Adenomyosis

Background

Uterine disorder characterized by endometrial glands and stroma being present within the myometrium resulting in hypertrophy of the surrounding myometrium
Two histopathological forms:
- Diffuse – results in the uterus being uniformly enlarged and boggy
- Focal (also known as an adenomyoma) – can appear similar to a fibroid but does not have a pseudocapsule
Pathogenesis is not well understood

Clinical Features

Heavy menstrual bleeding
Dysmenorrhea
Chronic pelvic pain

Differential Diagnosis

Reproductive Tract Causes

Atrophic endometrium
Dysfunctional uterine bleeding
Endometriosis
Fibroids
Foreign Body
Infection (vaginitis, PID)
IUD
Neoplasia
Uterine polyp
Vaginal Trauma

Systemic Causes

Cirrhosis Coagulopathy (Von Willebrand disease, ITP) Group A strep vaginitis (prepubertal girls) Hormone replacement therapy Hypothyroidism Secondary anovulation

Evaluation

Pelvic exam – bimanual usually reveals a mobile, enlarged, and soft or boggy uterus
Transvaginal US
MRI usually reserved in cases when providers are seeking to distinguish between adenomysosis and leiomyomas ^[1]
Definitive diagnosis relies on histology, and so it is usually made during pathology examination of the uterus after a hysterectomy

Management

Hysterectomy is the definitive treatment
Alternative options include
- Hormonal therapy such as with a levonorgestrel IUD ^[2] ^[3] ^[4]
Uterine artery embolization
Uterus sparing resection

Disposition

Final disposition should be made based on hemodynamic stability of the patient
If hemodynamically stable without clinically significant bleeding, patient can be discharged with gynecology referral

References

↑ Byun JY, Kim SE, Choi BG, Ko GY, Jung SE, Choi KH. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. 1999;19 Spec No:S161-S170. doi:10.1148/radiographics.19.suppl_1.g99oc03s161
↑ Fong YF, Singh K. Medical treatment of a grossly enlarged adenomyotic uterus with the levonorgestrel-releasing intrauterine system. Contraception. 1999;60(3):173-175. doi:10.1016/s0010-7824(99)00075-x
↑ Fedele L, Bianchi S, Raffaelli R, Portuese A, Dorta M. Treatment of adenomyosis-associated menorrhagia with a levonorgestrel-releasing intrauterine device. Fertil Steril. 1997;68(3):426-429. doi:10.1016/s0015-0282(97)00245-8
↑ Sheng J, Zhang WY, Zhang JP, Lu D. The LNG-IUS study on adenomyosis: a 3-year follow-up study on the efficacy and side effects of the use of levonorgestrel intrauterine system for the treatment of dysmenorrhea associated with adenomyosis. Contraception. 2009;79(3):189-193. doi:10.1016/j.contraception.2008.11.004

Authors:

[1] Byun JY, Kim SE, Choi BG, Ko GY, Jung SE, Choi KH. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. 1999;19 Spec No:S161-S170. doi:10.1148/radiographics.19.suppl_1.g99oc03s161

[2] Fong YF, Singh K. Medical treatment of a grossly enlarged adenomyotic uterus with the levonorgestrel-releasing intrauterine system. Contraception. 1999;60(3):173-175. doi:10.1016/s0010-7824(99)00075-x

[3] Fedele L, Bianchi S, Raffaelli R, Portuese A, Dorta M. Treatment of adenomyosis-associated menorrhagia with a levonorgestrel-releasing intrauterine device. Fertil Steril. 1997;68(3):426-429. doi:10.1016/s0015-0282(97)00245-8

[4] Sheng J, Zhang WY, Zhang JP, Lu D. The LNG-IUS study on adenomyosis: a 3-year follow-up study on the efficacy and side effects of the use of levonorgestrel intrauterine system for the treatment of dysmenorrhea associated with adenomyosis. Contraception. 2009;79(3):189-193. doi:10.1016/j.contraception.2008.11.004

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