Introduction
Benign invasion of endometrial tissue into the myometrium of uterus is known as Adenomyosis. It is found typically between the age of 35-50 years.1 Prevalence is 6- 39%. This wide range is due to the different diagnostic methods used.2 Microscopically, adenomyosis exhibits ectopic, non-neoplastic, endometrial glands and stroma surrounded by the hypertrophic and hyperplastic myometrium.3
Table 0
Diagnosis
Modern imaging techniques, both ultrasound (TAS, TVS) and MRI have made possible, for the first time, a non-invasive identification of adenomyosis.4
Material and Methods
It is a retrospective study done at hospitals attached to Bangalore Medical College & Research Institute during august 2016-august 2017.
The HPE reports of all the hysterectomy specimens were reviewed and was found that 50 cases showed evidence of adenomyosis.
Case records were reviewed.
Data regarding age, parity, symptoms, obstetric history, examination, co morbidities, investigation findings, associated pathology and treatment modality were noted.
They were tabulated and analysed with chi square test.
Table 1
Specimen retrieval from
|
TAH |
16 (32%) |
|
TAH + BSO |
25 (50%) |
|
VH |
1 (2%) |
|
TAH + RSO |
3 (6%) |
|
NDVH |
4 (8%) |
|
TAH + LSO |
1 (2%) |
90% of the cases underwent abdominal hysterectomy. 2% underwent vaginal hysterectomy and 2% NDVH.
Results
Table 2
Age distribution
|
<30 |
NIL |
|
30-40 |
14 cases (28%) |
|
41-50 |
28 cases (56%) |
|
>50 |
4 cases (8%) |
|
Postmenopausal |
4 cases (8%) |
Majority of patients were in 40-50 years of age. 28 cases were in the age group of 30-40 years.
4 patients were postmenopausal. 4 patients were more than 50yrs of age. None were less than 30years.
94% were multigravida while 4% were nulligravida. The least incidence was in nullipara with 2%.
Majority of the cases were between 40- 60kgs. 7 patients are of weight more than 60kg.
Presenting symptoms
There was varied presentation of complaints with menstrual disturbances being the most common.
Table 5
Menstrual disturbances
Table 6
Pain
|
Congestive dysmenorrhea |
3 (6%) |
|
Spasmodic dysmenorrhea |
4 (8%) |
|
Continuous pain |
6 (12%) |
|
Dyspareunia |
4 (8%) |
Table 7
Others
|
Retention of urine |
1 (2%) |
|
Incomplete voiding of urine |
1 (2%) |
|
Mass per vaginal |
2 (4%) |
|
Abdominal distension |
1 (2%) |
Among the menstrual complaints, increasing frequency of menstrual cycles was the most common followed by heavy menstrual bleeding.
Pain was another complaint which affected the lifestyle of patients. Most of the patients complained of continuous pain. The second most common type was dyspareunia and spasmodic dysmenorrhea.
History of infertility was present in 11 cases out of 50 cases (22%).
Age of menarche- majority of patients had menarche after 12 years with no evidence of prolonged oestrogen stimulation.
Most of them presented within 6 months of duration of illness- 58%.
Previous history of dilatation & curettage present in 13 cases out of 50 cases (26%).
History of previous operative procedures.
Table 8
Table 9
Duration of symptoms
|
<3 months |
14 (28%) |
|
3-6 months |
15 (30%) |
|
7m-1yr |
7 (14%) |
|
1yr-2yr |
11 (22%) |
|
>2yr |
3 (6%) |
14 patients had recent history of onset of symptoms from 3 months. Maximum patients had symptoms from one year. Very few of them had from 2 years.
Table 10
Pathological examination of specimens
|
Endometrium |
|
|
Secretory |
13 (26%) |
|
Proliferative |
20 (40%) |
|
Hyperplastic |
17 (34%) |
The most common type of endometrial histopathology was proliferative followed by hyperplastic. This indicates the role of oestrogen in the pathophysiology of adenomyosis.
Other associated pathology
Table 11
Endometrium
Most of the endometrial reports were normal. 13 patients had simple cystic hyperplasia without atypia.
Table 12
Myometrium
Majority patients had other associated pathology along with adenomyosis like fibroid, polyp, ovarian cyst. 21 patients were found to have only adenomyosis.
Table 14
Clinical diagnosis based on history and examination findings
|
Adenomyosis |
18(36%) |
|
PID |
8(16%) |
|
Fibroid |
17(34%) |
|
AUB(o) |
6(12%) |
|
CA endometrium |
1(2%) |
In 36% of cases, clinical diagnosis of adenomyosis was made. In the rest, the co- existing pathology was adenomyosis, but primary pathology was as mentioned above.
Table 15
Ultrasound imaging
28% were reported as normal uterus
Adenomyosis was picked up in 40% of cases and in the rest Adenomyosis was not reported
The most reliable method of diagnosis of adenomyosis was by histopathological examination of the specimen while clinical diagnosis has the least sensitivity of diagnosis of adenomyosis.
Discussion
Out of the 50 patients, 56% were in the age group of 41-50 years, which is the usual age of occurrence as similarly found in Bird et al. study.5 The prevalence of adenomyosis in our study was only 10% in post-menopausal women when compared to the age group 41-50yrs (56%). This indicates adenomyosis regresses after menopause but remains detectable. Kitawaki et al., conducted a similar study showing diagnosis of adenomyosis in post-menopausal women.6 In our study, multiparous women had 94% incidence of adenomyosis in correlation with high incidence in Wallwiener et al. study.7 Harmanli O H et al., study stated that prior uterine surgeries could be a risk factor for adenomyosis. In our study only 26% women had this history.8 There is no evidence of adenomyosis directly causing infertility. 22% of cases had history of infertility in this study. Chapron et al., also showed less correlation.9 Symptom wise, 56% had menstrual disturbances which were also seen in Vercellin e al., study.10 Dysmenorrhea & Dyspareunia were the next common symptoms. Fibroid was the commonest associated pathology (38%). Vercillin et al., study also had the same pathology as commonest.11 34% had hyperplasia of endometrium whereas 66% had no pathology. Similar results were seen in Cullen et al., study12 showing that no hyperplasia was present as there was absence of prolonged oestrogen exposure.
Imaging picked up only 40% of cases contrary to 36% of clinical diagnosis and was raised to 66% with gross examination of specimen and 100% with HPE. This shows that a good gynaecologist may suspect adenomyosis on clinical basis, stated Aziz et al., as he found similar outcome in his study.2
Conclusion
Adenomyosis has a varied presentation. Ultrasound fails to diagnose all the cases. Clinical examination is a better modality. Associated pathology may mask the clinical features of adenomyosis, and diagnosis may be missed. Presently HPE is probably the gold standard for diagnosing adenomyosis.
