].

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-23T17:17:39Z

Dina: /* Magnetic Resonance Imaging */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]]<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>.
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The '''basic Fibroblast Growth Factor (bFGF)''' receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[Caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[Pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==Risk Factors==
*Similar to the [[epidemiology]], the risk factors of [[adenomyosis]] are unknown and difficult to be accurately determined as [[diagnosis]] is based on examining [[pathological]] specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.
* [[Adenomyosis]] often coexists with other pelvic diseases namely [[endometriosis]] and [[leiomyoma]], so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.
* Prior [[uterine]] surgery has been shown to be a possible risk factor for the development of [[adenomyosis]]<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398 }} </ref>.

== Natural History, Complications and Prognosis==
*Early clinical features of adenomyosis include [[dysmenorrhea]], heavy [[menstrual bleeding]], and [[chronic pelvic pain]].
*Some reported [[complications]] of adenomyosis are [[preterm]] birth and [[miscarriage]] in young women diagnosed by pelvic imaging<ref name="pmid31318420">{{cite journal| author=Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y| title=Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. | journal=Hum Reprod Update | year= 2019 | volume= 25 | issue= 5 | pages= 592-632 | pmid=31318420 | doi=10.1093/humupd/dmz012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318420 }} </ref>. The relationship of adenomyosis to [[infertility]] is controversial<ref name="pmid22442261">{{cite journal| author=Maheshwari A, Gurunath S, Fatima F, Bhattacharya S| title=Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. | journal=Hum Reprod Update | year= 2012 | volume= 18 | issue= 4 | pages= 374-92 | pmid=22442261 | doi=10.1093/humupd/dms006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22442261 }} </ref>.
*[[Prognosis]] is generally good as [[surgical treatment]] by [[hysterectomy]] is often curable unless there is another associated [[uterine]] pathology that requires further attention. There is no increased risk for secondary development of [[endometrial carcinoma]].

==Diagnosis==
[[Adenomyosis]] is a [[histopathological]] [[diagnosis]] that is made after [[hysterectomy]]. The preoperative [[diagnosis]] is suggested by pelvic [[imaging]] such as [[transvaginal ultrasound]] and [[MRI]] along with the classical presentation of heavy [[menstrual bleeding]], [[dysmenorrhea]], and [[uniformly enlarged globular uterus]].

=== Symptoms ===
*[[Symptoms]] of [[adenomyosis]] may include the following<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Heavy [[menstrual bleeding]]
:*[[Dysmenorrhea]]
:*Chronic [[pelvic pain]]]

=== Physical Examination ===
*Bimanual [[pelvic examination]] may be remarkable for<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Diffusely enlarged [[uterus]] (Boggy soft uterus)
:*[[Uterus]] is mobile (not fixed as in endometriosis)
:*Uterine [[tenderness]] may be noted.

== Pelvic Imaging ==

The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost-effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

===Ultrasonography===

*Typical appearances of [[adenomyosis]] at [[transvaginal ultrasound]] include poorly marginated [[hypoechoic]] and [[heterogeneous]] areas within the [[myometrium]], [[myometrial]] cysts, and a globular or enlarged [[uterus]] with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

* [[MRI]] provides better diagnostic capability due to the increased spatial and contrast [[resolution]], and to not be limited by the presence of bowel gas or calcified [[uterine]] fibroids (as is [[ultrasound]]). In particular, [[MRI]] is better able to differentiate [[adenomyosis]] from multiple small [[leiomyoma|uterine fibroids]].

* [[MRI]] can be used to classify [[adenomyosis]] based on the depth of penetration of the ectopic [[endometrium]] into the [[myometrium]].

*[[Adenomyosis]] appears as either diffuse or focal thickening (greater than 12 mm )of the [[junctional zone]] forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on [[T2-weighted]] images.

*[[Histologically]], areas of low signal intensity correspond to [[smooth muscle]] [[hyperplasia]], and bright foci on [[T2-weighted]] images correspond to islands of ectopic [[endometrial]] tissue and cystic dilatation of [[glands]].

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-23T17:14:13Z

Dina: /* Ultrasonography */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]]<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>.
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The '''basic Fibroblast Growth Factor (bFGF)''' receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[Caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[Pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==Risk Factors==
*Similar to the [[epidemiology]], the risk factors of [[adenomyosis]] are unknown and difficult to be accurately determined as [[diagnosis]] is based on examining [[pathological]] specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.
* [[Adenomyosis]] often coexists with other pelvic diseases namely [[endometriosis]] and [[leiomyoma]], so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.
* Prior [[uterine]] surgery has been shown to be a possible risk factor for the development of [[adenomyosis]]<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398 }} </ref>.

== Natural History, Complications and Prognosis==
*Early clinical features of adenomyosis include [[dysmenorrhea]], heavy [[menstrual bleeding]], and [[chronic pelvic pain]].
*Some reported [[complications]] of adenomyosis are [[preterm]] birth and [[miscarriage]] in young women diagnosed by pelvic imaging<ref name="pmid31318420">{{cite journal| author=Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y| title=Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. | journal=Hum Reprod Update | year= 2019 | volume= 25 | issue= 5 | pages= 592-632 | pmid=31318420 | doi=10.1093/humupd/dmz012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318420 }} </ref>. The relationship of adenomyosis to [[infertility]] is controversial<ref name="pmid22442261">{{cite journal| author=Maheshwari A, Gurunath S, Fatima F, Bhattacharya S| title=Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. | journal=Hum Reprod Update | year= 2012 | volume= 18 | issue= 4 | pages= 374-92 | pmid=22442261 | doi=10.1093/humupd/dms006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22442261 }} </ref>.
*[[Prognosis]] is generally good as [[surgical treatment]] by [[hysterectomy]] is often curable unless there is another associated [[uterine]] pathology that requires further attention. There is no increased risk for secondary development of [[endometrial carcinoma]].

==Diagnosis==
[[Adenomyosis]] is a [[histopathological]] [[diagnosis]] that is made after [[hysterectomy]]. The preoperative [[diagnosis]] is suggested by pelvic [[imaging]] such as [[transvaginal ultrasound]] and [[MRI]] along with the classical presentation of heavy [[menstrual bleeding]], [[dysmenorrhea]], and [[uniformly enlarged globular uterus]].

=== Symptoms ===
*[[Symptoms]] of [[adenomyosis]] may include the following<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Heavy [[menstrual bleeding]]
:*[[Dysmenorrhea]]
:*Chronic [[pelvic pain]]]

=== Physical Examination ===
*Bimanual [[pelvic examination]] may be remarkable for<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Diffusely enlarged [[uterus]] (Boggy soft uterus)
:*[[Uterus]] is mobile (not fixed as in endometriosis)
:*Uterine [[tenderness]] may be noted.

== Pelvic Imaging ==

The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost-effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

===Ultrasonography===

*Typical appearances of [[adenomyosis]] at [[transvaginal ultrasound]] include poorly marginated [[hypoechoic]] and [[heterogeneous]] areas within the [[myometrium]], [[myometrial]] cysts, and a globular or enlarged [[uterus]] with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

* MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not be limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]].

* MRI can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.

*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-23T17:12:46Z

Dina: /* Pelvic Imaging */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]]<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>.
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The '''basic Fibroblast Growth Factor (bFGF)''' receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[Caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[Pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==Risk Factors==
*Similar to the [[epidemiology]], the risk factors of [[adenomyosis]] are unknown and difficult to be accurately determined as [[diagnosis]] is based on examining [[pathological]] specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.
* [[Adenomyosis]] often coexists with other pelvic diseases namely [[endometriosis]] and [[leiomyoma]], so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.
* Prior [[uterine]] surgery has been shown to be a possible risk factor for the development of [[adenomyosis]]<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398 }} </ref>.

== Natural History, Complications and Prognosis==
*Early clinical features of adenomyosis include [[dysmenorrhea]], heavy [[menstrual bleeding]], and [[chronic pelvic pain]].
*Some reported [[complications]] of adenomyosis are [[preterm]] birth and [[miscarriage]] in young women diagnosed by pelvic imaging<ref name="pmid31318420">{{cite journal| author=Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y| title=Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. | journal=Hum Reprod Update | year= 2019 | volume= 25 | issue= 5 | pages= 592-632 | pmid=31318420 | doi=10.1093/humupd/dmz012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318420 }} </ref>. The relationship of adenomyosis to [[infertility]] is controversial<ref name="pmid22442261">{{cite journal| author=Maheshwari A, Gurunath S, Fatima F, Bhattacharya S| title=Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. | journal=Hum Reprod Update | year= 2012 | volume= 18 | issue= 4 | pages= 374-92 | pmid=22442261 | doi=10.1093/humupd/dms006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22442261 }} </ref>.
*[[Prognosis]] is generally good as [[surgical treatment]] by [[hysterectomy]] is often curable unless there is another associated [[uterine]] pathology that requires further attention. There is no increased risk for secondary development of [[endometrial carcinoma]].

==Diagnosis==
[[Adenomyosis]] is a [[histopathological]] [[diagnosis]] that is made after [[hysterectomy]]. The preoperative [[diagnosis]] is suggested by pelvic [[imaging]] such as [[transvaginal ultrasound]] and [[MRI]] along with the classical presentation of heavy [[menstrual bleeding]], [[dysmenorrhea]], and [[uniformly enlarged globular uterus]].

=== Symptoms ===
*[[Symptoms]] of [[adenomyosis]] may include the following<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Heavy [[menstrual bleeding]]
:*[[Dysmenorrhea]]
:*Chronic [[pelvic pain]]]

=== Physical Examination ===
*Bimanual [[pelvic examination]] may be remarkable for<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Diffusely enlarged [[uterus]] (Boggy soft uterus)
:*[[Uterus]] is mobile (not fixed as in endometriosis)
:*Uterine [[tenderness]] may be noted.

== Pelvic Imaging ==

The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost-effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

* MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not be limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]].

* MRI can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.

*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
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Adenomyosis

2021-05-23T17:07:47Z

Dina: /* Pelvic Imaging */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]]<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>.
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The '''basic Fibroblast Growth Factor (bFGF)''' receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[Caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[Pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==Risk Factors==
*Similar to the [[epidemiology]], the risk factors of [[adenomyosis]] are unknown and difficult to be accurately determined as [[diagnosis]] is based on examining [[pathological]] specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.
* [[Adenomyosis]] often coexists with other pelvic diseases namely [[endometriosis]] and [[leiomyoma]], so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.
* Prior [[uterine]] surgery has been shown to be a possible risk factor for the development of [[adenomyosis]]<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398 }} </ref>.

== Natural History, Complications and Prognosis==
*Early clinical features of adenomyosis include [[dysmenorrhea]], heavy [[menstrual bleeding]], and [[chronic pelvic pain]].
*Some reported [[complications]] of adenomyosis are [[preterm]] birth and [[miscarriage]] in young women diagnosed by pelvic imaging<ref name="pmid31318420">{{cite journal| author=Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y| title=Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. | journal=Hum Reprod Update | year= 2019 | volume= 25 | issue= 5 | pages= 592-632 | pmid=31318420 | doi=10.1093/humupd/dmz012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318420 }} </ref>. The relationship of adenomyosis to [[infertility]] is controversial<ref name="pmid22442261">{{cite journal| author=Maheshwari A, Gurunath S, Fatima F, Bhattacharya S| title=Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. | journal=Hum Reprod Update | year= 2012 | volume= 18 | issue= 4 | pages= 374-92 | pmid=22442261 | doi=10.1093/humupd/dms006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22442261 }} </ref>.
*[[Prognosis]] is generally good as [[surgical treatment]] by [[hysterectomy]] is often curable unless there is another associated [[uterine]] pathology that requires further attention. There is no increased risk for secondary development of [[endometrial carcinoma]].

==Diagnosis==
[[Adenomyosis]] is a [[histopathological]] [[diagnosis]] that is made after [[hysterectomy]]. The preoperative [[diagnosis]] is suggested by pelvic [[imaging]] such as [[transvaginal ultrasound]] and [[MRI]] along with the classical presentation of heavy [[menstrual bleeding]], [[dysmenorrhea]], and [[uniformly enlarged globular uterus]].

=== Symptoms ===
*[[Symptoms]] of [[adenomyosis]] may include the following<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Heavy [[menstrual bleeding]]
:*[[Dysmenorrhea]]
:*Chronic [[pelvic pain]]]

=== Physical Examination ===
*Bimanual [[pelvic examination]] may be remarkable for<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Diffusely enlarged [[uterus]] (Boggy soft uterus)
:*[[Uterus]] is mobile (not fixed as in endometriosis)
:*Uterine [[tenderness]] may be noted.

== Pelvic Imaging ==
* The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost-effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].
* MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not be limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with a diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.
* MRI can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
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[[Category:Gynecology]]

Adenomyosis

2021-05-23T17:05:45Z

Dina: /* Diagnosis */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]]<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>.
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The '''basic Fibroblast Growth Factor (bFGF)''' receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[Caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[Pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==Risk Factors==
*Similar to the [[epidemiology]], the risk factors of [[adenomyosis]] are unknown and difficult to be accurately determined as [[diagnosis]] is based on examining [[pathological]] specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.
* [[Adenomyosis]] often coexists with other pelvic diseases namely [[endometriosis]] and [[leiomyoma]], so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.
* Prior [[uterine]] surgery has been shown to be a possible risk factor for the development of [[adenomyosis]]<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398 }} </ref>.

== Natural History, Complications and Prognosis==
*Early clinical features of adenomyosis include [[dysmenorrhea]], heavy [[menstrual bleeding]], and [[chronic pelvic pain]].
*Some reported [[complications]] of adenomyosis are [[preterm]] birth and [[miscarriage]] in young women diagnosed by pelvic imaging<ref name="pmid31318420">{{cite journal| author=Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y| title=Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. | journal=Hum Reprod Update | year= 2019 | volume= 25 | issue= 5 | pages= 592-632 | pmid=31318420 | doi=10.1093/humupd/dmz012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318420 }} </ref>. The relationship of adenomyosis to [[infertility]] is controversial<ref name="pmid22442261">{{cite journal| author=Maheshwari A, Gurunath S, Fatima F, Bhattacharya S| title=Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. | journal=Hum Reprod Update | year= 2012 | volume= 18 | issue= 4 | pages= 374-92 | pmid=22442261 | doi=10.1093/humupd/dms006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22442261 }} </ref>.
*[[Prognosis]] is generally good as [[surgical treatment]] by [[hysterectomy]] is often curable unless there is another associated [[uterine]] pathology that requires further attention. There is no increased risk for secondary development of [[endometrial carcinoma]].

==Diagnosis==
[[Adenomyosis]] is a [[histopathological]] [[diagnosis]] that is made after [[hysterectomy]]. The preoperative [[diagnosis]] is suggested by pelvic [[imaging]] such as [[transvaginal ultrasound]] and [[MRI]] along with the classical presentation of heavy [[menstrual bleeding]], [[dysmenorrhea]], and [[uniformly enlarged globular uterus]].

=== Symptoms ===
*[[Symptoms]] of [[adenomyosis]] may include the following<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Heavy [[menstrual bleeding]]
:*[[Dysmenorrhea]]
:*Chronic [[pelvic pain]]]

=== Physical Examination ===
*Bimanual [[pelvic examination]] may be remarkable for<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Diffusely enlarged [[uterus]] (Boggy soft uterus)
:*[[Uterus]] is mobile (not fixed as in endometriosis)
:*Uterine [[tenderness]] may be noted.

== Pelvic Imaging ==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost-effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not be limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with a diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.
===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-23T17:03:39Z

Dina: /* Physical Examination */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]]<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>.
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The '''basic Fibroblast Growth Factor (bFGF)''' receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[Caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[Pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==Risk Factors==
*Similar to the [[epidemiology]], the risk factors of [[adenomyosis]] are unknown and difficult to be accurately determined as [[diagnosis]] is based on examining [[pathological]] specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.
* [[Adenomyosis]] often coexists with other pelvic diseases namely [[endometriosis]] and [[leiomyoma]], so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.
* Prior [[uterine]] surgery has been shown to be a possible risk factor for the development of [[adenomyosis]]<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398 }} </ref>.

== Natural History, Complications and Prognosis==
*Early clinical features of adenomyosis include [[dysmenorrhea]], heavy [[menstrual bleeding]], and [[chronic pelvic pain]].
*Some reported [[complications]] of adenomyosis are [[preterm]] birth and [[miscarriage]] in young women diagnosed by pelvic imaging<ref name="pmid31318420">{{cite journal| author=Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y| title=Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. | journal=Hum Reprod Update | year= 2019 | volume= 25 | issue= 5 | pages= 592-632 | pmid=31318420 | doi=10.1093/humupd/dmz012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318420 }} </ref>. The relationship of adenomyosis to [[infertility]] is controversial<ref name="pmid22442261">{{cite journal| author=Maheshwari A, Gurunath S, Fatima F, Bhattacharya S| title=Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. | journal=Hum Reprod Update | year= 2012 | volume= 18 | issue= 4 | pages= 374-92 | pmid=22442261 | doi=10.1093/humupd/dms006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22442261 }} </ref>.
*[[Prognosis]] is generally good as [[surgical treatment]] by [[hysterectomy]] is often curable unless there is another associated [[uterine]] pathology that requires further attention. There is no increased risk for secondary development of [[endometrial carcinoma]].

==Diagnosis==
Adenomyosis is a histopathological diagnosis that is made after hysterectomy. The preoperative diagnosis is suggested by pelvic imaging such as transvaginal ultrasound and MRI along with the classical presentation of heavy menstrual bleeding, dysmenorrhea, and uniformly enlarged uterus.

=== Symptoms ===
*Symptoms of adenomyosis may include the following<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Heavy [[menstrual bleeding]]
:*[[Dysmenorrhea]]
:*Chronic [[pelvic pain]]]

=== Physical Examination ===
*Bimanual pelvic examination may be remarkable for<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Diffusely enlarged [[uterus]] (Boggy soft uterus)
:*[[Uterus]] is mobile (not fixed as in endometriosis)
:*Uterine tenderness may be noted.

== Pelvic Imaging ==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost-effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not be limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with a diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.
===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-23T17:03:13Z

Dina: /* Symptoms */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]]<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>.
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The '''basic Fibroblast Growth Factor (bFGF)''' receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[Caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[Pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==Risk Factors==
*Similar to the [[epidemiology]], the risk factors of [[adenomyosis]] are unknown and difficult to be accurately determined as [[diagnosis]] is based on examining [[pathological]] specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.
* [[Adenomyosis]] often coexists with other pelvic diseases namely [[endometriosis]] and [[leiomyoma]], so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.
* Prior [[uterine]] surgery has been shown to be a possible risk factor for the development of [[adenomyosis]]<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398 }} </ref>.

== Natural History, Complications and Prognosis==
*Early clinical features of adenomyosis include [[dysmenorrhea]], heavy [[menstrual bleeding]], and [[chronic pelvic pain]].
*Some reported [[complications]] of adenomyosis are [[preterm]] birth and [[miscarriage]] in young women diagnosed by pelvic imaging<ref name="pmid31318420">{{cite journal| author=Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y| title=Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. | journal=Hum Reprod Update | year= 2019 | volume= 25 | issue= 5 | pages= 592-632 | pmid=31318420 | doi=10.1093/humupd/dmz012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318420 }} </ref>. The relationship of adenomyosis to [[infertility]] is controversial<ref name="pmid22442261">{{cite journal| author=Maheshwari A, Gurunath S, Fatima F, Bhattacharya S| title=Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. | journal=Hum Reprod Update | year= 2012 | volume= 18 | issue= 4 | pages= 374-92 | pmid=22442261 | doi=10.1093/humupd/dms006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22442261 }} </ref>.
*[[Prognosis]] is generally good as [[surgical treatment]] by [[hysterectomy]] is often curable unless there is another associated [[uterine]] pathology that requires further attention. There is no increased risk for secondary development of [[endometrial carcinoma]].

==Diagnosis==
Adenomyosis is a histopathological diagnosis that is made after hysterectomy. The preoperative diagnosis is suggested by pelvic imaging such as transvaginal ultrasound and MRI along with the classical presentation of heavy menstrual bleeding, dysmenorrhea, and uniformly enlarged uterus.

=== Symptoms ===
*Symptoms of adenomyosis may include the following<ref name="pmid4608783">{{cite journal| author=McElin TW, Bird CC| title=Adenomyosis of the uterus. | journal=Obstet Gynecol Annu | year= 1974 | volume= 3 | issue= 0 | pages= 425-41 | pmid=4608783 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4608783 }} </ref>:
:*Heavy [[menstrual bleeding]]
:*[[Dysmenorrhea]]
:*Chronic [[pelvic pain]]]

=== Physical Examination ===
*Bimanual pelvic examination may be remarkable for:
:*Diffusely enlarged [[uterus]] (Boggy soft uterus)
:*[[Uterus]] is mobile (not fixed as in endometriosis)
:*Uterine tenderness may be noted.

== Pelvic Imaging ==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost-effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not be limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with a diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.
===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-23T17:01:11Z

Dina: /* Diagnosis */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]]<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>.
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The '''basic Fibroblast Growth Factor (bFGF)''' receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[Caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[Pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==Risk Factors==
*Similar to the [[epidemiology]], the risk factors of [[adenomyosis]] are unknown and difficult to be accurately determined as [[diagnosis]] is based on examining [[pathological]] specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.
* [[Adenomyosis]] often coexists with other pelvic diseases namely [[endometriosis]] and [[leiomyoma]], so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.
* Prior [[uterine]] surgery has been shown to be a possible risk factor for the development of [[adenomyosis]]<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398 }} </ref>.

== Natural History, Complications and Prognosis==
*Early clinical features of adenomyosis include [[dysmenorrhea]], heavy [[menstrual bleeding]], and [[chronic pelvic pain]].
*Some reported [[complications]] of adenomyosis are [[preterm]] birth and [[miscarriage]] in young women diagnosed by pelvic imaging<ref name="pmid31318420">{{cite journal| author=Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y| title=Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. | journal=Hum Reprod Update | year= 2019 | volume= 25 | issue= 5 | pages= 592-632 | pmid=31318420 | doi=10.1093/humupd/dmz012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318420 }} </ref>. The relationship of adenomyosis to [[infertility]] is controversial<ref name="pmid22442261">{{cite journal| author=Maheshwari A, Gurunath S, Fatima F, Bhattacharya S| title=Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. | journal=Hum Reprod Update | year= 2012 | volume= 18 | issue= 4 | pages= 374-92 | pmid=22442261 | doi=10.1093/humupd/dms006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22442261 }} </ref>.
*[[Prognosis]] is generally good as [[surgical treatment]] by [[hysterectomy]] is often curable unless there is another associated [[uterine]] pathology that requires further attention. There is no increased risk for secondary development of [[endometrial carcinoma]].

==Diagnosis==
Adenomyosis is a histopathological diagnosis that is made after hysterectomy. The preoperative diagnosis is suggested by pelvic imaging such as transvaginal ultrasound and MRI along with the classical presentation of heavy menstrual bleeding, dysmenorrhea, and uniformly enlarged uterus.

=== Symptoms ===
*Symptoms of adenomyosis may include the following:
:*Heavy [[menstrual bleeding]]
:*[[Dysmenorrhea]]
:*Chronic [[pelvic pain]]]

=== Physical Examination ===
*Bimanual pelvic examination may be remarkable for:
:*Diffusely enlarged [[uterus]] (Boggy soft uterus)
:*[[Uterus]] is mobile (not fixed as in endometriosis)
:*Uterine tenderness may be noted.

== Pelvic Imaging ==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost-effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not be limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with a diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.
===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
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Adenomyosis

2021-05-23T16:48:42Z

Dina: /* Diagnosis */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]]<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>.
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The '''basic Fibroblast Growth Factor (bFGF)''' receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[Caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[Pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==Risk Factors==
*Similar to the [[epidemiology]], the risk factors of [[adenomyosis]] are unknown and difficult to be accurately determined as [[diagnosis]] is based on examining [[pathological]] specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.
* [[Adenomyosis]] often coexists with other pelvic diseases namely [[endometriosis]] and [[leiomyoma]], so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.
* Prior [[uterine]] surgery has been shown to be a possible risk factor for the development of [[adenomyosis]]<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398 }} </ref>.

== Natural History, Complications and Prognosis==
*Early clinical features of adenomyosis include [[dysmenorrhea]], heavy [[menstrual bleeding]], and [[chronic pelvic pain]].
*Some reported [[complications]] of adenomyosis are [[preterm]] birth and [[miscarriage]] in young women diagnosed by pelvic imaging<ref name="pmid31318420">{{cite journal| author=Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y| title=Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. | journal=Hum Reprod Update | year= 2019 | volume= 25 | issue= 5 | pages= 592-632 | pmid=31318420 | doi=10.1093/humupd/dmz012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318420 }} </ref>. The relationship of adenomyosis to [[infertility]] is controversial<ref name="pmid22442261">{{cite journal| author=Maheshwari A, Gurunath S, Fatima F, Bhattacharya S| title=Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. | journal=Hum Reprod Update | year= 2012 | volume= 18 | issue= 4 | pages= 374-92 | pmid=22442261 | doi=10.1093/humupd/dms006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22442261 }} </ref>.
*[[Prognosis]] is generally good as [[surgical treatment]] by [[hysterectomy]] is often curable unless there is another associated [[uterine]] pathology that requires further attention. There is no increased risk for secondary development of [[endometrial carcinoma]].

==Diagnosis==
Adenomyosis is a histopathological diagnosis that is made after hysterectomy. The preoperative diagnosis is suggested by pelvic imaging such as transvaginal ultrasound and MRI along with the classical presentation of heavy menstrual bleeding, dysmenorrhea, and uniformly enlarged uterus.

===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]

=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of [disease name] may include the following:
:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]

=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Physical examination may be remarkable for:
:*[finding 1]
:*[finding 2]
:*[finding 3]
:*[finding 4]
:*[finding 5]
:*[finding 6]

The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.
===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

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Adenomyosis

2021-05-23T16:36:03Z

Dina: /* Natural History, Complications and Prognosis */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]]<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>.
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The '''basic Fibroblast Growth Factor (bFGF)''' receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[Caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[Pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==Risk Factors==
*Similar to the [[epidemiology]], the risk factors of [[adenomyosis]] are unknown and difficult to be accurately determined as [[diagnosis]] is based on examining [[pathological]] specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.
* [[Adenomyosis]] often coexists with other pelvic diseases namely [[endometriosis]] and [[leiomyoma]], so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.
* Prior [[uterine]] surgery has been shown to be a possible risk factor for the development of [[adenomyosis]]<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398 }} </ref>.

== Natural History, Complications and Prognosis==
*Early clinical features of adenomyosis include [[dysmenorrhea]], heavy [[menstrual bleeding]], and [[chronic pelvic pain]].
*Some reported [[complications]] of adenomyosis are [[preterm]] birth and [[miscarriage]] in young women diagnosed by pelvic imaging<ref name="pmid31318420">{{cite journal| author=Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y| title=Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. | journal=Hum Reprod Update | year= 2019 | volume= 25 | issue= 5 | pages= 592-632 | pmid=31318420 | doi=10.1093/humupd/dmz012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318420 }} </ref>. The relationship of adenomyosis to [[infertility]] is controversial<ref name="pmid22442261">{{cite journal| author=Maheshwari A, Gurunath S, Fatima F, Bhattacharya S| title=Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. | journal=Hum Reprod Update | year= 2012 | volume= 18 | issue= 4 | pages= 374-92 | pmid=22442261 | doi=10.1093/humupd/dms006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22442261 }} </ref>.
*[[Prognosis]] is generally good as [[surgical treatment]] by [[hysterectomy]] is often curable unless there is another associated [[uterine]] pathology that requires further attention. There is no increased risk for secondary development of [[endometrial carcinoma]].

==Diagnosis==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]

=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of [disease name] may include the following:
:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]

=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Physical examination may be remarkable for:
:*[finding 1]
:*[finding 2]
:*[finding 3]
:*[finding 4]
:*[finding 5]
:*[finding 6]

===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-23T16:35:27Z

Dina: /* Causes */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]]<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>.
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The '''basic Fibroblast Growth Factor (bFGF)''' receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[Caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[Pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==Risk Factors==
*Similar to the [[epidemiology]], the risk factors of [[adenomyosis]] are unknown and difficult to be accurately determined as [[diagnosis]] is based on examining [[pathological]] specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.
* [[Adenomyosis]] often coexists with other pelvic diseases namely [[endometriosis]] and [[leiomyoma]], so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.
* Prior [[uterine]] surgery has been shown to be a possible risk factor for the development of [[adenomyosis]]<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398 }} </ref>.

== Natural History, Complications and Prognosis==
*Early clinical features of adenomyosis include [[dysmenorrhea]], [[heavy menstrual bleeding]], and [[chronic pelvic pain]].
*Some reported [[complications]] of adenomyosis are [[preterm]] birth and [[miscarriage]] in young women diagnosed by pelvic imaging<ref name="pmid31318420">{{cite journal| author=Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y| title=Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. | journal=Hum Reprod Update | year= 2019 | volume= 25 | issue= 5 | pages= 592-632 | pmid=31318420 | doi=10.1093/humupd/dmz012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318420 }} </ref>. The relationship of adenomyosis to [[infertility]] is controversial<ref name="pmid22442261">{{cite journal| author=Maheshwari A, Gurunath S, Fatima F, Bhattacharya S| title=Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. | journal=Hum Reprod Update | year= 2012 | volume= 18 | issue= 4 | pages= 374-92 | pmid=22442261 | doi=10.1093/humupd/dms006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22442261 }} </ref>.
*[[Prognosis]] is generally good as [[surgical treatment]] by [[hysterectomy]] is often curable unless there is another associated [[uterine]] pathology that requires further attention. There is no increased risk for secondary development of [[endometrial carcinoma]].

==Diagnosis==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]

=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of [disease name] may include the following:
:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]

=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Physical examination may be remarkable for:
:*[finding 1]
:*[finding 2]
:*[finding 3]
:*[finding 4]
:*[finding 5]
:*[finding 6]

===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
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[[Category:Gynecology]]

Adenomyosis

2021-05-22T21:38:08Z

Dina: /* Historical Perspective{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]]<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>.
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The '''basic Fibroblast Growth Factor (bFGF)''' receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==Risk Factors==
*Similar to the [[epidemiology]], the risk factors of [[adenomyosis]] are unknown and difficult to be accurately determined as [[diagnosis]] is based on examining [[pathological]] specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.
* [[Adenomyosis]] often coexists with other pelvic diseases namely [[endometriosis]] and [[leiomyoma]], so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.
* Prior [[uterine]] surgery has been shown to be a possible risk factor for the development of [[adenomyosis]]<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398 }} </ref>.

== Natural History, Complications and Prognosis==
*Early clinical features of adenomyosis include [[dysmenorrhea]], [[heavy menstrual bleeding]], and [[chronic pelvic pain]].
*Some reported [[complications]] of adenomyosis are [[preterm]] birth and [[miscarriage]] in young women diagnosed by pelvic imaging<ref name="pmid31318420">{{cite journal| author=Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y| title=Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. | journal=Hum Reprod Update | year= 2019 | volume= 25 | issue= 5 | pages= 592-632 | pmid=31318420 | doi=10.1093/humupd/dmz012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318420 }} </ref>. The relationship of adenomyosis to [[infertility]] is controversial<ref name="pmid22442261">{{cite journal| author=Maheshwari A, Gurunath S, Fatima F, Bhattacharya S| title=Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. | journal=Hum Reprod Update | year= 2012 | volume= 18 | issue= 4 | pages= 374-92 | pmid=22442261 | doi=10.1093/humupd/dms006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22442261 }} </ref>.
*[[Prognosis]] is generally good as [[surgical treatment]] by [[hysterectomy]] is often curable unless there is another associated [[uterine]] pathology that requires further attention. There is no increased risk for secondary development of [[endometrial carcinoma]].

==Diagnosis==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]

=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of [disease name] may include the following:
:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]

=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Physical examination may be remarkable for:
:*[finding 1]
:*[finding 2]
:*[finding 3]
:*[finding 4]
:*[finding 5]
:*[finding 6]

===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-22T21:36:47Z

Dina: /* Risk Factors */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]].
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The '''basic Fibroblast Growth Factor (bFGF)''' receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==Risk Factors==
*Similar to the [[epidemiology]], the risk factors of [[adenomyosis]] are unknown and difficult to be accurately determined as [[diagnosis]] is based on examining [[pathological]] specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.
* [[Adenomyosis]] often coexists with other pelvic diseases namely [[endometriosis]] and [[leiomyoma]], so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.
* Prior [[uterine]] surgery has been shown to be a possible risk factor for the development of [[adenomyosis]]<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398 }} </ref>.

== Natural History, Complications and Prognosis==
*Early clinical features of adenomyosis include [[dysmenorrhea]], [[heavy menstrual bleeding]], and [[chronic pelvic pain]].
*Some reported [[complications]] of adenomyosis are [[preterm]] birth and [[miscarriage]] in young women diagnosed by pelvic imaging<ref name="pmid31318420">{{cite journal| author=Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y| title=Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. | journal=Hum Reprod Update | year= 2019 | volume= 25 | issue= 5 | pages= 592-632 | pmid=31318420 | doi=10.1093/humupd/dmz012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318420 }} </ref>. The relationship of adenomyosis to [[infertility]] is controversial<ref name="pmid22442261">{{cite journal| author=Maheshwari A, Gurunath S, Fatima F, Bhattacharya S| title=Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. | journal=Hum Reprod Update | year= 2012 | volume= 18 | issue= 4 | pages= 374-92 | pmid=22442261 | doi=10.1093/humupd/dms006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22442261 }} </ref>.
*[[Prognosis]] is generally good as [[surgical treatment]] by [[hysterectomy]] is often curable unless there is another associated [[uterine]] pathology that requires further attention. There is no increased risk for secondary development of [[endometrial carcinoma]].

==Diagnosis==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]

=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of [disease name] may include the following:
:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]

=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Physical examination may be remarkable for:
:*[finding 1]
:*[finding 2]
:*[finding 3]
:*[finding 4]
:*[finding 5]
:*[finding 6]

===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
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Adenomyosis

2021-05-22T21:35:08Z

Dina: /* Pathophysiology */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]].
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The '''basic Fibroblast Growth Factor (bFGF)''' receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
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==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==Risk Factors==
*Similar to the [[epidemiology]], the risk factors of adenomyosis are unknown and difficult to be accurately determined as diagnosis is based on examining pathological specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.
* Adenomyosis often coexists with other pelvic diseases namely endometriosis and leiomyoma, so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.
* Prior uterine surgery has been shown to be a possible risk factor for the development of adenomyosis<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398 }} </ref>.

== Natural History, Complications and Prognosis==
*Early clinical features of adenomyosis include [[dysmenorrhea]], [[heavy menstrual bleeding]], and [[chronic pelvic pain]].
*Some reported [[complications]] of adenomyosis are [[preterm]] birth and [[miscarriage]] in young women diagnosed by pelvic imaging<ref name="pmid31318420">{{cite journal| author=Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y| title=Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. | journal=Hum Reprod Update | year= 2019 | volume= 25 | issue= 5 | pages= 592-632 | pmid=31318420 | doi=10.1093/humupd/dmz012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318420 }} </ref>. The relationship of adenomyosis to [[infertility]] is controversial<ref name="pmid22442261">{{cite journal| author=Maheshwari A, Gurunath S, Fatima F, Bhattacharya S| title=Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. | journal=Hum Reprod Update | year= 2012 | volume= 18 | issue= 4 | pages= 374-92 | pmid=22442261 | doi=10.1093/humupd/dms006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22442261 }} </ref>.
*[[Prognosis]] is generally good as [[surgical treatment]] by [[hysterectomy]] is often curable unless there is another associated [[uterine]] pathology that requires further attention. There is no increased risk for secondary development of [[endometrial carcinoma]].

==Diagnosis==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]

=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of [disease name] may include the following:
:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]

=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Physical examination may be remarkable for:
:*[finding 1]
:*[finding 2]
:*[finding 3]
:*[finding 4]
:*[finding 5]
:*[finding 6]

===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

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[[he:אדנומיוזיס]]

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[[Category:Gynecology]]

Adenomyosis

2021-05-22T21:34:00Z

Dina: /* Natural History, Complications and Prognosis */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]].
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The basic Fibroblast Growth Factor (bFGF) receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==Risk Factors==
*Similar to the [[epidemiology]], the risk factors of adenomyosis are unknown and difficult to be accurately determined as diagnosis is based on examining pathological specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.
* Adenomyosis often coexists with other pelvic diseases namely endometriosis and leiomyoma, so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.
* Prior uterine surgery has been shown to be a possible risk factor for the development of adenomyosis<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398 }} </ref>.

== Natural History, Complications and Prognosis==
*Early clinical features of adenomyosis include [[dysmenorrhea]], [[heavy menstrual bleeding]], and [[chronic pelvic pain]].
*Some reported [[complications]] of adenomyosis are [[preterm]] birth and [[miscarriage]] in young women diagnosed by pelvic imaging<ref name="pmid31318420">{{cite journal| author=Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y| title=Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. | journal=Hum Reprod Update | year= 2019 | volume= 25 | issue= 5 | pages= 592-632 | pmid=31318420 | doi=10.1093/humupd/dmz012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318420 }} </ref>. The relationship of adenomyosis to [[infertility]] is controversial<ref name="pmid22442261">{{cite journal| author=Maheshwari A, Gurunath S, Fatima F, Bhattacharya S| title=Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. | journal=Hum Reprod Update | year= 2012 | volume= 18 | issue= 4 | pages= 374-92 | pmid=22442261 | doi=10.1093/humupd/dms006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22442261 }} </ref>.
*[[Prognosis]] is generally good as [[surgical treatment]] by [[hysterectomy]] is often curable unless there is another associated [[uterine]] pathology that requires further attention. There is no increased risk for secondary development of [[endometrial carcinoma]].

==Diagnosis==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]

=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of [disease name] may include the following:
:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]

=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Physical examination may be remarkable for:
:*[finding 1]
:*[finding 2]
:*[finding 3]
:*[finding 4]
:*[finding 5]
:*[finding 6]

===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-22T20:17:09Z

Dina: /* Risk Factors */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]].
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The basic Fibroblast Growth Factor (bFGF) receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==Risk Factors==
*Similar to the [[epidemiology]], the risk factors of adenomyosis are unknown and difficult to be accurately determined as diagnosis is based on examining pathological specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.
* Adenomyosis often coexists with other pelvic diseases namely endometriosis and leiomyoma, so it is unknown whether it exhibits specific risk factors<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.
* Prior uterine surgery has been shown to be a possible risk factor for the development of adenomyosis<ref name="pmid15516398">{{cite journal| author=Panganamamula UR, Harmanli OH, Isik-Akbay EF, Grotegut CA, Dandolu V, Gaughan JP| title=Is prior uterine surgery a risk factor for adenomyosis? | journal=Obstet Gynecol | year= 2004 | volume= 104 | issue= 5 Pt 1 | pages= 1034-8 | pmid=15516398 | doi=10.1097/01.AOG.0000143264.59822.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15516398 }} </ref>.

== Natural History, Complications and Prognosis==
*The majority of patients with [disease name] remain asymptomatic for [duration/years].
*Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
*If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
*Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
*Prognosis is generally [excellent/good/poor], and the [1/5/10year mortality/survival rate] of patients with [disease name] is approximately [#%].
There is no increased risk for cancer development. As the condition is estrogen-dependent, menopause presents a natural cure. Patients with adenomyosis often also have [[leiomyoma]]ta and/or [[endometriosis]].

==Diagnosis==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]

=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of [disease name] may include the following:
:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]

=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Physical examination may be remarkable for:
:*[finding 1]
:*[finding 2]
:*[finding 3]
:*[finding 4]
:*[finding 5]
:*[finding 6]

===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-22T20:07:19Z

Dina: /* Risk Factors */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]].
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The basic Fibroblast Growth Factor (bFGF) receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==Risk Factors==
*Similar to the [[epidemiology]], the risk factors of adenomyosis are unknown and difficult to be accurately determined as diagnosis is based on examining pathological specimens only in women undergoing [[hysterectomy]]<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

== Natural History, Complications and Prognosis==
*The majority of patients with [disease name] remain asymptomatic for [duration/years].
*Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
*If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
*Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
*Prognosis is generally [excellent/good/poor], and the [1/5/10year mortality/survival rate] of patients with [disease name] is approximately [#%].
There is no increased risk for cancer development. As the condition is estrogen-dependent, menopause presents a natural cure. Patients with adenomyosis often also have [[leiomyoma]]ta and/or [[endometriosis]].

==Diagnosis==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]

=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of [disease name] may include the following:
:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]

=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Physical examination may be remarkable for:
:*[finding 1]
:*[finding 2]
:*[finding 3]
:*[finding 4]
:*[finding 5]
:*[finding 6]

===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-22T20:02:43Z

Dina: /* Race */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]].
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The basic Fibroblast Growth Factor (bFGF) receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>

==Risk Factors==
*Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

== Natural History, Complications and Prognosis==
*The majority of patients with [disease name] remain asymptomatic for [duration/years].
*Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
*If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
*Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
*Prognosis is generally [excellent/good/poor], and the [1/5/10year mortality/survival rate] of patients with [disease name] is approximately [#%].
There is no increased risk for cancer development. As the condition is estrogen-dependent, menopause presents a natural cure. Patients with adenomyosis often also have [[leiomyoma]]ta and/or [[endometriosis]].

==Diagnosis==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]

=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of [disease name] may include the following:
:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]

=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Physical examination may be remarkable for:
:*[finding 1]
:*[finding 2]
:*[finding 3]
:*[finding 4]
:*[finding 5]
:*[finding 6]

===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-22T20:01:40Z

Dina: /* Overview */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

[[Adenomyosis]] is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus). The condition is typically found in women between the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]].
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The basic Fibroblast Growth Factor (bFGF) receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>..

==Risk Factors==
*Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

== Natural History, Complications and Prognosis==
*The majority of patients with [disease name] remain asymptomatic for [duration/years].
*Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
*If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
*Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
*Prognosis is generally [excellent/good/poor], and the [1/5/10year mortality/survival rate] of patients with [disease name] is approximately [#%].
There is no increased risk for cancer development. As the condition is estrogen-dependent, menopause presents a natural cure. Patients with adenomyosis often also have [[leiomyoma]]ta and/or [[endometriosis]].

==Diagnosis==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]

=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of [disease name] may include the following:
:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]

=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Physical examination may be remarkable for:
:*[finding 1]
:*[finding 2]
:*[finding 3]
:*[finding 4]
:*[finding 5]
:*[finding 6]

===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-22T20:00:27Z

Dina: /* Epidemiology and Demographics */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

'''Adenomyosis''' is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus).<ref>Katz VL. Benign gynecologic lesions: vulva, vagina, cervix, uterus, oviduct, ovary. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007: Chapter 18.</ref> <ref>Speroff L, Fritz MA. Dysfunction uterine bleeding. In. Speroff L, Fritz MA, eds. Clinical Gynecologic Endocrinology and Infertility. 7th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2005: Chapter 15.</ref> The condition is typically found in women in the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]].
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The basic Fibroblast Growth Factor (bFGF) receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that [[adenomyosis]] is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The [[incidence]] and [[prevalence]] of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing [[hysterectomy]], so the total population of women having the disease is not known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*[[Adenomyosis]] is more commonly observed among women aged 40-50 years in those undergoing [[hysterectomy]] for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*[[Adenomyosis]] is less commonly diagnosed in adolescents who undergo pelvic imaging by [[transvaginal ultrasound]] or [[MRI]] rather than a [[hysterectomy]] for [[diagnosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>..

==Risk Factors==
*Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

== Natural History, Complications and Prognosis==
*The majority of patients with [disease name] remain asymptomatic for [duration/years].
*Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
*If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
*Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
*Prognosis is generally [excellent/good/poor], and the [1/5/10year mortality/survival rate] of patients with [disease name] is approximately [#%].
There is no increased risk for cancer development. As the condition is estrogen-dependent, menopause presents a natural cure. Patients with adenomyosis often also have [[leiomyoma]]ta and/or [[endometriosis]].

==Diagnosis==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]

=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of [disease name] may include the following:
:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]

=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Physical examination may be remarkable for:
:*[finding 1]
:*[finding 2]
:*[finding 3]
:*[finding 4]
:*[finding 5]
:*[finding 6]

===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-22T19:58:14Z

Dina: /* Epidemiology and Demographics */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

'''Adenomyosis''' is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus).<ref>Katz VL. Benign gynecologic lesions: vulva, vagina, cervix, uterus, oviduct, ovary. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007: Chapter 18.</ref> <ref>Speroff L, Fritz MA. Dysfunction uterine bleeding. In. Speroff L, Fritz MA, eds. Clinical Gynecologic Endocrinology and Infertility. 7th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2005: Chapter 15.</ref> The condition is typically found in women in the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]].
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The basic Fibroblast Growth Factor (bFGF) receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that adenomyosis is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The incidence and prevalence of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing hysterectomy, so the total population of women having the disease isn't known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*Adenomyosis is more commonly observed among women aged 40-50 years in those undergoing hysterectomy for diagnosis<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*Adenomyosis is less commonly diagnosed in adolescents who undergo pelvic imaging by transvaginal ultrasound or MRI rather than a hysterectomy for diagnosis<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }} </ref>.

===Race===
*There is no racial predilection for adenomyosis.
* Almost all cases of adenomyosis present in multiparous women, however there is no clear causal relationship between multiparty and the development of the disease<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>..

==Risk Factors==
*Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

== Natural History, Complications and Prognosis==
*The majority of patients with [disease name] remain asymptomatic for [duration/years].
*Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
*If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
*Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
*Prognosis is generally [excellent/good/poor], and the [1/5/10year mortality/survival rate] of patients with [disease name] is approximately [#%].
There is no increased risk for cancer development. As the condition is estrogen-dependent, menopause presents a natural cure. Patients with adenomyosis often also have [[leiomyoma]]ta and/or [[endometriosis]].

==Diagnosis==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]

=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of [disease name] may include the following:
:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]

=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Physical examination may be remarkable for:
:*[finding 1]
:*[finding 2]
:*[finding 3]
:*[finding 4]
:*[finding 5]
:*[finding 6]

===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-22T19:45:35Z

Dina: /* Pathophysiology */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

'''Adenomyosis''' is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus).<ref>Katz VL. Benign gynecologic lesions: vulva, vagina, cervix, uterus, oviduct, ovary. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007: Chapter 18.</ref> <ref>Speroff L, Fritz MA. Dysfunction uterine bleeding. In. Speroff L, Fritz MA, eds. Clinical Gynecologic Endocrinology and Infertility. 7th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2005: Chapter 15.</ref> The condition is typically found in women in the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]].
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests due to metaplasia.
*The basic Fibroblast Growth Factor (bFGF) receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that adenomyosis is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The incidence and prevalence of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing hysterectomy, so the total population of women having the disease isn't known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*Patients of all age groups may develop [disease name].

*[Disease name] is more commonly observed among patients aged [age range] years old.
*[Disease name] is more commonly observed among [elderly patients/young patients/children].

===Race===
*There is no racial predilection for [disease name].

*[Disease name] usually affects individuals of the [race 1] race.
*[Race 2] individuals are less likely to develop [disease name].

==Risk Factors==
*Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

== Natural History, Complications and Prognosis==
*The majority of patients with [disease name] remain asymptomatic for [duration/years].
*Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
*If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
*Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
*Prognosis is generally [excellent/good/poor], and the [1/5/10year mortality/survival rate] of patients with [disease name] is approximately [#%].
There is no increased risk for cancer development. As the condition is estrogen-dependent, menopause presents a natural cure. Patients with adenomyosis often also have [[leiomyoma]]ta and/or [[endometriosis]].

==Diagnosis==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]

=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of [disease name] may include the following:
:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]

=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Physical examination may be remarkable for:
:*[finding 1]
:*[finding 2]
:*[finding 3]
:*[finding 4]
:*[finding 5]
:*[finding 6]

===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-22T19:28:08Z

Dina: /* Epidemiology and Demographics */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

'''Adenomyosis''' is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus).<ref>Katz VL. Benign gynecologic lesions: vulva, vagina, cervix, uterus, oviduct, ovary. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007: Chapter 18.</ref> <ref>Speroff L, Fritz MA. Dysfunction uterine bleeding. In. Speroff L, Fritz MA, eds. Clinical Gynecologic Endocrinology and Infertility. 7th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2005: Chapter 15.</ref> The condition is typically found in women in the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]].
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests.
*The basic Fibroblast Growth Factor (bFGF) receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* It is generally estimated that adenomyosis is present in 20-35% of women<ref name="pmid16563868">{{cite journal| author=Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L| title=Adenomyosis: epidemiological factors. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 465-77 | pmid=16563868 | doi=10.1016/j.bpobgyn.2006.01.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563868 }} </ref>.
* The incidence and prevalence of adenomyosis are, however, difficult to be accurately estimated and biased by studying only women undergoing hysterectomy, so the total population of women having the disease isn't known<ref name="pmid27810281">{{cite journal| author=Abbott JA| title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2017 | volume= 40 | issue= | pages= 68-81 | pmid=27810281 | doi=10.1016/j.bpobgyn.2016.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27810281 }} </ref>.

===Age===
*Patients of all age groups may develop [disease name].

*[Disease name] is more commonly observed among patients aged [age range] years old.
*[Disease name] is more commonly observed among [elderly patients/young patients/children].

===Race===
*There is no racial predilection for [disease name].

*[Disease name] usually affects individuals of the [race 1] race.
*[Race 2] individuals are less likely to develop [disease name].

==Risk Factors==
*Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

== Natural History, Complications and Prognosis==
*The majority of patients with [disease name] remain asymptomatic for [duration/years].
*Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
*If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
*Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
*Prognosis is generally [excellent/good/poor], and the [1/5/10year mortality/survival rate] of patients with [disease name] is approximately [#%].
There is no increased risk for cancer development. As the condition is estrogen-dependent, menopause presents a natural cure. Patients with adenomyosis often also have [[leiomyoma]]ta and/or [[endometriosis]].

==Diagnosis==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]

=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of [disease name] may include the following:
:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]

=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Physical examination may be remarkable for:
:*[finding 1]
:*[finding 2]
:*[finding 3]
:*[finding 4]
:*[finding 5]
:*[finding 6]

===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-22T19:13:07Z

Dina: /* Causes */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

'''Adenomyosis''' is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus).<ref>Katz VL. Benign gynecologic lesions: vulva, vagina, cervix, uterus, oviduct, ovary. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007: Chapter 18.</ref> <ref>Speroff L, Fritz MA. Dysfunction uterine bleeding. In. Speroff L, Fritz MA, eds. Clinical Gynecologic Endocrinology and Infertility. 7th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2005: Chapter 15.</ref> The condition is typically found in women in the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]].
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests.
*The basic Fibroblast Growth Factor (bFGF) receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[caesarean section]]
* [[Tubal ligation]]
* [[Abortion]]
* [[pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
* In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].

===Age===
*Patients of all age groups may develop [disease name].

*[Disease name] is more commonly observed among patients aged [age range] years old.
*[Disease name] is more commonly observed among [elderly patients/young patients/children].

===Gender===
*[Disease name] affects men and women equally.

*[Gender 1] are more commonly affected with [disease name] than [gender 2].
* The [gender 1] to [Gender 2] ratio is approximately [number > 1] to 1.

===Race===
*There is no racial predilection for [disease name].

*[Disease name] usually affects individuals of the [race 1] race.
*[Race 2] individuals are less likely to develop [disease name].

==Risk Factors==
*Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

== Natural History, Complications and Prognosis==
*The majority of patients with [disease name] remain asymptomatic for [duration/years].
*Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
*If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
*Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
*Prognosis is generally [excellent/good/poor], and the [1/5/10year mortality/survival rate] of patients with [disease name] is approximately [#%].
There is no increased risk for cancer development. As the condition is estrogen-dependent, menopause presents a natural cure. Patients with adenomyosis often also have [[leiomyoma]]ta and/or [[endometriosis]].

==Diagnosis==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]

=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of [disease name] may include the following:
:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]

=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Physical examination may be remarkable for:
:*[finding 1]
:*[finding 2]
:*[finding 3]
:*[finding 4]
:*[finding 5]
:*[finding 6]

===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-22T19:12:48Z

Dina: /* Causes */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

'''Adenomyosis''' is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus).<ref>Katz VL. Benign gynecologic lesions: vulva, vagina, cervix, uterus, oviduct, ovary. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007: Chapter 18.</ref> <ref>Speroff L, Fritz MA. Dysfunction uterine bleeding. In. Speroff L, Fritz MA, eds. Clinical Gynecologic Endocrinology and Infertility. 7th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2005: Chapter 15.</ref> The condition is typically found in women in the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]].
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests.
*The basic Fibroblast Growth Factor (bFGF) receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as:
* [[caesarean section]]
* [[Tubal ligation]]
* [[Pregnancy termination]]
* [[pregnancy]]

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
* In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].

===Age===
*Patients of all age groups may develop [disease name].

*[Disease name] is more commonly observed among patients aged [age range] years old.
*[Disease name] is more commonly observed among [elderly patients/young patients/children].

===Gender===
*[Disease name] affects men and women equally.

*[Gender 1] are more commonly affected with [disease name] than [gender 2].
* The [gender 1] to [Gender 2] ratio is approximately [number > 1] to 1.

===Race===
*There is no racial predilection for [disease name].

*[Disease name] usually affects individuals of the [race 1] race.
*[Race 2] individuals are less likely to develop [disease name].

==Risk Factors==
*Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

== Natural History, Complications and Prognosis==
*The majority of patients with [disease name] remain asymptomatic for [duration/years].
*Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
*If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
*Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
*Prognosis is generally [excellent/good/poor], and the [1/5/10year mortality/survival rate] of patients with [disease name] is approximately [#%].
There is no increased risk for cancer development. As the condition is estrogen-dependent, menopause presents a natural cure. Patients with adenomyosis often also have [[leiomyoma]]ta and/or [[endometriosis]].

==Diagnosis==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]

=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of [disease name] may include the following:
:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]

=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Physical examination may be remarkable for:
:*[finding 1]
:*[finding 2]
:*[finding 3]
:*[finding 4]
:*[finding 5]
:*[finding 6]

===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-22T19:02:37Z

Dina: /* Pathophysiology */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

'''Adenomyosis''' is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus).<ref>Katz VL. Benign gynecologic lesions: vulva, vagina, cervix, uterus, oviduct, ovary. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007: Chapter 18.</ref> <ref>Speroff L, Fritz MA. Dysfunction uterine bleeding. In. Speroff L, Fritz MA, eds. Clinical Gynecologic Endocrinology and Infertility. 7th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2005: Chapter 15.</ref> The condition is typically found in women in the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]].
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests.
*The basic Fibroblast Growth Factor (bFGF) receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[prolactin]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==

The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as a [[caesarean section]], [[tubal ligation]], [[pregnancy termination]], and any [[pregnancy]].

Some say that the reason adenomyosis is common in women between the ages of 35 and 50 is because it is between these ages that women have an excess of estrogen. Near the age of 35, women typically cease to create as much natural [[progesterone]], which counters the effects of estrogen. After the age of 50, due to menopause, women do not create as much [[estrogen]].

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
* In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].

===Age===
*Patients of all age groups may develop [disease name].

*[Disease name] is more commonly observed among patients aged [age range] years old.
*[Disease name] is more commonly observed among [elderly patients/young patients/children].

===Gender===
*[Disease name] affects men and women equally.

*[Gender 1] are more commonly affected with [disease name] than [gender 2].
* The [gender 1] to [Gender 2] ratio is approximately [number > 1] to 1.

===Race===
*There is no racial predilection for [disease name].

*[Disease name] usually affects individuals of the [race 1] race.
*[Race 2] individuals are less likely to develop [disease name].

==Risk Factors==
*Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

== Natural History, Complications and Prognosis==
*The majority of patients with [disease name] remain asymptomatic for [duration/years].
*Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
*If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
*Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
*Prognosis is generally [excellent/good/poor], and the [1/5/10year mortality/survival rate] of patients with [disease name] is approximately [#%].
There is no increased risk for cancer development. As the condition is estrogen-dependent, menopause presents a natural cure. Patients with adenomyosis often also have [[leiomyoma]]ta and/or [[endometriosis]].

==Diagnosis==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]

=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of [disease name] may include the following:
:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]

=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Physical examination may be remarkable for:
:*[finding 1]
:*[finding 2]
:*[finding 3]
:*[finding 4]
:*[finding 5]
:*[finding 6]

===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-22T19:02:03Z

Dina: /* Pathophysiology */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

'''Adenomyosis''' is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus).<ref>Katz VL. Benign gynecologic lesions: vulva, vagina, cervix, uterus, oviduct, ovary. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007: Chapter 18.</ref> <ref>Speroff L, Fritz MA. Dysfunction uterine bleeding. In. Speroff L, Fritz MA, eds. Clinical Gynecologic Endocrinology and Infertility. 7th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2005: Chapter 15.</ref> The condition is typically found in women in the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]].
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible [[pathogenesis]]<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the [[endometrium]]; due to weakness of the uterine [[smooth muscles]].
# De novo development of adenomyosis from [[mullerian]] rests.
*The basic Fibroblast Growth Factor (bFGF) receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal [[uterine bleeding]] and [[menorrhagia]]<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* [[Estrogen]] and [[progesterone]] hormones play a role in the [[pathogenesis]] of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as [[oxytocin]] <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, [[FSH]]<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and [[PRL]]<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross [[pathology]], there is a globular enlargement of the [[myometrium]] of the [[uterus]] showing cysts filled with hemolysed [[red blood cells]] and [[sideroblasts]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are [[endometrial]] glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the [[myometrium]]<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==

The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as a [[caesarean section]], [[tubal ligation]], [[pregnancy termination]], and any [[pregnancy]].

Some say that the reason adenomyosis is common in women between the ages of 35 and 50 is because it is between these ages that women have an excess of estrogen. Near the age of 35, women typically cease to create as much natural [[progesterone]], which counters the effects of estrogen. After the age of 50, due to menopause, women do not create as much [[estrogen]].

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
* In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].

===Age===
*Patients of all age groups may develop [disease name].

*[Disease name] is more commonly observed among patients aged [age range] years old.
*[Disease name] is more commonly observed among [elderly patients/young patients/children].

===Gender===
*[Disease name] affects men and women equally.

*[Gender 1] are more commonly affected with [disease name] than [gender 2].
* The [gender 1] to [Gender 2] ratio is approximately [number > 1] to 1.

===Race===
*There is no racial predilection for [disease name].

*[Disease name] usually affects individuals of the [race 1] race.
*[Race 2] individuals are less likely to develop [disease name].

==Risk Factors==
*Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

== Natural History, Complications and Prognosis==
*The majority of patients with [disease name] remain asymptomatic for [duration/years].
*Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
*If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
*Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
*Prognosis is generally [excellent/good/poor], and the [1/5/10year mortality/survival rate] of patients with [disease name] is approximately [#%].
There is no increased risk for cancer development. As the condition is estrogen-dependent, menopause presents a natural cure. Patients with adenomyosis often also have [[leiomyoma]]ta and/or [[endometriosis]].

==Diagnosis==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]

=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of [disease name] may include the following:
:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]

=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Physical examination may be remarkable for:
:*[finding 1]
:*[finding 2]
:*[finding 3]
:*[finding 4]
:*[finding 5]
:*[finding 6]

===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-22T13:54:29Z

Dina: /* Pathophysiology */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

'''Adenomyosis''' is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus).<ref>Katz VL. Benign gynecologic lesions: vulva, vagina, cervix, uterus, oviduct, ovary. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007: Chapter 18.</ref> <ref>Speroff L, Fritz MA. Dysfunction uterine bleeding. In. Speroff L, Fritz MA, eds. Clinical Gynecologic Endocrinology and Infertility. 7th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2005: Chapter 15.</ref> The condition is typically found in women in the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]].
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible pathogenesis<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the endometrium; due to weakness of the uterine smooth muscles.
# De novo development of adenomyosis from mullerian rests.
*The basic Fibroblast Growth Factor (bFGF) receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal uterine bleeding and menorrhagia<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* Estrogen and progesterone hormones play a role in the pathogenesis of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as oxytocin <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, FSH<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and PRL<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.
*On gross pathology, there is a globular enlargement of the myometrium of the uterus showing cysts filled with hemolysed red blood cells and sideroblasts<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
*On microscopic histopathological analysis, there are endometrial glands, and stroma surrounded by hypertrophic smooth muscle bundles haphazardly scattered within the myometrium<ref name="pmid16563870">{{cite journal| author=Bergeron C, Amant F, Ferenczy A| title=Pathology and physiopathology of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 511-21 | pmid=16563870 | doi=10.1016/j.bpobgyn.2006.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16563870 }} </ref>.
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==

The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as a [[caesarean section]], [[tubal ligation]], [[pregnancy termination]], and any [[pregnancy]].

Some say that the reason adenomyosis is common in women between the ages of 35 and 50 is because it is between these ages that women have an excess of estrogen. Near the age of 35, women typically cease to create as much natural [[progesterone]], which counters the effects of estrogen. After the age of 50, due to menopause, women do not create as much [[estrogen]].

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
* In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].

===Age===
*Patients of all age groups may develop [disease name].

*[Disease name] is more commonly observed among patients aged [age range] years old.
*[Disease name] is more commonly observed among [elderly patients/young patients/children].

===Gender===
*[Disease name] affects men and women equally.

*[Gender 1] are more commonly affected with [disease name] than [gender 2].
* The [gender 1] to [Gender 2] ratio is approximately [number > 1] to 1.

===Race===
*There is no racial predilection for [disease name].

*[Disease name] usually affects individuals of the [race 1] race.
*[Race 2] individuals are less likely to develop [disease name].

==Risk Factors==
*Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

== Natural History, Complications and Prognosis==
*The majority of patients with [disease name] remain asymptomatic for [duration/years].
*Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
*If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
*Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
*Prognosis is generally [excellent/good/poor], and the [1/5/10year mortality/survival rate] of patients with [disease name] is approximately [#%].
There is no increased risk for cancer development. As the condition is estrogen-dependent, menopause presents a natural cure. Patients with adenomyosis often also have [[leiomyoma]]ta and/or [[endometriosis]].

==Diagnosis==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]

=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of [disease name] may include the following:
:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]

=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Physical examination may be remarkable for:
:*[finding 1]
:*[finding 2]
:*[finding 3]
:*[finding 4]
:*[finding 5]
:*[finding 6]

===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Gynecology]]

Adenomyosis

2021-05-22T13:42:38Z

Dina: /* Pathophysiology */

'''For patient information, click [[Adenomyosis (patient information)|here]]'''

{{DiseaseDisorder infobox |
Name = Adenomyosis |
ICD10 = {{ICD10|N|80|0|n|80}} |
ICD9 = {{ICD9|617.0}} |
ICDO = |
Image = Adenomyosis MRI 105.jpg|
Caption = MRI, T2: Adenomyosis. [http://www.radswiki.net Image courtesy of RadsWiki]|
OMIM = 600458 |
MedlinePlus = 001513 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = |
MeshID = D004715 |
}}
{{SI}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Zorkun|Cafer Zorkun M.D. PhD.]][mailto:czorkun@wikidoc.org], [[User:Dina|Dina Elantably, MD]][mailto:dina.antably@gmail.com]

==Overview==

'''Adenomyosis''' is a medical condition characterized by the presence of ectopic [[endometrium|endometrial tissue]] (the inner lining of the [[uterus]]) within the [[uterus|myometrium]] (the thick, muscular layer of the uterus).<ref>Katz VL. Benign gynecologic lesions: vulva, vagina, cervix, uterus, oviduct, ovary. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007: Chapter 18.</ref> <ref>Speroff L, Fritz MA. Dysfunction uterine bleeding. In. Speroff L, Fritz MA, eds. Clinical Gynecologic Endocrinology and Infertility. 7th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2005: Chapter 15.</ref> The condition is typically found in women in the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse [[menses]] ([[dysmenorrhea]] & [[menorrhagia]], respectively).
Adenomyosis may involve the uterus focally, creating an [[adenomyoma]], or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

==Historical Perspective<ref name="pmid16515887">{{cite journal| author=Benagiano G, Brosens I| title=History of adenomyosis. | journal=Best Pract Res Clin Obstet Gynaecol | year= 2006 | volume= 20 | issue= 4 | pages= 449-63 | pmid=16515887 | doi=10.1016/j.bpobgyn.2006.01.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16515887 }} </ref>==
*[[Adenomyosis]] was first discovered by '''Carl von Rokitansky''', a German pathologist, in '''1860''' when he found endometrial glands in the myometrium and designated this finding as 'cystosarcoma adenoids uterinum'. 
* In '''1892''' the first systematic investigation of [[adenomyosis]] was carried out by ''''Thomas Stephen Cullen'''', a gynecologist. He distinguished 3 types of [[adenomyoma]]: intramural, subperitoneal and submucous [[adenomyoma]].
*In '''1893''', '''Kelly and Cullen''' described the [[pathogenesis]] of [[adenomyoma]]. The 'gradual ascendancy of Cullen’s mucosal theory' stated that [[endometrium]] invades the inner [[myometrium]] through the presence in it of ‘chinks’, or fissures.
*In '''1892''', '''Cullen''' described that abdominal [[hysterectomy]] is indicated for [[treatment]] as the [[endometrial]] growths are interwoven with the normal muscle of the [[uterus]].

==Classification==
*Adenomyosis can be classified according to its [[histopathology]] into 2 groups:
:*'''Diffuse adenomyosis:''' Uniformly enlarged boggy [[uterus]].
:*'''Focal adenomyosis [[(adenomyoma)]]:''' Grossly it resembles [[fibroid]] but without a surrounding pseudocapsule.

*Other variants of adenomyosis include '''juvenile cystic adenomyosis'''; which is the presence of [[endometrial]] cysts > 1cm in diameter within the [[myometrium]]. It is usually seen in young women <30 years old <ref name="pmid19539912">{{cite journal| author=Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kuroda K, Jinushi M| title=Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. | journal=Fertil Steril | year= 2010 | volume= 94 | issue= 3 | pages= 862-8 | pmid=19539912 | doi=10.1016/j.fertnstert.2009.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19539912 }} </ref>.

==Pathophysiology==
*The pathogenesis of [[Adenomyosis]] is poorly understood. There two theories that explain the possible pathogenesis<ref name="pmid9825847">{{cite journal| author=Ferenczy A| title=Pathophysiology of adenomyosis. | journal=Hum Reprod Update | year= 1998 | volume= 4 | issue= 4 | pages= 312-22 | pmid=9825847 | doi=10.1093/humupd/4.4.312 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9825847 }} </ref>:
# Endomyometrial invagination of the endometrium; due to weakness of the uterine smooth muscles.
# De novo development of adenomyosis from mullerian rests.
*The basic Fibroblast Growth Factor (bFGF) receptor/ligand system has shown to be upregulated in adenomyosis which explain the abnormal uterine bleeding and menorrhagia<ref name="pmid11528364">{{cite journal| author=Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA| title=Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium. | journal=Menopause | year= 2001 | volume= 8 | issue= 5 | pages= 368-71 | pmid=11528364 | doi=10.1097/00042192-200109000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11528364 }} </ref>.
* Estrogen and progesterone hormones play a role in the pathogenesis of adenomyosis<ref name="pmid15816354">{{cite journal| author=Green AR, Styles JA, Parrott EL, Gray D, Edwards RE, Smith AG | display-authors=etal| title=Neonatal tamoxifen treatment of mice leads to adenomyosis but not uterine cancer. | journal=Exp Toxicol Pathol | year= 2005 | volume= 56 | issue= 4-5 | pages= 255-63 | pmid=15816354 | doi=10.1016/j.etp.2004.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15816354 }} </ref>. Other hormones such as oxytocin <ref name="pmid22999795">{{cite journal| author=Guo SW, Mao X, Ma Q, Liu X| title=Dysmenorrhea and its severity are associated with increased uterine contractility and overexpression of oxytocin receptor (OTR) in women with symptomatic adenomyosis. | journal=Fertil Steril | year= 2013 | volume= 99 | issue= 1 | pages= 231-240 | pmid=22999795 | doi=10.1016/j.fertnstert.2012.08.038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22999795 }} </ref>, FSH<ref name="pmid11750866">{{cite journal| author=Stewart EA| title=Gonadotropins and the uterus: is there a gonad-independent pathway? | journal=J Soc Gynecol Investig | year= 2001 | volume= 8 | issue= 6 | pages= 319-26 | pmid=11750866 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11750866 }} </ref>, and PRL<ref name="pmid1853904">{{cite journal| author=Mori T, Singtripop T, Kawashima S| title=Animal model of uterine adenomyosis: is prolactin a potent inducer of adenomyosis in mice? | journal=Am J Obstet Gynecol | year= 1991 | volume= 165 | issue= 1 | pages= 232-4 | pmid=1853904 | doi=10.1016/0002-9378(91)90258-s | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1853904 }} </ref> also contribute to the pathogenesis of the disease.

*On gross pathology, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
*On microscopic histopathological analysis, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
{{#ev:youtube|nOCtpIwCZ-Y}}

==Causes==

The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as a [[caesarean section]], [[tubal ligation]], [[pregnancy termination]], and any [[pregnancy]].

Some say that the reason adenomyosis is common in women between the ages of 35 and 50 is because it is between these ages that women have an excess of estrogen. Near the age of 35, women typically cease to create as much natural [[progesterone]], which counters the effects of estrogen. After the age of 50, due to menopause, women do not create as much [[estrogen]].

==Differential Diagnosis of Adenomyosis==
Adenomyosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding and the following table is a description of various causes of excessive uterine bleeding.

{| class="wikitable"
!
!Clinical Features
!Physical Examination
!Diagnostic Findings
|-
|[[Endometriosis]]
|
*[[Dysmenorrhea]]
*[[Dyspareunia]]
*[[Infertility]]
*Common in women between 25 to 35 years
|
*Nodules in the [[posterior fornix]]
*Adnexal masses
*Fixed retroverted [[uterus]]
*Lateral displacement of the [[cervix]]
|
*Increased [[CA-125|serum cancer antigen-125]]
*Nodules of the recto vaginal septum and hypoechoic, vascular mass on [[MRI]]
*Laproscopic visualization confirms the diagnosis
|-
|[[Adenomyosis]]<ref name="pmid16782099">{{cite journal| author=Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P| title=Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis. | journal=Fertil Steril | year= 2006 | volume= 86 | issue= 3 | pages= 711-5 | pmid=16782099 | doi=10.1016/j.fertnstert.2006.01.030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16782099 }}</ref>
|
*[[Abnormal uterine bleeding]]
*[[Dysmenorrhea]]
*Common in women aged 40 and 50 years
|
* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of [[gestation]]
|
*Asymmetric thickening of the [[myometrium]] on [[MRI]]
|-
|Submucous uterine [[Leiomyoma|leiomyomas]]<ref name="pmid26477496">{{cite journal| author=Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J et al.| title=Long-term medical management of uterine fibroids with ulipristal acetate. | journal=Fertil Steril | year= 2016 | volume= 105 | issue= 1 | pages= 165-173.e4 | pmid=26477496 | doi=10.1016/j.fertnstert.2015.09.032 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26477496 }}</ref>
|
*[[Menorrhagia]]
*Pelvic pressure and pain
*[[Infertility]]
*Peak age of onset 25 to 44 years of age
|
*Mobile [[uterus]] with an irregular contour
|
*[[Transvaginal ultrasound]] will demonstrate the presence of myomas
|-
|[[PID|Pelvic Inflammatory disease]]<ref name="pmid24216035">{{cite journal| author=Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections| title=2012 European guideline for the management of pelvic inflammatory disease. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 1 | pages= 1-7 | pmid=24216035 | doi=10.1177/0956462413498714 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24216035 }}</ref>
|
*Seen in patients with history of [[sexually transmitted disease]]
*History of multiple sexual partners
*Common in women younger than 25 years of age
|
*[[Abdominal tenderness]]
*Acute [[Cervical motion tenderness|cervical motion]], [[Uterus|uterine]], and adnexal tenderness
*Visualization of purulent endocervical discharge
|
*Positive [[Nucleic acid test|Nucleic acid amplification tests]] for [[Chlamydia trachomatis]] and [[Neisseria gonorrhoeae|N. gonorrhoeae]]
*Gram negative [[diplococci]] on [[gram stain]]
|-
|Pelvic congestion Syndrome<ref name="pmid11133549">{{cite journal| author=Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES| title=Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. | journal=AJR Am J Roentgenol | year= 2001 | volume= 176 | issue= 1 | pages= 119-22 | pmid=11133549 | doi=10.2214/ajr.176.1.1760119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11133549 }}</ref>
|
*Shifting lower abdominal pain
*Deep [[dyspareunia]]
*Post-coital pain
*Exacerbation of pain after prolonged standing
|
*Bimanual tenderness
*[[Cervical motion tenderness]]
|
*Pelvic [[varicosities]] on ultrasound with reduced blood flow
|}

==Epidemiology and Demographics==
* The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
* In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].

===Age===
*Patients of all age groups may develop [disease name].

*[Disease name] is more commonly observed among patients aged [age range] years old.
*[Disease name] is more commonly observed among [elderly patients/young patients/children].

===Gender===
*[Disease name] affects men and women equally.

*[Gender 1] are more commonly affected with [disease name] than [gender 2].
* The [gender 1] to [Gender 2] ratio is approximately [number > 1] to 1.

===Race===
*There is no racial predilection for [disease name].

*[Disease name] usually affects individuals of the [race 1] race.
*[Race 2] individuals are less likely to develop [disease name].

==Risk Factors==
*Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

== Natural History, Complications and Prognosis==
*The majority of patients with [disease name] remain asymptomatic for [duration/years].
*Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
*If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
*Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
*Prognosis is generally [excellent/good/poor], and the [1/5/10year mortality/survival rate] of patients with [disease name] is approximately [#%].
There is no increased risk for cancer development. As the condition is estrogen-dependent, menopause presents a natural cure. Patients with adenomyosis often also have [[leiomyoma]]ta and/or [[endometriosis]].

==Diagnosis==
The [[uterus]] may be imaged using [[ultrasound]] (US) or [[magnetic resonance imaging]] (MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize [[leiomyoma|uterine fibroids]].

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small [[leiomyoma|uterine fibroids]]. The uterus will have a thickened [[uterus|junctional zone]] with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the [[uterus|junctional zone]] greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]

=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of [disease name] may include the following:
:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]

=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Physical examination may be remarkable for:
:*[finding 1]
:*[finding 2]
:*[finding 3]
:*[finding 4]
:*[finding 5]
:*[finding 6]

===Ultrasonography===

*Typical appearances of adenomyosis at transvaginal ultrasound include poorly marginated hypoechoic and heterogeneous areas within the myometrium, myometrial cysts, and a globular or enlarged uterus with asymmetry.

[http://www.radswiki.net Image courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis ultrasound 101.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 102.jpg|US: Adenomyosis
Image:Adenomyosis ultrasound 103.jpg|US: Adenomyosis
</gallery>

===Computed Tomography===

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="3">
Image:Adenomyosis CT 108.jpg|CT: Adenomyosis
Image:Adenomyosis CT 109.jpg|CT: Adenomyosis
</gallery>

===Magnetic Resonance Imaging===

*Adenomyosis appears as either diffuse or focal thickening (greater than 12 mm )of the junctional zone forming an ill-defined area of low signal intensity, occasionally with embedded bright foci on T2-weighted images.
*Histologically, areas of low signal intensity correspond to smooth muscle hyperplasia, and bright foci on T2-weighted images correspond to islands of ectopic endometrial tissue and cystic dilatation of glands.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Adenomyosis MRI 104.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 105.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 106.jpg|T2: Adenomyosis
Image:Adenomyosis MRI 107.jpg|T1 fat sat contrast: Adenomyosis
</gallery>

[http://www.radswiki.net Images courtesy of RadsWiki]

[[Image:Adenomyosis 001.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

[[Image:Adenomyosis 002.jpg|thumb|left|350px|MR: T2 image demonstrates adenomyosis]]
 

== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.

*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].

=== Prevention ===
*There are no primary preventive measures available for [disease name].

*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Treatment options range from use of [[NSAIDS]] & hormonal suppression for symptomatic relief, with [[hysterectomy]] the only permanent cure option. Women with Adenomyosis fail [[endometrial ablation]] because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with [[xenoestrogen]]s and/or recommend taking natural progesterone supplements.

==References==
{{Reflist|2}}

==Additional Resources==
{{refbegin|2}}
* Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90.
* Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602.
* Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6.
* Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70.
* Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75.
* Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8.
* Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.
* Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40.
* Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50.
* Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54.
* Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50.
* Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;
* Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5.
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;
* Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14.
* Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60.
* Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602.
* Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40.
* Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404.
{{refend}}

{{Diseases of the pelvis, genitals and breasts}}

[[nl:Adenomyose]]
[[he:אדנומיוזיס]]

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