Adenomyosis
Sun-Wei Guo
Shanghai OB/GYN Hospital
Fudan University
Parsing the word…
• “Adeno-”: glands
• “myo-”: muscle
• “-osis”: condition
Adenomyosis
• Definition:
– A disorder that is characterized by the benign
invasion of endometrial glands and stroma deep
and haphazardly into the myometrium
– Used to be called “endometriosis interna”
• A common gynecologic disorder
– with a poorly understood pathogenesis
Symptomology
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About 1/3 of women with adenomyosis are asymptomatic
Cyclic and non-cyclic pelvic pain
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Intense debilitating pain all the time and/or
Acute & increasing pain at menstration and ovulation
Strong 'contraction' feel of uterus
Abdominal cramps
A 'bearing' down feeling
Pressure on bladder
Dragging sensation down thighs and legs
Abnormal uterine bleeding
– Heavy bleeding and flooding
– Large blood clots
– Prolonged bleeding i.e.; up to 8–14 days
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Subfertility
Hall mark:
– a soft and diffusely enlarged uterus
Two subtypes
• Focal adenomyosis
– Less common: ~ 1/3
• Diffuse adenomyosis
– More common: ~2/3
– Diffusely spread throughout the uterus
– Even or uneven
– symmetric or asymmetric
Diagnosis
• Gynecological examination (not definite)
• Transvaginal sonography (TVS)
– Accuracy of ~85%
– Highly dependent on experience
• MRI
– Similar to or slightly higher accuracy than
ultrasound
– Less dependent on experience
Adenomyosis: TVS
Focal adenomyosis: MRI
Diffuse adenomyosis: MRI
Diffuse adenomyosis.
Sagittal T2-weighted image
shows indistinct zonal
anatomy. Widening of the
junctional zone is clearly seen
in the region around the
distorted endometrium
(arrowheads). The
myometrium has decreased
signal intensity with tiny spots
of high signal intensity
(arrows).
Epidemiology
• Incidence
– Unknown
• Prevalence
– Mostly from women who underwent hysterectomy
– Ranges from 14%-66%
– In our hospital, ~ 43%
• Risk factors
– Parity, age (older than those with endometriosis),
number of abortions, endometrial surgery,
endometrial hyperplasia, menorrhagia
Some known facts
• No consensus on diagnostic criteria to define
presence, depth of penetration, degree of
extension, and configuration of adenomyosis
• Menorrhagia and dysmenorrhea are
associated with severe forms of adenomyosis
• Often co-exists with
– Endometriosis
– Uterine leiomyomas
Treatment
• Medical
– GnRH agonists
– Progestins
– Oral contraceptives
– Progestin-containing IUDs
– Danazol
• Surgical
– Uterine artery embolization (UAE)
– Hysterectomy
Some considerations
• Drug treatment has
– a high rate of recurrence
– Side-effects
• Hysterectomy can be very traumatic
– Especially for women who still desire a family
Some known molecular aberrations
• Increased local production of estrogens
• Increased production of proinflammatory
cytokines
– TNFalpha, IL-6, IL-8
– Increased gene and protein expression of COX-2
• Increased angiogenesis
• Increased uterine contractility
Novel treatment on the horizon
• Histone deactylase inhibitors
– Valproic acid
• GnRH antagonists
• Aromatase inhibitors
Current state
• More research is needed
Questions
• As with eutopic endometrium, endometriotic
lesions also experience cyclic bleeding. Some
authors argue that by stopping bleeding, one
can relieve endometriosis-associated
symptoms. Does this argument has any merit
at all? Why?
Questions
• Many endometriotic lesions are often found
to contain fibrotic tissues. In fact, adhesion is
one cause for pain.
– How do you think they come into being? Why?
– What would be the best approach to eliminate the
fibrotic tissues? Why?
Questions
• In many hospitals in China, traditional Chinese medicine (TCM) is
practiced and for endometriosis in particular, TCM medications are
prescribed to patients. However, a recent systematic review
indicates that, despite well over 150 publications—all in Chinese
journals, no affirmative conclusion can be reached regarding the
efficacy, indications, and side-effects of TCM in treating
endometriosis, due mostly to poor quality in study design,
execution, analysis, or reporting.
– If you or your loved one had endometriosis, would you consider using
TCM? Why?
– Why no single TCM study could show the efficacy of TCM?
– Why many physicians are still prescribing TCM even though there is no
well-established evidence?
– Would ancient medicine books sufficient for the TCM practice?