Adenomyosis

Hysterectomy of adenomyosis

-A spongy appearance and protrudes convexly. -Thickened myometrium is trabeculated and occasionally contains hemorrhagic foci -At microscopy, the ectopic endometrium may form small or large islands within the myometrium surrounded by myometrial hypertrophy

differential diagnosis

-Adenomyosis -Endometriosis -Fibroid -Uterine Cancer

Laboratory investigation

-FBC- anemia, thrombocytopenia -Coagulation profile-PT/APTT -TFT-thyroid and/or pituitary dysfunction, bleeding disorders -Renal profile-Hyponatremia -Urinalysis

Pathophysiology of adenomyosis

-Tissue that normally lines the uterus (endometrial tissue) grows into the muscular wall of the uterus. -The displaced tissue continues to act — thickening, breaking down and bleeding during each menstrual cycle. -An enlarged uterus and painful, heavy periods can result.

The ultrasound of adenomyosis looks like

-showing haemorrhage-filled, distended glands by observing any altered echogenicity of the myometrium

causes of adenomyosis

1. Invasive tissue growth -Endometrial cells from the lining of the uterus invade the muscle that forms the uterine walls -Uterine incisions made during an operation promote the direct invasion of the endometrial cells into the wall of the uterus. 2.Developmental origins -Endometrial tissue is deposited in the uterine muscle when the uterus is first formed in the fetus. 3. Uterine inflammation related to childbirth. -Inflammation of the uterine lining during the postpartum period might cause a break in the normal boundary of cells that line the uterus. 4.Stem cell origins -Bone marrow stem cells might invade the uterine muscle, causing adenomyosis.

Imaging Investigations

1. Transvaginal ultrasound- adenomyosis is particularly localized, showing haemorrhage-filled, distended glands by observing any altered echogenicity of the myometrium 2. MRI-provides excellent images of myometrium, endometrium and areas of adenomyosis 3. Hysterectomy- only way to after hysterectomy

What is adenomyosis?

Adenomyosis is a disorder in which endometrial glands and stroma are found deep within myometrium Ectopic nests of endometrial glands and stroma within the myometrium, surrounded by reactive smooth muscle hyperplasia

What is type of adenomyosis

Adenomyosis may be present -diffuse There is a diffuse noncapsulated involvement of both anterior and posterior walls of the uterus. The posterior wall is the most commonly affected side. -adenomyoma -focal This results in an asymmetric uterus, and the area of adenomyosis may have a pseudocapsule

What relation of oestrogen and adenomyosis?

Polymorphisms in the oestrogen receptor alpha gene are associated with a risk of adenomyosis. -Adenomyotic tissue contains steroid receptors as well as aromatase and sulphatase enzymes -Together with the circulating oestrogen, locally produced oestrogens stimulate the growth of tissue mediated by the oestrogen receptors

Treatment

○ Anti-inflammatory drug- ibuprofen ○ Hormone medication- Danazol, gestrinone, GnRH agonist ○ Hysterectomy-definitive management ■ Indication- -Perimenopausal age -Poor response to medical therapy -Associated with other pathology eg; leiomyoma

Clinical features

○ Heavy and prolonged menstrual bleeding (menorrhagia) ○ Severe cramping or sharp, knifelike pelvic pain during menstruation (dysmenorrhea) ○ Chronic pelvic pain ○ Painful intercourse (dyspareunia) ○ Infertility

Physical examination

○ Unremarkable or bulky and sometimes tender 'boggy' uterus - Diffusely enlarged uterus - Adenomyoma may cause asymmetrical enlargement of the uterus, making it difficult to differentiate from fibroids (but significant feature of severe dysmenorrhea usually makes adenomyosis more likely as fibroids are classically painless)

Risk factor

● Age ( 4th-5th decade of life ) ● Multiparity ● Early menarche ● Ectopic pregnancy ● Surgery that involving disruption of endometrial-myometrial border / trauma ● Smoking