Adenomyosis Thomas M DHooghe MD Ph D Coordinator

Adenomyosis Thomas M. D’Hooghe, MD, Ph. D Coordinator Leuven Univ Fertil Ctr VVOG Postgraduate Course Grobbendonk 3 dec 09

Definition • Adenomyosis is a disease entity characterized by the presence of endometrial glands and stroma deep within the myometrium associated with myometrial hypertrophy and hyperplasia. • A histologic diagnosis is made when endometrial glands and stroma are found within at least one low-power field beneath the endo-myometrial junction (≥ 4 mm). • Focal or disseminated

Histology

Adenomyosis epidemiology • Prevalence: 1% • Mostly women > 40 and multipara • Often associated with endometriosis, myomata, endometrial hyperplasia, and sometimes adenocarcinoma of the endometrium. • 15 -20% in uteri after hysterectomy

Adenomyosis symptoms • Signs and symptoms (nonspecific): - soft and diffusely enlarged uterus - menorrhagia (40 -50%), metrorrhagia (10 -12%), - dysmenorrhoea (10 -30%) - Dyspareunia and dyschezia

Adenomyosis and subfertility Preliminary data suggesting an association between adenomyosis and subfertility: 1. Case-control study in baboons: strong assocation, even in absence of endometriosis 2. Association makes epidemiological and biological sense 3. Dose-response effect has been observed between degree of adenomyosis, and degree of abnormal uterotubal transport (HSSG model), and degree of endometriosis

Adenomyosis and pain Preliminary data suggesting an association between adenomyosis and pain, 1. Dose-effect relationship 2. Temporal relationship 3. Association makes epidemiological and biological sense MAJOR QUESTION: IS ASSOCIATION SPECIFIC?

Adenomyosis and infertil/pain Needed: Better designed studies to assess the prevalence of adenomyosis in symptomatic women (infertility, pain) and asymptomatic controls with and without endometriosis Important remaining question: is adenomyosis more than an ultrasound marker for endometriosis?

Adenomyosis diagnosis: • Vaginal ultrasound: echolucent zones close to endometrium/insided myometrium (DD myoma) • Often associated with endometriosis • Differential diagnosis: benign (myoma, polyp) and malignant (carcinoma, sarcoma) uterine pathology • Exact diagnosis: hysterectomy and histology

Adenomyosis management: • Family completed, suggestive symptoms, US evidence +: hysterectomy • If child wish: expectant or hormonal treatment like for endometriosis-associated pain (continuous OAC or P, LNG IUD) • Medical suppression in infertility patients - Gn. RH analogues (Hirata et al, 1993; Silva et al, 1994; Lin et al, 2000) - Danazol-loaded intrauterine device (Igarashi et al, 2000). Only small series of case reports with successful pregnancy (no controlled studies)