ADENOMIOSIS

GYN INDUCTION T2B

DECEMBER 2012

CASE ILUSTRATION (JUNE 1ST 2012)

Mrs. D V, 32 yo (BC 352 35 99)

Chief complained:
Lower abdominal pain since 2 years
Recent history since last 2 years patient
complained lower abdominal pain during
menstruation.
Menorrhagia 10 pad/day, duration 14 days.
Vaginal discharge (+) itchy (-) and
odour(-)mass in abdomen (-).
Previous
history
and
family
history:
Hypertension (-), Asma (-), DM (-), Allergy (-)
Obstetrical history : P0
Menstrual story: Menarche 13yo,. Regular
cycle 30 days, duration 6 days, pain (-), 3-4
pads/day
Marital history: 1x,
Contraception: (-)

Physical examination:
BP : 120/80 PR 88x/mnt RR
20x/mnt t:afebris
General state wnl
Gynecologic state:
I : v/u wnl
Io :smooth portio, ostium closed,
Fluor (-),
fluxus (-)
RVT: uterine cavity
size and
shape enlarged, cystic mass
with solid part fulfilled cavum
douglas until 3 finger above
the symphisis, with anal
mucose cannot be assessed

US FM
Uterus anteflexed, enlarged,
At posterior corpus hypoechoic
mass with irregular edge size 61x40
mm originated from adenomiosis.
Stratum basale endometrium is
reguler,
thickness
7
mm.
Endoserviks and portio normal
HSG:
Right Hydrosalphing with right tuba
non patent and left tube is patent
Spermaanalysis: normozoospermia
A: Adenomiosis
P: adenomyosis resection

INTRAOPERATIVE
Spinal- anesthesia, Pfanenstiel incision
Exploration: uterus enlarged correspond
to 12 wga
Posterior wall of the uterus adhered to
the rectum, right fallopian tube adhere to
the rectum, both ovarian and left tube
wnl
Performed adhesiolisis.
Performed chromotubation both tubes
were patent
Performed osada technique, the mass
was 6x5 cm in the posterior corpus.
Done hemostatic electrocauterization and
stitches
Bleeding was 800cc
Ensure there were no bleeding,abdominal
washing 500cc saline, and the gauze
were complete
Closed the abdominal wall, layer by layer

DEFINITION

A benign uterine condition in which endometrial glands

and stroma are found deep in the myometrium
A benign disease of the uterus characterized by ectopic
endometrial glands and stroma within the myometrium
It is associated with myometrial hypertrophy and may be
either diffuse or focal
= myometrial endometriosis

PREVALENCES

Occurs primarily in women in 25 45s

Increase significantly
Range from 1 50%
General population 1 2 %
Infertile women 30 50 %

RISK FACTORS
Multi-parous
Previously history of
Endometrial hyperplasia
(OR 2.7; 1.3-5.8)
Spontaneous abortion (OR 1.6; 1.0-2.4)
Dilatation and curratage (OR 2.1; 1.1-3.8)

Neither on the evidence of

Caesarean section
(OR 1.19; 0.95-1.50)
Myomectomy
(OR 1.12; 0.68-1.85)
Endometrial ablation
(OR 3.62; 0.71-14.83)

1.
2.

Parazzini et al. Hum Reprod 1997;12:1275-1279

Panganamamula et al. Obstet Gynecol 2004;104:1034-1038

ETIOLOGY OF ADENOMYOSIS
Four primary theories
1. Heredity
(transformation)
2. Trauma (mechanical
injuries)
3. Hyper-estrogenemia
(food, diseases, medical
treatment
4. Viral transmission

DIAGNOSIS

Medical History
Pelvic examinations
Serum markers CA-125
Imaging Diagnostic
Ultrasonography
CT-scan
MRI

Biopsy of uterus(at diagnostic hysteroscopy or

laparoscopy procedure)

DIAGNOSTIC CRITERIA

Asymptomatic adenomyosis occurs in 30-45% parous women

in reproductive age

Symptomatic adenomyosis
Classic symptoms (secondary dysmenorrhea, abnormal uterine
bleeding)
Most common physical sign particularly tender during menstruation

Diagnosis
Laboratory diagnostic
methods
There has been a hope to find specific
markers in blood with which the diagnosis
endometriosis could be verified
One such marker is CA-125 that is produced
by cells from the celome epithelium. High
concentrations of CA-125 have been seen
together with ovarian cancer. Moderately
high concentrations are seen together with
inflammatory pelvic diseases and also
together with endometriosis. This lack of
specificity reduces the value of the
determination of CA-125.

THE DIAGNOSTIC CRITERIA FOR ADENOMYOSIS

THE PRINCIPLES FOR IMAGING ANALYSIS

Uterus enlargement
Asymetrical of uterine shape to midline echo
Hetero-echogenicity of myometrial
imaging
Diffuse junctional-zone thickened
(not clearly discenible well defined
margins from the myometrium layer)
Increase vascular density of tumour
in myometrium area (profused
vascularization may be suggestive of
malignancy)

ULTRASOUND CHARACTERISTICS OF ADENOMYOSIS.

Brosens and coworkers

assessed
ultrasonographi
c details such
as:

uterine dimensions
Symmetry of myometrium
echogenicity of the
myometrium

They found that the most predictive is the illdefined heterogeneous echotexture within the
myometrium.

MRI
On T2-weighted MRI, diffuse adenomyosis usually
manifested as diffuse thickening of the junctional zone
with homogeneous low signal intensity .T2-weighted
imaging provided significantly better lesion detection than
unenhanced or contrast materialenhanced T1-weighted
imaging

Sagittal T2-weighted MR image shows diffuse,

even thickening of the junctional zone (arrows),
a finding consistent with diffuse adenomyosis

Diagnosis
MRT, Magnetic
Resonance
Tomography
Magnetic Resonance Tomography
has hitherto been use very little but
there is a hope that the technique
might develop into a useful
diagnostic method.
Endometriomas esp. with blood
under degradation give rise to a
relatively characteristic picture,
provided they are more than 0,5
cm in diameter.

PATHOLOGICAL FINDINGS OF

ADENOMYOSIS

Usually hyperemic with thickened walls

The foci are frequently scattered diffusely throughout the myometrium.
Occasionally may be more circumscribed with the formation of a distinct
nodule an adenomyoma
Basal endometrial hyperplasia invading a hyperplastic myometrial stroma

TREATMENT CHOICES FOR

ADENOMYOSIS
CONSERVATIVE
MEDICINE
Hormonal (GnRHagonists)
Enzymes
(Aromatase
inhibitots, anti
Estrogen sulfatase)

CONSERVATIVE
RADICAL
SURGERY
SURGERY
Wedge Resection Histerectomy
Adenomyosis
Operative
Laparotomy
Operative
Laparoscopy
Interventional
imaging

Laparoscopy
Laparotomy

MANAGEMENT
The only definitive treatment for adenomyosis is
total hysterectomy, with or without ovarian
conservation.

Gonadotropin Releasing Hormone Agonists In The Treatment Of

Adenomyosis With Infertility

1. GnRH- agonists is efficient in reducing the adenomyotic

uterine size, and may facilitate fertility.
2. For ademyomata associated with infertility, GnRHalpha therapy may avoid the risk of rupture of uterus
which may occur after adenomyomectomy pregnancy.
3. For
infertility,
GnRH-alpha
treatment
before
laparoscopic surgery greatly decreases surgical
difficulties and blood loss in certain cases.

Obstetricts and Gynecology Hospital, Shanghai Medical

University, Shanghai 2011
Zhonghua Fu Chan Ke Za Zhi 1999 Apr; 34:214-6

CONSERVATIVE SURGERY FOR ADENOMYOSIS

The conservative surgery for adenomyoma can reduce

symptom and raise pregnancy rate significantly, it can be
accepted by young women who want to preserve their
reproductive capacity.
Though the pregnancy rate of conservative surgery for
diffused adenomyosis was low, it still has therapeutic
value

Zhongguo Yi Xue Ke Xue Yuan Xue Bao 1998 Dec; 20:440-4

ADENOMYOSIS

CLINICAL MANAGEMENT
DIAGNOSTIC PROCEDURES (Laboratory, Biopsy, Imaging)

CONCERN FOR THE

FUTURE REPRODUCTIVE
FUNCTION
CONSERVATIVE
MANAGEMENT &
INTERVENTION

NOT-CONCERN FOR
REPRODUCTIVE
FUNCTION

MEDICAL TREATMENT
(HORMONES, ANTI-ENZYMES)

RADICAL
MANAGEMENT &
INTERVENTION

INTERVENTIONAL NON-SURGERY
UTERINE ARTERY EMBOLIZATION
(MRI MICROVIBRATION)

LAPAROTOMY
UTERINE WEDGE RESECTION &
METROPLASTIC SURGERY

LAPAROTOMY / LAPAROSCOPY
TOTAL HYSTERECTOMY
(VAGINAL/ ABDOMINAL/ LAPAROSCOPICALLY)

Thank you
FOR KIND ATTETION

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