Adenomyosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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Overview
Adenomyosis is a medical condition characterized by the presence of ectopic endometrial tissue (the inner lining of the uterus) within the myometrium (the thick, muscular layer of the uterus).
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.
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.
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 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 uterine fibroids. The uterus will have a thickened 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 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 Findings
US
- 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.
MRI
- 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.
Treatment
Treatment options range from use of NSAIDS & hormonal suppression for symptomatic relief, to endometrial ablation or hysterectomy for a more or less permanent cure.
Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with xenoestrogens and/or recommend taking natural progesterone supplements.
Other considerations
The differential of abnormal uterine bleeding includes
- endometrial polyps
- submucosal fibroids
- endometrial hyperplasia
- endometrial carcinoma
In a younger woman, considerations should be broadened to include
Prognosis
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 leiomyomata and/or endometriosis.
External links
Template:Diseases of the pelvis, genitals and breasts Template:SIB