Adenomyosis
Background
Adenomyosis uteri seen during laparoscopy: soft and enlarged uterus; the blue spots represent subserous endometriosis.
- Uterine disorder characterized by endometrial glands and stroma being present within the myometrium resulting in hypertrophy of the surrounding myometrium
- Two histopathological forms:
- Diffuse – results in the uterus being uniformly enlarged and boggy
- Focal (also known as an adenomyoma) – can appear similar to a fibroid but does not have a pseudocapsule
- Pathogenesis is not well understood
Clinical Features
- Heavy vaginal bleeding
- Dysmenorrhea
- Chronic pelvic pain
Differential Diagnosis
Nonpregnant Vaginal Bleeding
Systemic Causes
- Cirrhosis
- Coagulopathy (Von Willebrand disease, ITP)
- Group A strep vaginitis (prepubertal girls)
- Hormone replacement therapy
- Hypothyroidism
- Secondary anovulation
Reproductive Tract Causes
- Adenomyosis
- Atrophic endometrium
- Dysfunctional uterine bleeding
- Endometriosis
- Fibroids
- Foreign Body
- Infection (vaginitis, PID)
- IUD
- Neoplasia
- Vaginal Trauma
Evaluation
Sagittal MRI showing uterus with adenomyosis in the posterior wall: gross enlargement with many foci of hyperintensity.
- Pelvic exam – bimanual usually reveals a mobile, enlarged, and soft or boggy uterus
- Transvaginal US
- MRI usually reserved in cases when providers are seeking to distinguish between adenomysosis and leiomyomas [1]
- Definitive diagnosis relies on histology, and so it is usually made during pathology examination of the uterus after a hysterectomy
Management
Disposition
- Final disposition should be made based on hemodynamic stability of the patient
- If hemodynamically stable without clinically significant bleeding, patient can be discharged with gynecology referral
See Also
- Vaginal Bleeding (Non-Pregnant)
References
- Byun JY, Kim SE, Choi BG, Ko GY, Jung SE, Choi KH. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. 1999;19 Spec No:S161-S170. doi:10.1148/radiographics.19.suppl_1.g99oc03s161
- Fong YF, Singh K. Medical treatment of a grossly enlarged adenomyotic uterus with the levonorgestrel-releasing intrauterine system. Contraception. 1999;60(3):173-175. doi:10.1016/s0010-7824(99)00075-x
- Fedele L, Bianchi S, Raffaelli R, Portuese A, Dorta M. Treatment of adenomyosis-associated menorrhagia with a levonorgestrel-releasing intrauterine device. Fertil Steril. 1997;68(3):426-429. doi:10.1016/s0015-0282(97)00245-8
- Sheng J, Zhang WY, Zhang JP, Lu D. The LNG-IUS study on adenomyosis: a 3-year follow-up study on the efficacy and side effects of the use of levonorgestrel intrauterine system for the treatment of dysmenorrhea associated with adenomyosis. Contraception. 2009;79(3):189-193. doi:10.1016/j.contraception.2008.11.004
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