adenomyosis, ectopic endometrium, adenomyosis & infertility, congestive dtsmenorrhea, menorrhagia, enlarged uterys

1. ADENOMYOSIS
Magdy Abdelrahman Mohamed
2014

2. DEFINITION
• Adenomyosis is defined by the presence
of ectopic endometrial glands and stroma
within the myometrium.
• The presence of ectopic endometrial
glands and stroma induces a hypertrophic
and hyperplastic reaction in the
surrounding myometrial tissue.

3. • It usually occurs in 4th
or 5th
decade.
• Associated with high parity
• usually associated with other
conditions, such as myoma,
endometrial polyps and endo
metriosis.

4. TYPES
• Diffuse
• Local

5. • adenomyoma describes a
focus of adenomyosis within a
leiomyoma.
• Both conditions are common
so it is not surprising that this
overlap condition may occur

6. Presentation
• Menorrhagia.
• Congestive dysmenorrhoea.
• Dyspareunia.
• Chronic pelvic pain.

7. Adenomyosis & subfertility
• It thought to be a condition of
parous women, with the final
diagnosis made after
hysterectomy.
• Thus, an association between
adenomyosis and subfertility has
not been fully established.

8. • Some believe that adenomyosis is
not common in subfertile women,
while others think that adenomyosis
plays a critical role in subfertility.

9. • The hypothesis of a possible link between
adenomyosis and infertility is becoming
more and more plausible.
• There is observation that adenomyosis is
present even in younger women and can
be associated with pelvic endometriosis
and infertility.
• (Kissler et al., 2007; Kunz et al.,2005).

10. Possible mechanism
1-Altered uterine peristaltic activity.
Kissler et al. (2006) placed into the
posterior vaginal fornix radio-labelled
macro-albumin aggregates (with a size of
5–20 um mimicking sperm size) and
scanned with a gamma camera
immediately after application and at
various time intervals up to 30 min.

11. • Fertile women. Positive, uni- and
ipsilateral transport of radionuclides to the
side bearing the dominant follicle.
• Diffuse adenomysis & infertility.
– 70% remain in uterus.
– 22% transport to contralateral side.
– 8% to ipsilateral side of dominant follicle.

12. 2-Altered endometrial function and receptivity.

13. DIAGNOSIS
• The sure diagnosis of adenomyosis
is made on a pathologic specimen.
• The pathologic diagnosis is
dependent on the visualization of
endometrial glands and stroma in
more than 1 low-power field from the
endometrial basalis layer.
• Katz VL. Benign gynecologic lesions. 5th Edition. 2007:419–471.

14. TVS
• Operator dependent.
• meta-analysis on the accuracy of
sonography in the diagnosis of
adenomyosis showed that it had
sensitivity of 82.5% (77.5–87.9) and
specificity of 84.6% (79.8–89.8).
Meredith SM et al, 2009.

15. • Uterine enlargement.
• Cystic anechoic spaces or lakes in
the myometrium.
• Heterogeneous echo texture.
• Obscure endometrial/myometrial
border.
• Subendometrial halo thickening.

16. • Globular uterine enlargement with an obscure
endometrial/myometrial border (arrow).

17. • Anechoic cystic lacunae in the posterior uterine
wall (arrow) with a heterogeneous echo texture.

18. • Linear striations (arrows) in the presence of a
heterogeneous echo texture

19. MRI
• More accurate.
• Findings
– Diffuse or local widening of junctional
zones on T2 weighted images >12 mm.
– Low intensity lesion (ill-defined).
– Uterine enlargement.
– Small hypointense myometrial spots.

20. Sagittal T2-weighted MR image shows diffuse, even
thickening of the junctional zone (arrows), a finding
consistent with diffuse adenomyosis

21. • focal thickening of the JZ (short arrows).

22. OTHER TESTS
• Ca-125.
• Hyserosalpingraphy.

23. MANEGMENT
The only definitive treatment for
adenomyosis is hysterectomy, with or
without ovarian conservation.

24. ALTERNATIVES
• GNRH Analogues.
• Levonorgestrel releasing IUD.
• Uterine artery embolization.
• Focused U/S……….. For localized
adenomyosis.
• Endometrial ablation.
• Conservative surgery.

25. MANAGEMENT OF INFERTILITY.
• Data available on treatment of
infertility associated with
adenomyosis are still fairly limited
and mostly confined to case reports
or uncontrolled small series.

26. CONSERVATIVE
SURGERIES

27. Nishida. Conservative surgery for adenomyosis.

30. • Of 44 patient results were.

31. Triple flap (Osada) method.

33. Other options
A- GnRH analogue:
Few case reports (Silva et al.,1994)
published the first term pregnancy in
a patient with a 10-year history of
secondary infertility, after 5 months of
therapy with GnRHa.

34. B- IUD containing danazol.
• a Japanese group (Igarashi et al.,
2000) have published results of 14
women with symptomatic
adenomyosis that had relapsed after
previous medical therapy.
• There was good relief of the
symptoms.
• Three of the four infertile women
conceived after removal.

35. C- Uterine artery embolization.
few case series
D- MRI-assisted high-intensity focused
ultrasound (HIFU). Only one case of
successful treatment of adenomyosis
associated infertility with HIFU has been
published. (Rabinovici et al., 2006b)