ADENOMIOSIS... the Cinderella of gynaecological diseases
Reading Time: 2 minutesAdenomyosis is a pathological condition characterised by the heterotopic presence of stroma and endometrial glands in the myometrium, which cause hyperplasia and hypertrophy of the surrounding myometrium resulting in increased uterine volume. The ectopic endometrium may be diffuse or may form focal lesions (adenomas), most commonly in the posterior wall of the uterus. In 20% of cases it affects women under 40 years of age, in 80% it affects the 40-50 age group. It is a disease frequently associated with endometriosis and shares many of its characteristics. It is also an oestrogen-dependent disease that causes chronic pelvic pain, dysmenorrhoea, menometrorrhagia and infertility, but is asymptomatic in one third of cases.
Diagnosis
On transvaginal ultrasound, the most typical findings include an inhomogeneous myometrium with hypoechogenic radiating striae, diffuse vascularisation within the myometrium, poor demarcation of the endomyometrial junction, a globular and increased uterus volume, asymmetrical anterior and posterior wall thickness, the presence of small anechogenic myometrial cysts and/or hyperechogenic myometrial islands. Despite this, the minimum criteria for ultrasound diagnosis have not yet been defined. Magnetic resonance imaging shows an asymmetric uterus, increased in size and free of leiomyomas, a thickening of the endometrium-myometrium junctional zone greater than 8-12 mm or an altered ratio (>40%) between the thickness of the junctional zone and the myometrium, an abnormal signal intensity of the myometrium and a T2 sequence hyperintensity of the myometrial foci. The definitive diagnosis is histological, using material obtained by myometrial biopsy or hysterectomy.

Treatment
Adenomyosis can be treated with the same drugs used to treat endometriosis. Intrauterine devices medicated with levonorgestrel (LNG-IUS) appear to be the most promising treatment for the reduction of dysmenorrhoea and menorrhagia. Oral contraceptives also provide symptom relief and can be used for a long period of time, while GnRH agonists, although effective, cause long-term side effects that limit their use. As far as the surgical treatment of adenomyosis is concerned, hysterectomy is the definitive therapy, although obviously this approach cannot be used in women desiring offspring. However, there is also the option of conservative or minimally invasive surgical treatment. Treatment options include ablation, electrocoagulation and endometrial resection, laparoscopic excision of adenomyosis and embolisation of the uterine artery, techniques that, however, exclude future pregnancy. On the other hand, the use of focused ultrasound under MRI guidance seems to be suitable for women wishing to preserve their fertility, as the beams are directed towards the target tissue, which is sent into necrosis while safeguarding the surrounding myometrium and uterine walls.
Bibliography
- Pontis A, D'Alterio MN, Pirarba S, de Angelis C, Tinelli R, Angioni S. Adenomyosis: a systematic review of medical treatment. Gynecol Endocrinol. 2016 Sep;32(9):696-700.
- Struble J, Reid S, Bedaiwy MA. Adenomyosis: A Clinical Review of a Challenging Gynecologic Condition. J Minimally Invasive Gynecol. 2016 Feb 1;23(2):164-85.
- Van den Bosch T, Dueholm M, Leone FPG, Valentin L, Rasmussen CK, Votino A, et al. Terms, definitions and measurements to describe sonographic features of myometrium and uterine masses: a consensus opinion from the Morphological Uterus Sonographic Assessment (MUSA) group. Ultrasound Obstet Gynecol Off J Int Soc Ultrasound Obstet Gynecol. 2015 Sep;46(3):284-98.