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Adenomyosis

Essentials

  • The risk of adenomyosis is increased by childbirth, miscarriage, uterine curettage and menorrhagia.
  • The symptoms resemble those of endometriosis.
  • An underdiagnosed disease
  • In fertile age treated like endometriosis
  • Hysterectomy is the best and final treatment for older women with severe symptoms.

In general

  • Adenomyosis is characterised by the presence of intramyometrial foci of endometrial glandular and stromal cells (in endometriosis, endometriotic tissue is found outside the uterus).
  • The foci of adenomyosis react to oestrogen in a manner similar to that of endometrium.
  • The foci have either diffuse (usually in the posterior uterine wall) or local (adenomyoma) distribution where a large number of foci become localised in one area.
  • The aetiology remains unclear.
  • The risk of adenomyosis is increased by childbirth, miscarriage, uterine curettage and menorrhagia.
  • Currently adenomyosis is suspected to be associated also with infertility and hence to be more common than previously thought; in 5–70% of women.
  • Most common at the age of 35–50 years
  • Changes are found in 15–20% of hysterectomy patients.
  • About 40% of patients with endometriosis also have adenomyosis.

Symptoms

  • An enlarged and tender uterus
  • Feeling of heaviness in the lower abdomen
  • Infertility; impaired attachment of the embryo to the uterine wall
  • 40–50% have menorrhagia
  • 10–30% have dysmenorrhoea
  • 30–40% are symptom free
  • The symptoms are similar to those of endometriosis (Endometriosis) and differential diagnosis may prove to be difficult.

Diagnosis

  • Gynaecological examination will reveal uterine tenderness.
  • The ultrasound appearance is that of thickened posterior uterine wall and hypoechoic areas of 1–5 mm in the myometrium.
  • An MRI scan will show thickening of the junctional zone (the interface between the endometrium and myometrium) or a lesion with poorly defined borders (adenomyoma).
  • Diagnosis is challenging and can only be confirmed with a histopathological examination carried out after hysterectomy.
  • Diagnosis may also be obtained by a biopsy taken through hysteroscopy or laparoscopy.

Treatment

  • Prostaglandin inhibitors (anti-inflammatory drugs) reduce menorrhagia and pain in one third of patients.
  • Tranexamic acid halves menorrhagia.
  • Oral contraceptives are effective in reducing both menorrhagia and pain.
  • Levonorgestrel-releasing intrauterine device (IUD) reduces menorrhagia and pain in up to 90% of patients.
  • A gonadotropin-releasing hormone agonist (GnRH agonist) will cause a hypo-oestrogenic state and amenorrhoea leading to both cessation of menorrhagia and pain as well as reduction in the size of the foci (adverse effects include menopausal symptoms if oestrogen/progestogen is not used as add-back therapy).
  • Uterine artery embolization reduces menorrhagia related to adenomyosis and the number of bleeding days.
  • Surgical excision of a localised adenomyoma is possible.
  • The new MRI- or ultrasound-guided focused ultrasound (HIFU, high-intensity focused ultrasound) seems to alleviate the symptoms of adenomyosis.
  • The aforementioned treatments alleviate symptoms but there is no scientific evidence on them in improving fertility.
  • Hysterectomy is the best and final treatment for older women with severe symptoms in whom the above treatment forms have proved ineffective.

References

1. Benagiano G, Habiba M, Brosens I. The pathophysiology of uterine adenomyosis: an update. Fertil Steril 2012;98(3):572-9.  [PMID:22819188]

2. Farquhar C, Brosens I. Medical and surgical management of adenomyosis. Best Pract Res Clin Obstet Gynaecol 2006 Aug;20(4):603-16.  [PMID:16563872]

3. 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 Mar;79(3):189-93.  [PMID:19185671]

4. Maheshwari A, Gurunath S, Fatima F et al. Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. Hum Reprod Update 2012;18(4):374-92.  [PMID:22442261]

5. Dakhly DM, Abdel Moety GA, Saber W et al. Accuracy of Hysteroscopic Endomyometrial Biopsy in Diagnosis of Adenomyosis. J Minim Invasive Gynecol 2016;23(3):364-71.  [PMID:26581187]

6. Wang S, Meng X, Dong Y. The evaluation of uterine artery embolization as a nonsurgical treatment option for adenomyosis. Int J Gynaecol Obstet 2016;133(2):202-5.  [PMID:26868068]

7. Chong GO, Lee YH, Hong DG et al. Long-Term Efficacy of Laparoscopic or Robotic Adenomyomectomy with or without Medical Treatment for Severely Symptomatic Adenomyosis. Gynecol Obstet Invest 2016;81(4):346-52.  [PMID:26894488]

8. Ferrari F, Arrigoni F, Miccoli A et al. Effectiveness of Magnetic Resonance-guided Focused Ultrasound Surgery (MRgFUS) in the uterine adenomyosis treatment: technical approach and MRI evaluation. Radiol Med 2016;121(2):153-61.  [PMID:26349572]

9. Liu X, Wang W, Wang Y et al. Clinical Predictors of Long-term Success in Ultrasound-guided High-intensity Focused Ultrasound Ablation Treatment for Adenomyosis: A Retrospective Study. Medicine (Baltimore) 2016;95(3):e2443.  [PMID:26817877]

10. Whitaker L, Critchley HO. Abnormal uterine bleeding. Best Pract Res Clin Obstet Gynaecol 2016;34():54-65.  [PMID:26803558]


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Citation

"Adenomyosis." Evidence-Based Medicine Guidelines, Duodecim Medical Publications Limited, 2019. Evidence Central, evidence.unboundmedicine.com/evidence/view/EBMG/452041/all/Adenomyosis.
Adenomyosis. Evidence-Based Medicine Guidelines. Duodecim Medical Publications Limited; 2019. https://evidence.unboundmedicine.com/evidence/view/EBMG/452041/all/Adenomyosis. Accessed August 18, 2019.
Adenomyosis. (2019). In Evidence-Based Medicine Guidelines. Available from https://evidence.unboundmedicine.com/evidence/view/EBMG/452041/all/Adenomyosis
Adenomyosis [Internet]. In: Evidence-Based Medicine Guidelines. Duodecim Medical Publications Limited; 2019. [cited 2019 August 18]. Available from: https://evidence.unboundmedicine.com/evidence/view/EBMG/452041/all/Adenomyosis.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Adenomyosis ID - 452041 BT - Evidence-Based Medicine Guidelines UR - https://evidence.unboundmedicine.com/evidence/view/EBMG/452041/all/Adenomyosis PB - Duodecim Medical Publications Limited DB - Evidence Central DP - Unbound Medicine ER -