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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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New rules apply after NovaSure
From OB/GYN News, 12/15/05 by Patrice Wendling

CHICAGO -- The exact state of the uterus 1 year after global endometrial ablation with Nova-Sure is largely unknown, but certain characteristics are beginning to emerge, Robert Sabbah, M.D., reported at the annual meeting of the AAGL.

Even though global endometrial ablation is becoming increasingly common, radiologists are hard-pressed to describe their findings as there are no data available to allow adequate correlation between ultrasound images, hysteroscopic images, and uterine cavity endometrial sampling.

In addition, there are no clear treatment guidelines for women who have continuous bleeding after global endometrial ablation, he said.

One of the first rules to emerge is that abnormal bleeding after endometrial ablation should always be investigated first with transvaginal rather than transab-dominal ultrasound, said Dr. Sabbah, director of obstetrics and gynecology at Sacred Heart Hospital and professor of obstetrics and gynecology at the University of Montreal.

Transabdominal ultrasound does not properly identify normal endometrial thickening or echogenicity.

Secondly, irregular slight thickening of the endometrial stripe can be simply islets of residual tissue in the cavity.

Dr. Sabbah came to these conclusions based on an ongoing prospective study in which the uteri of 45 women were evaluated with both transvaginal and transabdominal ultrasound 1 year after NovaSure (Cytyc Corp., Palo Alto, Calif.) endometrial ablation. In select cases, the women went on to hysteroscopy or were evaluated with magnetic resonance imaging if the ultrasound appearance of the uterus was abnormal.

On average, the women were aged 44 years and had two children each.

Of the 45 women, 27 (60%) were totally amenorrheic, 15 (33%) had spotting, and 3 (7%) had no improvement with the ablation.

A total of 38 patients had a totally normal echogenic stripe--a more accurate term post ablation than endometrium--and, of these, 8 had myomas.

Three patients had suspicion of islets of residual endometrium due to the focal thickening of the echogenic stripe and echogenic appearance, three had abnormal endometrial images compatible with adenomyosis or postablation alterations, and one patient had a possible synechia.

There were no abnormal pathologies.

In none of the cases did the echogenic stripe exceed 6 mm in thickness by transvaginal ultrasound.

Physicians should read the ultrasound of a premenopausal woman who has undergone endometrial ablation as if she were a postmenopausal patient, and should always expect to find an echogenic stripe of 6 mm or less, he said.

"If you have anything above that, worry and go to hysteroscopy," he said.

Abnormal echogenic stripes or enterogenous myometrium are suggestive of adenomyosis and should be followed by MRI, which is more sensitive and better defines the uterine cavity than ultrasound.

Finally, the preferred method for endometrial stripe should be hysteroscopy and dilation and curettage. Hysteroscopy can confirm the benign nature of ultrasound anomalies, scarring, synechia, and fibrotic tissue in most cases, he said.

BY PATRICE WENDLING

Chicago Bureau

COPYRIGHT 2005 International Medical News Group
COPYRIGHT 2006 Gale Group

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