Adenomyosis

Aka: Adenomyosis, Endometriosis of Uterus

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II. Definitions

  1. Adenomyosis
    1. Endometrial glands embedded within the uterine myometrium
    2. Contrast with Endometriosis, in which endometrial glands are embedded in tissue outside the Uterus

III. Risk Factors

  1. Multiparous women
  2. Age over 40 years old
  3. Prior cesarean delivery
  4. Prior uterine surgery

IV. Epidemiology

  1. Incidence: 1% (29 per 10,000 person years over 10 years)
    1. Symptomatic in >90% of cases in this series
    2. Yu (2020) Am J Obstet Gynecol 223(1): 94 [PubMed]
  2. Prevalence data is highly variable
    1. Original Prevalence of 10 to 35% was obtained from Hysterectomy tissue samples
      1. However, there are no standardized histologic criteria for the Adenomyosis diagnosis
    2. One Ultrasound-based study in symptomatic women identified Adenomyosis in 20%
      1. Naftalin (2012) Human Reprod 27(12):3432-9 [PubMed]
    3. Prevalence varies by age
      1. Overall Prevalence (female patients of all ages): 0.8%
      2. Age 41 to 45 years old (peak age): 1.5%

V. Pathophysiology

  1. Endometrial glands and stroma embed within the myometrium of the Uterus
    1. Colloquially known as Endometriosis of the Uterus (or internal Endometriosis)
  2. Pathogenesis theories
    1. Basalis endometrium, on injury, invaginates into the myometrium via an interrupted junctional zone OR
    2. Metaplasia of pluripotent Mullerian duct remnants
  3. Types
    1. Diffuse involvement of myometrium
    2. Focal

VI. Symptoms

  1. Asymptomatic in one third of patients
  2. Symptom onset typically at age 40 to 50 years old
  3. Dysmenorrhea (Painful Menstrual Periods, occurring in 15 to 30% of patients)
    1. May be worse in comorbid Uterine Fibroids
  4. Menorrhagia (heavy menstrual periods, occurring in 40-60% of patients)
  5. Metrorrhagia (prolonged menstrual periods)
  6. Other more variable symptoms
    1. Dyspareunia
    2. Chronic Pelvic Pain
    3. Infertility

VII. Signs

  1. Enlarged Uterus that is tender and boggy

VIII. Associated Conditions

  1. Uterine Fibroids (50%)
  2. Endometriosis (11%)

IX. Differential Diagnosis

  1. See Abnormal Uterine Bleeding Causes
  2. See Dysmenorrhea
  3. See Chronic Pelvic Pain Causes
  4. See Dyspareunia

X. Imaging

  1. Transvaginal Ultrasound
    1. Efficacy
      1. Test Sensitivity: 83.8%
      2. Test Specificity: 63.9%
    2. Findings
      1. Globular Uterus
      2. Fan-shaped shadowing
      3. Indistinct margin between outer myometrium and junctional zone
      4. Cystic changes involve the junctional zone and myometrium
      5. Hyperechoic islands within the junctional zone
    3. References
      1. Andes (2018) J Minim Invasive Gynecol 25(2): 257-64 [PubMed]
  2. MRI Pelvis
    1. Indicated in non-diagnostic Ultrasound
    2. Test Sensitivity: 77%
    3. Test Specificity: 89%
    4. Bazot (2018) Fertil Steril 109(3): 389-97 [PubMed]
    5. Liu (2021) J Ultrasound Med 40(11): 2289-306 [PubMed]
  3. Hysteroscopy
    1. Hypervascularization
    2. Endometrial defects
    3. Submucosal hemorrhagic cysts

XI. Management

  1. Non-surgical symptomatic management
    1. See Dysmenorrhea
    2. NSAIDs
    3. Hormonal management
      1. Oral Contraceptives
      2. Progestin-Releasing IUD (e.g. Mirena)
      3. Gonadotropin-Releasing Hormone Analogues and Antagonists
  2. Surgical Management
    1. Hysterectomy (80% of women with Adenomyosis)
    2. Uterine artery embolization

XII. References

  1. Osayande (2014) Am Fam Physician 89(5): 341-6 [PubMed]
  2. Schrager (2022) Am Fam Physician 105(1): 33-8 [PubMed]
  3. Taran (2013) Geburtshilfe Frauenheilkd 73(9):924-31 +PMID: 24771944 [PubMed]

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Related Studies

Ontology: Endometriosis of uterus (C0341858)

Definition (MSH) The extension of endometrial tissue (ENDOMETRIUM) into the MYOMETRIUM. It usually occurs in women in their reproductive years and may result in a diffusely enlarged uterus with ectopic and benign endometrial glands and stroma.
Definition (NCI) The growth of endometrial tissue inside the muscular wall of the uterus. Clinical manifestations include pain, dysmenorrhea, and menorrhagia.
Concepts Disease or Syndrome (T047)
MSH D062788 , D004715
ICD9 617.0
ICD10 N80.0
SnomedCT 76376003, 198246007, 198249000, 198248008, 155988000, 237115002, 198247003
English Endometriosis of uterus, Endometriosis of uterus NOS, ADENOMYOSIS, endometriosis adenomyosis (diagnosis), endometriosis adenomyosis, endometriosis of uterus, internal endometriosis (diagnosis), endometriosis of myometrium, endometriosis of myometrium (diagnosis), uterine endometriosis, endometriosis of uterus (diagnosis), internal endometriosis, adenomyosis, Uterine endometriosis, adenomyosis uteri, endometriosis uterus, uteri adenomyosis, endometriosis internal, uterus adenomyosis, uterus endometriosis, adenomyosis uterus, Adenomyosis, Adenomyoses, Adenomyosis [Disease/Finding], Endometriosis of uterus NOS (disorder), Adenomyosis - uterine endomet., Endometriosis internal, Internal endometriosis, Endometriosis of myometrium, Endometriosis interna, Adenomyosis uteri, Endometriosis interna (disorder), Endometriosis of myometrium (disorder), Endometriosis of uterus (disorder), endometriosis; uterus, uterus; endometriosis, Endometriosis of uterus, NOS, Adenomyosis of Uterus, Adenomyosis of the Uterus, Uterine Adenomyosis, Uterus Corpus Adenomyosis, Endometriosis, internal, Endometriosis, myometrium
Dutch adenomyosis uteri, endometriose op de uterus, endometriose inwendig, endometriose; uterus, uterus; endometriose, Endometriose van uterus, adenomyose, Adenomyose
French Endométriose interne, Adénomyose utérine, Endométriose de l'utérus, Endométriose intra-utérine, Adénomyose
German Adenomyosis uteri, Endometriose des Uterus, Endometriosis interna, Adenomyosis, Adenomyose
Italian Endometriosi interna, Adenomiosi uterina, Endometriosi dell'utero, Adenomiosi
Portuguese Adenomatose uterina, Endometriose do útero, Endometriose interna, Adenomiose
Spanish Endometriosis de útero, Adenomiosis uteri, Endometriosis interna, Adenomiosis, endometriosis de útero, SAI (trastorno), endometriosis de útero, SAI, adenomiosis, endometriosis del miometrio (trastorno), endometriosis del miometrio, endometriosis del útero (trastorno), endometriosis del útero, endometriosis interna (trastorno), endometriosis interna, endometriosis uterina
Japanese 内性子宮内膜症, 子宮腺筋症, 腺筋症, 子宮子宮内膜症, ｼｷｭｳｾﾝｷﾝｼｮｳ, ｼｷｭｳｼｷｭｳﾅｲﾏｸｼｮｳ, ﾅｲｾｲｼｷｭｳﾅｲﾏｸｼｮｳ, ｾﾝｷﾝｼｮｳ
Czech Vnitřní endometrióza, Adenomyóza, Endometrióza dělohy, Adenomyóza dělohy, adenomyóza, adenomyoza
Korean 자궁의 자궁내막증
Hungarian Endometriosis interna, Adenomyosis, méhendometriosis, Adenomyosis uteri
Polish Adenomioza
Russian ADENOMIOZ, АДЕНОМИОЗ, VNUTRENNII GENITAL'NYI ENDOMETRIOZ, ВНУТРЕННИЙ ГЕНИТАЛЬНЫЙ ЭНДОМЕТРИОЗ
Norwegian Intern endometriose, Adenomyose
Derived from the NIH UMLS (Unified Medical Language System)

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