Adenomyosis

Sun-Wei GuoShanghai 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• About 1/3 of women with adenomyosis are asymptomatic• Cyclic and non-cyclic pelvic pain

– 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

• 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?