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Adenomyosis

Adenomyosis is a medical condition characterized by the presence of ectopic endometrial tissue (the inner lining of the uterus) within the myometrium (the thick, muscular layer of the uterus). more...

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The condition is typically found in women in the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse menses (dysmenorrhea & menorrhagia, respectively).

Adenomyosis may involve the uterus focally, creating an adenomyoma, or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

Causes

The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as Cesarean sections, tubal ligation, pregnancy termination, and any pregnancy.

Some say that the reason adenomyosis is common in women between the ages of 35 and 50 is because it is between these ages that women have an excess of estrogen. Near the age of 35, women typically cease to create as much natural progesterone, which counters the effects of estrogen. After the age of 50, due to menopause, women do not create as much estrogen.

Diagnosis

The uterus may be imaged using ultrasound (US) or magnetic resonance imaging (MR). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize uterine fibroids.

MR provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small uterine fibroids the uterus will have a thickened junctional zone with diminished signal on both T1 and T2 weighted sequences due to succeptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the junctional zone greater than 10 or 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MR can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

Treatment

Treatment options range from use of NSAIDS & hormonal suppression for symptomatic relief, to endometrial ablation or hysterectomy for a more or less permanent cure.

Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with xenoestrogens and/or recommend taking natural progesterone supplements.

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Interstitial cystitis and adenomyosis frequently coexist in chronic pelvic pain syndrome
From OB/GYN News, 11/15/04 by Miriam E. Tucker

NEW YORK -- Interstitial cystitis often coexists with adenomyosis, just as it does with endometriosis, Stephen A. Grochmal, M.D., said at an international congress of the Society of Laparoendoscopic Surgeons.

"How many patients do we have who continue to have pain after endometrial ablation or after hysterectomy? Before we send them to a psychiatrist, perhaps we ought to give them a 5-minute screening questionnaire to see if they have associated interstitial cystitis," Dr. Grochmal of the division of operative gynecology, endoscopy, and laser surgery at Howard University. Washington.

If the patient's score on that questionnaire--the Pelvic Pain and Urgency/Frequency (PUF) patient symptom scale--suggests interstitial cystitis (IC), then diagnostic tests are indicated (Urology 2002;60:573-8).

In 2002, Maurice K. Chung, M.D., and his associates described the "evil twins" of endometriosis and IC in chronic pelvic pain syndrome. They found a 70% overlap of the two conditions among 60 women (JSLS 2002;6:311-4).

"After I read that, I considered that we might see the same thing with adenomyosis. After all, it is endometriosis of the myometrium," Dr. Grochmal explained.

So he retrospectively analyzed 287 women who were part of an ongoing study that compared the long-term effect on amenorrhea rates of endometrial resection by Nd:YAG laser versus resectoscope. Despite alleviation of their uterine bleeding, 60% (172) of the women reported postoperative chronic pelvic pain, along with urinary urgency and frequency, dysuria, rectal pain, perineal pain, dysmenorrhea, decreased sexual intimacy, and decreased quality of life.

Following a review of their surgical pathology reports and examination of uterine shavings or laser-excised tissue strips to exclude subbasalis diagnoses, "pure" adenomyosis was confirmed in 48 (28%) of the 172 women. Of those 48, 32 (67%) had a score greater than 6 out of a total of 35 on the PUF scale, suggesting IC. Of those 32, 27 (84%) had positive potassium sensitivity test scores.

With use of established criteria for cystoscopy/hydrodistention, IC was confirmed in 25 (78%) of the 32 women, and in 1 (6%) of the 16 women with PUF scores less than 6.

Among the remaining 124 chronic pelvic pain patients who did not have adenomyosis, 54 were randomly selected for the same testing. Of those, six (11%) also had confirmed IC, in contrast to the total 60% of those with adenomyosis.

In patients who have chronic pelvic pain after the treatment of excessive uterine bleeding, adenomyosis may be the cause of the bleeding and the bladder may the cause of the chronic pelvic pain, Dr. Grochmal speculated at the meeting.

BY MIRIAM E. TUCKER

Senior Writer

COPYRIGHT 2004 International Medical News Group
COPYRIGHT 2004 Gale Group

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