Adenomyosis 

Adenomyosis is the main pathology in this subgroup. It is diagnosed when benign endometrial glands and stroma invade 2-3 mm into the uterine muscle (1-2 high power fields below the endometrium). This is usually followed by hyperplasia and hypertrophy of the adjacent muscles due to repeated bleeding episodes during menstruation. It is more common in women over the age of 40 years who might account for 80% of all cases. However, it is also more associated with the following:

1. Previous repeated childbirth as 80% of all cases are parous women;
2. After intrauterine operations including D&C and evacuation of the uterus;
3. Some reports associate adenomyosis with previous caesarean section and tubal ligation.

A common factor in most of these causes is the breakdown in the normal endometrial / myometrial interface which can allow migration of endometrial glands and stroma into the adjacent muscle. There is 80% chance of an associated other pelvic pathology, mainly fibroids in 50%, endometriosis in 11% and endometrial polyps in 7% of the cases. The association with endometriosis was further elucidated by a recent study conducted by Kunz et al [2007]. Using MRI studies, they showed that the dorsal junctional zone of the uterus had already been invaded by the basal endometrium by the third decade of life in women with endometriosis. No such invasion was seen in women with no endometriosis up to the age of 34 years. 

Presentation

• Pelvic pain
• painful menstruation
• Heavy periods
• Painful intercourse
• Infertility

However, in almost 50% of the cases there are no related symptoms and it is only a chance finding. It is more likely that symptoms occur with deeper penetration and wider distribution of the pathology.

Distribution of adenomyosis  

There are two types of adenomyosis, diffuse and focal types. Diffuse adenomyosis occupies a wider area of the uterine muscle and may show as:

• Asymmetrical areas of altered myometrial echogenicity on transvaginal scan examination. These may show as multiple stripes down the picture.
• Hypoechoic cysts or focal areas with hypo or hyperechogenic texture.
• Colour Doppler may show normal blood vessels distribution in small focal subendometrial lesions. However, a diffuse pattern can be seen with extensive lesions, unlike the basket pattern characterised by peripheral blood vessels usually seen with fibroids. This is best demonstrated immediately after injecting a contrast medium. However, Doppler studies are not usually necessary to help with the diagnosis of adenomyosis.

On the other hand focal adenomyosis may be localised to one or two areas mostly subendometrial. Alternatively, it may show as an indiscriminate endometrial / myometrial interface, causing difficulty in clear identification of the junctional during transvaginal scan examination.

Other differences may also exist in relation to the histological features, growth pattern, and response to ovarian hormonal changes and response to different treatment modalities, as reported by Tamai et al in 2005. This may explain the differences in presentation mode and response to treatment shown by different patients with the same degree of the disease.  

Diagnosis of adenomyosis

The uterus is usually enlarged but regular in shape. It may be tender during bimanual vaginal examination. Previously histological examination of hysterectomy specimens was the only means for diagnosing adenomyosis. However, recently both MRI and transvaginal scan examinations proved useful for the pre-surgical diagnosis of the disease. MRI is very sensitive in showing widening of the junctional zone but transvaginal scan examination can also be 80% sensitive in diagnosing adenomyosis. In a recent study, Kepkep et al (2007) examined the most reliable ultrasonic uterine findings in women with histologically confirmed adenomyosis. They found that regular enlargement of the uterus with a globular appearance and myometrial cysts were very accurate in diagnosing adenomyosis. However, the highest accuracy was shown by the presence of subendometrial linear striations. Interestingly, the same study showed a stronger role for transvaginal scan examination in excluding adenomyosis than confirming it. The negative and positive diagnostic values were 84.4% and 55.3% respectively. This might have ben a reflection of the small number of patients examined. Then again, transvaginal scanning may facilitate needle biopsy and histological examination of suspected areas. On the other hand, hysterosalpingography is not very sensitive and may show 1-4 mm spikes into the myometrium.

Adenomyotic glands are not fully responsive to progesterone yet transvaginal scan examinations during the luteal phase are more likely to give a better illustration of subendometrial focal lesions as shown by Abdel-Gadir et al in 2012. The echogenic endometrium will stand out against the hypoechoic myometrial cystic shadows. Accordingly,  a better picture can be obtained by timing examinations during the late luteal phase in suspected cases. 

In some cases, 3D ultrasonography is superior to 2D imaging and may be the only way for diagnosing adenomyosis in suspected cases. This is especially so in cases with fundal lesions as shown by the two ultrasound images below.

• The first image is a full multiplanar view of a uterus. The sagittal and axial views showed no evidence of any areas suggestive of adenomyosis. However the 4th enclosed images showed few phalanges extending out of the fundal area.
• The second image is a 3D view of the same uterus magnified to show the extent of extension of the adenomyotic projections into the fundal area of the uterus.

Doppler studies for adenomyosis

In some cases, the use of Doppler colour mapping may help in confirming the diagnosis of adenomyosis, especially when 2D ultrasonography is not very affirmative. It is also useful to differentiate it from fibroids.

• The first colour Doppler image above shows a cluster of vessels passing into a circumscribed adenomyotic area on the posterior fundal wall of a retroverted uterus. The posterior endometrial / myometrial junctional zone was not involved. This was made clear by the trilaminar endometrium in front.
• The second image shows an anteverted uterus with a wide non-homogenous area in front and behind the inconspicuous early follicular endometrial line. Also note the through vascular flow pattern into the adenomyotic area in the front wall. Compare this to the pattern seen in fibroids as depicted below. This patient had menorrhagia, very bad dysmenorrhoea and dyspareunia. The extent of the uterine lesions were reflected by her very intense symptoms.

Role of hysteroscopy in diagnosing adenomyosis

Generally speaking, hysteroscopy is not very useful as a primary technique for establishing the diagnosis in most cases. A hysteroscopically directed single biopsy is less than 20% sensitive in diagnosing adenomyosis. However, it is 100% specific when the correct area has been biopsied. This low sensitivity may be improved by using transvaginal scan directed biopsies. Deep diffuse lesions are not accessible hysteroscopically, but subendometrial lesions can occasionally show in different ways, mainly as bruised circumscribed areas. Reducing intrauterine pressure during endometrial resection may allow the adenomyotic lesions to hang down as dark or black projections into the uterine cavity after excision of the superficial area overlying the lesions.

• The first hysteroscopic image above shows landmarks within the cavity. Points 1 - 4 depict adenomyotic lesions while 5 depicts the ostium of the left tube. Subendometrial adenomyotic lesions may show as bruised areas or haemorrhagic bullae. 
• The second image depicts the same uterus after excision of the superficial area over point 1 in the first image. It revealed dark adenomyotic tissue hanging into the cavity after reducing the pressure during the procedure.

Management of adenomyosis

As up to 50% of patients with adenomyosis are not symptomatic, treatment should not be offered on a coincidental ultrasonic diagnosis. It should depend on the mode of presentation whether it is pain, menorrhagia or infertility. 

Medical treatment is usually directed towards controlling pain and abnormal uterine bleeding with:

·     Nonsteroidal anti-inflammatory drugs could be used for pain control but are not definitive treatment of the disease. They could reduce menstrual blood loss as well. However, their use could be restricted by gastrointestinal symptoms and changes in platelets function. They could be used both for pain rescue and in a time contingent protocol. Patients who wish to get pregnant could use them to relieve menstrual pains.

·     Prolonged suppression with GnRH-analogues is currently the medical treatment of choice as it suppresses ovulation and hence menstruation. However, it causes severe hypo-oestrogenic side effects unless used with add-on medication. However, in all cases symptoms do recur after suspending medication.

·     The levonorgestrel intrauterine device (mirena) has emerged as a very useful method for controlling both adenomyosis symptoms namely pelvic pain and excessive blood loss.  However, its use should be limited to those patients who are not keen to get pregnant. 

It is evident that medical treatment can only offer symptomatic relief and recently uterine artery embolisation has been used for the treatment of adenomyosis. Several studies reported improvement in symptoms and quality of life with a decrease in uterine size and shrinkage of the junctional zone thickness after embolisation [Siskin et al, 2001; and Kim et al, 2007]. A further advantage was the fact that hysterectomy was avoided in the vast majority of patients [Lohle et al, 2007]. On the other hand, despite the good success rates reported after uterine artery embolisation, laparoscopic uterine arteries ligation did not give favourable results with adenomyosis [Wang et al, 2002]. This is in contradistinction with fibroids where both techniques proved to be clinically successful.

Ultimately a conservative or more likely a radical surgical intervention may be necessary. This is especially so in cases of advanced adenomyosis causing uncontrollable pain and heavy bleeding in women with no fertility aspiration. A review of the therapeutic options for the treatment of adenomyosis has been published by Levgur M [2007].

·     Selective hysteroscopic resection after GnRH-a therapy may be helpful in patients with up to 3 mm subendometrial focal lesions presenting with excessive bleeding. However, it is only 50% successful in controlling pain. Both deep focal and diffused lesions can be managed by laparoscopic electrocoagulation or myometrial excision when future fertility is required. However, all these measures are only temporary with a high risk of recurrence.

·      On the other hand hysterectomy can be offered as a primary procedure to women who completed their families and the uterus is totally damaged by extensive adenomyosis or multiple fibroids. It may as well be offered to patienrts who failed to respond to medical or conservative surgical treatment. Supra cervical hysterectomy is regaining popularity, when there is no cervical pathology, as it entails no disturbace to the bladder bed or vaginal vault. It is an easier procedure with less morbidity and quicker recovery time. The patient, however, needs to continue with her cervical screening tests as usual. Furthermore, up to 80% pain relief has been suggested after a hysterectomy. This is because severe pelvic pain is usually multifactorial and other causes may be present. This is especially so as 80% of patients may have both adenomyosis and pelvic endometriosis at the same time. Accordingly, exclusion of the presence of later may be advisable before proceeding with a hysterectomy, bearing in mind that 50% of women with isolated diagnosis of adenomyosis are symptomatic.

    In our practice, we usually deal with any coexisting deep endometriosis, both surgically and medically before resorting to a more drastic hysterectomy. The presence of the uterus may sometimes help in preventing severe adhesions between the bladder anteriorly and the rectum and sigmoid posteriorly.

The two ultrasound images shown above demonstrate sagittal views of the same uterus before and after hysteroscopic excision of 2 histologically diagnosed adenomyotic areas. The patient had menorrhagia with dysmenorrhoea, and intermenstrual bleeding. Her bleeding problems improved dramatically after surgery, but she continued to have some pain, yet of lesser intensity, during her periods.

The above hysteroscopic image shows adenomyosis within the anterior uterine muscle during resection. Note the multiple cavities and tubular structures interconnected together within scar tissue. This 37 years old parous patient presented with dysmenorrhoea, deep dyspareunea and occasional menorrhagia. Transvaginal scan examination showed anterior subendometrial adenomyosis.