Pocket ObGyn – Adenomyosis
See Abbreviations
Definition & Pathogenesis
- Presence of endometrial glands & stroma w/i the uterine musculature
- Amt & degree of invasion Diffuse or circumscribed focal glandular deposits.
Epidemiology
- Unclear etiology, but several Possibly invagination of endometrium into myometrium, or misplaced stem cells or Müllerian remnants.
- 70–80% of cases seen in 4th & 5th Only 5–25% of adenomyosis seen <39 yo.
- Estrogen & progesterone likely play role in dev & Often develops during reproductive years & regresses after menopause. Risk factors: Parity, age
Clinical Manifestations & Physical Exam Findings
- Menorrhagia & Many asx. Severity correlates w/ ectopic foci & extent of invasion. Less common complaints: Dyspareunia, CPP, infertility.
- Ectopic endometrial tissue ® proliferates ® enlarged globular uterus on exam
Diagnostic Workup (J Minim Invasive Gynecol 2011;18:428)
- Dx by histology. Uniform dx based on histology not yet
- Ca-125 levels may be seen, but not proven to be helpful in mgmt or
- TVUS preferred imaging technique = ill-defined myometrial heterogeneity, may be myometrial cysts (round anechoic areas). MRI may be complementary = large asym uterus, thickened junctional zone (innermost myometrial layer), no
Treatment & Medications
- No medical therapy exists at this time to treat sx while allowing pts to
- Conservative, medical mgmt for symptomatic adenomyosis similar to 1° menorrhagia or Goal = temporarily induce regression of adenomyosis.
- NSAIDs often May consider: Continuous oral contraceptives, progestins, Mirena IUD, danazol, & GnRH agonist.
- Surgical Mgmt (J Minim Invasive Gynecol 2011;18:428):
Hysterectomy = Std rx option for those done w/ childbearing.
Endometrial ablation = Treats menorrhagia sx. Less successful if penetration of adenomyosis into uterus is present.
UAE: Controversial. Less successful if fibroids also present.
Focal excision: Must be able to identify area, margins, & extent of dz. Low efficacy (50%). Addition of GnRH agonist ¯ relapse rates by 20% in 2 y. May have fertility & deliv implications depending on size & location of excision.