adenomyosis presentation
TRANSCRIPT
ADENOMYOSIS
Magdy Abdelrahman Mohamed2014
DEFINITION• Adenomyosis is defined by the presence
of ectopic endometrial glands and stroma within the myometrium.
• The presence of ectopic endometrial glands and stroma induces a hypertrophic and hyperplastic reaction in the surrounding myometrial tissue.
• It usually occurs in 4th or 5th decade.
• Associated with high parity• usually associated with other
conditions, such as myoma, endometrial polyps and endo metriosis.
TYPES
• Diffuse
• Local
• adenomyoma describes a focus of adenomyosis within a leiomyoma.
• Both conditions are common so it is not surprising that this overlap condition may occur
Presentation
• Menorrhagia.• Congestive dysmenorrhoea.• Dyspareunia.• Chronic pelvic pain.
Adenomyosis & subfertility
• It thought to be a condition of parous women, with the final diagnosis made after hysterectomy.
• Thus, an association between adenomyosis and subfertility has not been fully established.
• Some believe that adenomyosis is not common in subfertile women, while others think that adenomyosis plays a critical role in subfertility.
• The hypothesis of a possible link between adenomyosis and infertility is becoming more and more plausible.
• There is observation that adenomyosis is present even in younger women and can be associated with pelvic endometriosis and infertility.
• (Kissler et al., 2007; Kunz et al.,2005).
Possible mechanism
1-Altered uterine peristaltic activity.Kissler et al. (2006) placed into the posterior vaginal fornix radio-labelled macro-albumin aggregates (with a size of 5–20 um mimicking sperm size) and scanned with a gamma camera immediately after application and at various time intervals up to 30 min.
• Fertile women. Positive, uni- and ipsilateral transport of radionuclides to the side bearing the dominant follicle.
• Diffuse adenomysis & infertility.– 70% remain in uterus.– 22% transport to contralateral side.– 8% to ipsilateral side of dominant follicle.
2-Altered endometrial function and receptivity.
DIAGNOSIS
• The sure diagnosis of adenomyosis is made on a pathologic specimen.
• The pathologic diagnosis is dependent on the visualization of endometrial glands and stroma in more than 1 low-power field from the endometrial basalis layer.
• Katz VL. Benign gynecologic lesions. 5th Edition. 2007:419–471.
TVS• Operator dependent.• meta-analysis on the accuracy of
sonography in the diagnosis of adenomyosis showed that it had sensitivity of 82.5% (77.5–87.9) and specificity of 84.6% (79.8–89.8).
Meredith SM et al, 2009.
• Uterine enlargement.• Cystic anechoic spaces or lakes in
the myometrium.• Heterogeneous echo texture.• Obscure endometrial/myometrial
border.• Subendometrial halo thickening.
• Globular uterine enlargement with an obscure endometrial/myometrial border (arrow).
• Anechoic cystic lacunae in the posterior uterine wall (arrow) with a heterogeneous echo texture.
• Linear striations (arrows) in the presence of a heterogeneous echo texture
MRI• More accurate.• Findings
– Diffuse or local widening of junctional zones on T2 weighted images >12 mm.
– Low intensity lesion (ill-defined).– Uterine enlargement.– Small hypointense myometrial spots.
Sagittal T2-weighted MR image shows diffuse, even thickening of the junctional zone (arrows), a finding consistent with diffuse adenomyosis
• focal thickening of the JZ (short arrows).
OTHER TESTS
• Ca-125.• Hyserosalpingraphy.
MANEGMENT
The only definitive treatment for adenomyosis is hysterectomy, with or without ovarian conservation.
ALTERNATIVES• GNRH Analogues.• Levonorgestrel releasing IUD.• Uterine artery embolization.• Focused U/S……….. For localized
adenomyosis.• Endometrial ablation.• Conservative surgery.
MANAGEMENT OF INFERTILITY.
• Data available on treatment of infertility associated with adenomyosis are still fairly limited and mostly confined to case reports or uncontrolled small series.
CONSERVATIVE SURGERIES
Nishida. Conservative surgery for adenomyosis.
• Of 44 patient results were.
Triple flap (Osada) method.
Other options
A- GnRH analogue: Few case reports (Silva et al.,1994) published the first term pregnancy in a patient with a 10-year history of secondary infertility, after 5 months of therapy with GnRHa.
B- IUD containing danazol.• a Japanese group (Igarashi et al.,
2000) have published results of 14 women with symptomatic adenomyosis that had relapsed after previous medical therapy.
• There was good relief of the symptoms.
• Three of the four infertile women conceived after removal.
C- Uterine artery embolization. few case seriesD- MRI-assisted high-intensity focused
ultrasound (HIFU). Only one case of successful treatment of adenomyosis associated infertility with HIFU has been published. (Rabinovici et al., 2006b)