Adenomyosis

Dr Sathya

Adenomyosis is a myometrial lesion characterized by the presence of ectopic endometrium with or without hyperplasia of the surrounding myometrium.

Prevalence in women <35 yrs

A)9% in fertile women

B) 79% in women with coexisting endometriosis(based on MRI data)

Risk factors for adenomyosis are age, multiparity, surgical disruptions of the endometrial–myometrial border, elevated levels of both FSH and prolactin (PRL), smoking habits and history of depression.

Adenomyosis has been shown to be significantly associated with peritoneal endometriosis in infertile patients.

Directed sperm transport is significantly impaired in infertile women with pelvic endometriosis which may be caused by the destruction of the myometrial architecture by adenomyotic lesions.

Therefore, it could be that uterine adenomyosis could constitute a major cause of infertility in pelvic endometriosis.

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Brosens, I. et al. Hum. Reprod. 2010 0:dep474v1-474; doi:10.1093/humrep/dep474

(a) The JZ in the non-pregnant uterus

Very variable phenotypes of adenomyosis as documented by MRI can be obtained such as enlargement of the AJZ and/or PJZ or focal protrusions of variable size and location intothe outer myometrium.

it is mainly the posterior wall that is affected and only exhibits, with respect to theenlargement of the junctional zone.

it is mainly the posterior wall that is affected and only exhibits, with respect to theenlargement of the junctional zone.

Posterior junctional zone thickness>10mm is considered significant.

Measurements obtained from MRI scans of uteri with and without endometriosis With endometriosis , Without endometriosis Significance (P)

Diameter of the anterior junctional zone 10.1±4 9.2±5.1 >0.05

Diameter of the anterior total myometrium17.1±3.6 18.2±4.2 0.03

Diameter of the posterior junctional zone 11.5±5.3 8.3±2.6 <0.001

Mean values in mm±SD.

The mean diameter of the normal junctionalzone, representing the innermost myometriallayer, or archimyometrium, has been established to be in the range of 7–8 mm.

The diagnosis of adenomyosis by MRI is considered to be established with a thickness of the junctional zone of 12 mm.

Within a thickness of 8–12 mm, the diagnosis of adenomyosis requires specific secondary criteria such as

A) relative thickening of the junctional zone in a localized area,

B) poor definition of borders or high signal intensity foci.

Presence of focal areas with ill defined borders or abnormal echo texture

When these areas are present, the following criteria for adenomyosis :

A) presence of heterogeneity,

B) increased or decreased areas of echogenicity,

C) presence of myometrial cysts.

MRI superior to TVS for the diagnosis of adenomyosis.

Magnetic resonance imaging have a higher specificity(0.86 vs 0.65) than TVS, but their sensitivities are similar (0.87 vs 0.86).

The diagnostic accuracy of MRI, as that of TVS, was at an intermediate level, but the diagnostic accuracy of MRI improved by exclusion of uteri >400 mL.

The combination of MRI and TVS produced the highest level of accuracy for exclusion of adenomyosis, but the low specificity may necessitate further investigation of positive findings.

Measurement of the difference in junctionalzone thickness may optimize the diagnosis of adenomyosis at MRI (>5-7mm).

OBJECTIVES: To establish the effect of adenomyosis on IVF/ICSI outcomes in infertile patients with endometriosis who were pretreated with long-term (>/=3 months) GnRH-agonist prior to IVF/ICSI.

STUDY DESIGN: Retrospective study in 74 infertile patients with surgically proven endometriosis who were treated with IVF/ICSI.

The diagnosis of adenomyosis was based on transvaginal ultrasound criteria.

All patients were pretreated with long-term (>/=3 months) GnRH-agonist prior to IVF/ICSI.

RESULTS: 90.4% pts endometriosis rASRM stages III-IV.

Adenomyosis in 27% of them . Predominantly in the posterior wall of the uterus.

IVF/ICSI outcomes : a mean duration of GnRH-agonist use prior to IVF/ICSI of 5.35 months (3-26);

a mean dosage of FSH used of 208IU (75-450);

the mean number of oocytes retrieved was 8.73 (1-30);

the mean number of embryos obtained was 3.86 (0-16);

the mean number of embryos transferred was 1.6; a mean implantation rate of 26.3%;

a mean miscarriage rate of 24.3%;

and a clinical pregnancy rate of 31.7%.

No significant differences were found for any of the IVF/ICSI outcomes between women with and without adenomyosis.

CONCLUSIONS: Adenomyosis had no adverse effects on IVF/ICSI outcomes in infertile women with proven endometriosis who were pretreated with long-term GnRH-agonist.

Thirty-eight women with symptomatic adenomyosis with or without uterine leiomyomas were treated with UAE with calibrated tris-acryl gelatin microspheres.

Based on MR findings, women were categorized as having pure adenomyosis(group A; n = 15),

adenomyosis dominance with fibroid tumors (group B; n = 14),

or fibroid tumor dominance with adenomyosis (group C; n = 9).

RESULTS: Heavy menstrual bleeding, pain, and bulk-related symptoms at last follow-up at a median of 16.5 months (range, 3-38 months) were compared with baseline symptoms.

With follow-up MR imaging at a median of 12 months (range, 3-36 months), changes in uterine volume, leiomyoma volume, junctional zone thickness, and contrast enhancement of adenomyosis were assessed.

After embolization, adenomyosis infarction could be depicted on contrast medium-enhanced MR in 44.1% of cases.

Median reductions of uterine volume, fibroid tumor volume, and junctional zone thickness were 44.8%, 77.1%, and 23.9%, respectively.

In group A, three patients needed additional surgery after UAE, in addition to two in group B and one in group C.

In the remaining 32 patients, except for one patient in group C, all preexisting symptoms (eg, bleeding, pain, bulk-related symptoms) improved or resolved after UAE.

Overall, 84.2% of women were satisfied with the results of UAE.

CONCLUSION: In this study, midterm results (at a median of 16.5 months) showed that UAE in symptomatic adenomyosis with or without uterine leiomyomas is effective. Hysterectomy was avoided in the vast majority of patients. MR imaging showed reduction of uterine volume and junctional zone thickness.

Twelve women (mane age 40.3 years) with adenomyosis and uterine cavity depth over 11 cm received injections of GnRH-a, every 4 weeks, and after the uterine cavity depth was reduced to below 10 cm, LNG-IUS was deployed.

VAS pain score, PBAC bleeding score, uterine volume, and hemoglobin levels of the women were measured before the treatment and at 6 and 12 months after LNG-IUS placement.

RESULTS: The VAS pain score was significantly lowered at 6 and 12 month after LNG-IUS placement (P<0.05), and the PBAC bleeding score also showed significant reductions (P<0.05).

The uterine volume decreased significantly at 6 and 12 months after LNG-IUS placement as compared with that before the treatment.

Serum hemoglobin levels underwent significant increments after LNG-IUS placement (P<0.05).

CONCLUSION: LNG-IUS combined with GnRHanalogue injection can be effective in the treatment of adenomyosis with dysmenorrheaand hypermenorrhea.

CHINESE MED JOUR MAR 2010

The LNG-IUS was inserted into 94 women who had moderate or severe dysmenorrhea associated with adenomyosis diagnosed by transvaginalsonography during Cycle Days 5-7.

A visual analogue scale (VAS) of dysmenorrhea, uterine volume and serum CA125 levels were used to assess the efficacy of the treatment at baseline and 3, 6, 12, 24 and 36 months after the LNG-IUS insertion. Side effects were recorded at every follow-up visit.

RESULTS: The VAS of dysmenorrhea dropped continuously and significantly from the baseline score of 77.9+/-14.7 to 11.8+/-17.9 after 36 months of the LNG-IUS insertion (p<.001).

The uterine volume decreased significantly from 113.8+/-46.9 mL to 94.5+/-40.1 mL (p=.003) at 6 months and to 87.7+/-35.8 mL (p<.001) at 12 months and then rose slightly, but the variables at 24 and 36 months still decreased significantly in comparison with the baseline variable (p<.001

The serum CA125 levels reduced significantly starting from 6 months after device insertion (p<.001).

The most common side effects were weight gain (28.7%), simple ovarian cyst formation (22.3%) and lower abdominal pain (12.8%).

At 36 months, the overall satisfaction rate of the treatment was 72.5%.

CONCLUSIONS: The LNG-IUS appears to be an effective method in alleviating dysmenorrheaassociated with adenomyosis during 3 years. It may be a valuable long-term alternative for the treatment of adenomyosis.

Adenomyosis is not uncommon in women< 35 years.

It probably contributes to infertility by altering sperm trasnsport due to changes induce in the junctional zone.

MRI and TVS-similar sensitivity, MRI-higher specificity.

Not enough evidence found for its role in reducing endometrial receptivity.

Medical treatment with GnRH@ depot for atleast3 months prior to IVF appears to minimise any inhibitory effect on implantation.

LN-IUS appears to be a promising method to study prior to IVF if time is available(atleast 6 months).Not enough evidence.

Not enough evidence found regarding High intensity focussed ultrasound or MR-Focussed ultrasound.

Not enough evidence regarding efficacy or safety of adenomyomectomy.

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