Adenomyosis

Question 1

What is adenomyosis?

Answer 1

The presence of functional endometrial tissue within the myometrium of the uterrus

Question 2

Which layer of the uterine wall is invaded by endometrium in adenomyosis?

Answer 2

Middle layer

Question 3

What is the relationships between adenomyosis and endometriosis?

Answer 3

Adenomyosis has been described as a variant of endometriosis, but although the conditions can occur together, they are distinct diagnoses

Question 4

How common is adenomyosis in hysterectomy specimens?

Answer 4

It is found in up to 40% of hysterectomy specimens

Question 5

What is the pathophysiology of adenomyosis?

Answer 5

It is thought to occur when the endometrial stroma is allowed to communicate with the underlying myometrium after uterine damage

Question 6

What is the endometrial stroma?

Answer 6

Connective/supporting tissue

Question 7

What might cause interaction between the underlying myometrium and the endometrial stroma?

Answer 7

• Pregnancy and childbirth
• C-section
• Uterine surgery
• Surgical management of miscarriage or termination of pregnancy

Question 8

Give an example of a uterine surgery that might allow the interaction of myometrium and endometrial stroma

Answer 8

Endometrial curettage

Question 9

Is the invasion of endometrium focal or diffusion in adenomyosis?

Answer 9

Can be either

Question 10

Where is invasion of endometrium in adenomyosis most commonly found?

Answer 10

In the posterior wall of the uterus

Question 11

How extensive is the invasion of endometrium in adenomyosis?

Answer 11

Variable

Question 12

What can happen in severe cases of adenomyosis?

Answer 12

Pockets of menstrual blood can be seen in the myometrium of the hysterectomy specimens

Question 13

What is an adenomyoma?

Answer 13

When a collection of endometrial glands form grossly visible nodules

Question 14

What receptors are found in the ectopic endometrial tissue in adenomyosis?

Answer 14

Oestrogen, progesterone, and androgen receptors

Question 15

What is the result of oestrogen, progesterone, and androgen receptors being found in the endometrial tissue in adenomyosis?

Answer 15

Makes it responsive to hormones

Question 16

What are the risk factors for adenomyosis?

Answer 16

• High parity
• Uterine surgery
• Previous C-section
• Family history

Question 17

Give 2 examples of uterine surgery that increase the risk of adenomyosis

Answer 17

• Endometrial curettage

- Endometrial ablation

Question 18

What are the main presenting symptoms of adenomyosis?

Answer 18

• Menorrhagia
• Dysmenorrhoea
• Deep dyspareunia
• Irregular bleeding

Question 19

Describe the dysmenorrhoea in adenomyosis

Answer 19

It is commonly progressive, beginning as cyclical pain but can worsen to daily pain

Question 20

What may be found on examination in adenomyosis?

Answer 20

Symmetrically enlarged tender uterus

Question 21

What are the differential diagnoses for adenomyosis?

Answer 21

• Endometriosis
• Fibroids
• Endometrial hyperplasia/endometrial carcinoma
• Endometrial polyps
• Pelvic inflammatory disease
• Hypothyroidism and coagulation disorders

Question 22

How is the definitive diagnosis of adenomyosis made?

Answer 22

Histological diagnosis after hysterectomy

Question 23

What recent advances have there been in the diagnosis of adenomyosis?

Answer 23

Advances in histological diagnosis from specimens obtained at hysteroscopic biopsy

Question 24

What can assist the diagnosis of adenomyosis in clinically suspected cases?

Answer 24

Imaging

Question 25

What imaging is used in adenomyosis?

Answer 25

- Transvaginal ultrasound | - MRI

Question 26

What is the limitation of transvaginal ultrasound in adenomyosis?

Answer 26

Highly observer dependant

Question 27

What are the signs of adenomyosis on transvaginal ultrasound?

Answer 27

- Globular uterine configuration - Poor definition of the endometrial-myometrial interface - Myometrial anterior-posterior asymmetry - Intramyometrial cysts - Heterogenous myometrial echo texture

Question 28

What does MRI show in adenomyosis?

Answer 28

'Endo-myometrial junctional zone' that can be distinguished from the endometrium and outer myometrium

Question 29

What is recognised as a hallmark of adenomyosis on MRI?

Answer 29

Irregular thickening of the endometrial junction

Question 30

What is the main aim of the management of adenomyosis?

Answer 30

Control dysmenorrhoea and menorrhagia

Question 31

What is the only curative therapy for adenomyosis at present?

Answer 31

Hysterectomy

Question 32

What are the more conservative approaches aimed at symptom control in adenomyosis?

Answer 32

- Analgesia - Hormone therapy - Non-hormone treatments

Question 33

What analgesics are used in adenomyosis?

Answer 33

NSAIDs

Question 34

What hormone therapies are available for the management of adenomyosis?

Answer 34

- Combined oral contraceptives - Progestogens - Gonadotrophin releasing hormone agonists - Aromatase inhibitors

Question 35

How can progesterones be administered in adenomyosis?

Answer 35

- Oral | - intrauterine system. e.g. Mirena

Question 36

What is the purpose of hormonal therapy in adenomyosis?

Answer 36

Reduction of bleeding and cycle control

Question 37

How do hormonal therapies work in adenomyosis?

Answer 37

Proposed that hormones reduce the proliferation of the ectopic endometrial cells, therefore reducing their mass and subsequently decreasing uterine size and volume of blood lost

Question 38

What can temporarily induce the regression of adenomyosis?

Answer 38

Continuous combined oral contraceptive and high dose progestins, e.g. SC depot medroxyprogesterone

Question 39

What are the non-hormonal treatments available in adenomyosis?

Answer 39

- Hysterectomy - Uterine artery embolism - Endometrial ablation and resection - Laparoscopic excision - MR-guided focused ultrasound

Question 40

Is uterine embolism a long or short term management option for adenomyosis?

Answer 40

Short and medium

Question 41

Who is uterine artery embolism a good option for in adenomyosis?

Answer 41

Women who wish to avoid hysterectomy and/or preserve their fertility

Question 42

What is the aim of uterine artery embolism in adenomyosis?

Answer 42

Block blood supply to the adenomyosis, causing it to shrink