What is Medicine – Adenomyosis
Basic description: Benign invasion of the endometrium into the myometrium, resulting in a diffusely enlarged uterus; considered a specific entity in the PALM-COEIN FIGO classification of causes of abnormal uterine bleeding (polyp; adenomyosis; leiomyoma; malignancy and hyperplasia; coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet classified; International Usually connected with the uterus, however the term "adenomyosis" can also be used to describe benign hyperplastic alterations in the bile ducts, gallbladder, and ampulla of Vater. It most frequently affects the posterior wall of the uterus. EPIDEMIOLOGY Adenomyosis was previously thought to manifest more frequently in the fourth and fifth decades. However, imaging techniques like transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) are now being used to identify it in younger women who have pain, unusual uterine bleeding, infertility, or no symptoms at all. Significant variance across racial and ethnic groups as well as between various geographic regions (3) Incidence Usually thought to be a uterine condition of multiparous women, women who have had prior caesarean sections, or women who have had prior uterine surgery; however, a growing body of evidence suggests that there may also be an association with infertility and reproductive failure. Variability in the diagnostic criteria makes it difficult to accurately estimate the true incidence. The incidence has been calculated to range between 10% and 80%, depending on the diagnostic criteria utilised. Women who come with endometriosis have a higher incidence, according to reports. Prevalence Depending on the criteria used for diagnosis, the prevalence has been reported to vary from 5% to 70%, with the mean frequency of adenomyosis at hysterectomy given as approximately 20-30%. PATHOPHYSIOLOGY AND AETIOLOGY An abnormal ingrowth and invagination of the basal endometrium into the inner layer of the myometrium (junctional zone [JZ]) is known as adenomyosis. The precise method by which this happens and is sustained is unclear and probably complicated. There are two primary hypotheses that describe the pathophysiology and development of adenomyosis: - Dysregulated tissue injury and repair that encourages cell migration and invagination of the endometrial basalis into the myometrium - De novo epithelial-mesenchymal transformation among displaced embryonic müllerian remnants or adult stem cellThe survival and migration of ectopic endometrial implants outside the myometrial interface appear to be influenced by molecular changes in eutopic endometrium.The primary pathogenic pathways of pain, bleeding, and infertility in adenomyosis presumably involve abnormalities of the sex steroid hormones, inflammation, aberrant cell proliferation, and neuroangiogenesis.. The JZ may be an area of structural weakness and morphologic malfunction in women with adenomyosis, with varied susceptibilities to endometrial stromal cell invagination. Increased uterine pressure brought on by pregnancy, leiomyomas, or other pathologies may alter the JZ environment and make endometrial stromal cell invasion more likely. Specific genes that are differentially expressed in adenomyosis and matching eutopic endometrium have been discovered using genetics, DNA microarray, and proteomics investigation. According to data, anomalies in genetic and epigenetic regulation are involved in the aetiology of adenomyosis. RISK FACTORS Age >40 years; nevertheless, the disease has been found in more young women, including teenagers, as of late. According to reports, early-stage adenomyosis may exhibit a distinct clinical pattern from late-stage disease. Other potential risk factors include: - Infertility and reproductive failure (increasing body of research); - Multiparity; - Tamoxifen medication. - Smoking (studies have shown mixed results) - Previous uterus surgery. CONDITIONS OFTEN Associated with Endometriosis, Leiomyomas (uterine fibroids), Endometrial polyps Urinary tract disease Pelvic pain, dysmenorrhea, and an enlarged uterus are the typical cues that prompt imaging by ultrasound or MRI; endometrial or uterine biopsies may be necessary in some cases. DIAGNOSIS The diagnosis is made through physical examination, radiographic imaging, biopsy, and subsequent histopathologic evaluation. HISTORY One-third of people with adenomyosis are asymptomatic, and the symptoms that do present are nonspecific. The following symptoms are frequently present: Menorrhagia, dysmenorrhea, chronic pelvic discomfort, abnormal uterine bleeding, and urinary tract symptoms (such as urge incontinence, stress incontinence, urgency, and daytime frequency) have all been linked to an elevated risk of adenomyosis, albeit the evidence is sparse. MEDICAL ANALYSIS The uterus may be painful and swollen. Pregnancy, benign uterine tumours, malignant uterine tumours, and metastatic illness are all different diagnoses. Initial tests (lab, imaging) Diagnostic tests and interpretation There hasn't been a unified histologic and radiologic classification system created to specify the kind and degree of adenomyosis. Additionally, there hasn't been a systematic radiologic classification system created to specify the kind and degree of adenomyosis. The Morphological Uterus Sonographic Assessment (MUSA) criteria have recently been used to produce a universal, standardised reporting method for ultrasound findings of adenomyosis. The preferred imaging technique for the initial assessment of suspected adenomyosis is TVUS. Two-dimensional TVUS cannot offer JZ thickness, whereas three-dimensional TVUS can. Two-dimensional TVUS is slightly less sensitive and slightly more specific than three-dimensional TVUS, which has a sensitivity of 65-81% and a specificity of 65- 100%. As compared to MRI, TVUS is less sensitive and has more interobserver variability in identifying adenomyosis from leiomyoma. The results of MRI are superior to those of TVUS, with a pooled sensitivity of 77%, specificity of 89%, positive likelihood ratio of 6.5, and negative likelihood ratio of 0.2 for all subtypes. MRI is the best imaging technique for leiomyomas because, in 36–50% of cases, adenomyosis is present. If cost is not a factor, MRI might be the ideal imaging technique when it is accessible. MRI should unquestionably be taken into account when TVUS cannot make a conclusive diagnosis. Diagnostic Procedures/Other Hysterectomy with histologic interpretation Uterine biopsy with histologic interpretation Uterine-sparing operative treatment (USOT) with histologic interpretation Test Interpretation The following are some examples of the two-dimensional sonographic signs of adenomyosis: - Expansion of the uterus (without a visible leiomyoma) - Cysts - Islands with high echoes - Asymmetrical thickening of the uterine wall Subendometrial linear echogenic striations - Vascularity in translesions - Shadows in the form of fans - A JZ that is irregular, thicker, or interrupted Although many criteria have been put forth, adenomyosis appears to be strongly predicted by a JZ thickness more than 12 mm. On T2-weighted images, the JZ widens with low intensity, which is a sign of adenomyosis and corresponds to thickening of the JZ and smooth muscle hyperplasia. Three distinct criteria have been established to diagnose adenomyosis using an MRI: - Increased JZ thickness of 8 to 12 mm or more; JZ maximum/total myometrium >40% (2)[B] JZ maximum-JZ minimum >5 mm Histologic analysis has historically been regarded as the most practical method of making a conclusive diagnosis of adenomyosis. Uterine biopsy pathologic interpretation: Due to sampling bias and/or biopsy artefact, it is frequently difficult to conclusively diagnose adenomyosis on smaller samples. - Presence of endometrial glands and stromal elements within the myometrium Pathologic interpretation of hysterectomy and USOT: – Diagnostic challenges exist with morcellated specimens because the tissue's spatial organisation has been altered, making it challenging to reference the surface. Sampling bias can also be a problem; even when the surface is correctly referred, pathologists may have different standards for what "definitively" characterises adenomyosis based on the depth of invasion. TREATMENT The cornerstone of treatment for adenomyosis has been surgical therapy, however medicinal therapy has shown success in some patients; there are no universal standards to follow. MEDICATION Consistent use of oral contraceptives, high-dose progestins, and selective progesterone receptor modulators can alleviate symptoms momentarily. The best first-line treatment for adenomyosis is the use of a levonorgestrel-releasing intrauterine device, which is also a successful, long-term, reversible method of treatment. Second-line options include gonadotropin-releasing hormone (GnRH) agonists, which are used to treat menstrual discomfort and bleeding, and GnRH antagonists, which are used to treat leiomyomas and endometriosis. ADVANCED THERAPIES Adenomyosis is being treated with selective progesterone receptor modulators, aromatase inhibitors, valproic acid, and anti-platelet medication. SURGICAL AND OTHER PROCEDURE USOT may be an option for women who want to protect their fertility or do not want to have a hysterectomy because hysterectomy is curative. USOT excisional procedures - Total removal (adenomyomectomy) • Cytoreduction (partial adenomyomectomy); • Resection of the uterine wedge Nonexcisional USOT methods - Laparoscopic procedures such as uterine artery ligation and electrocoagulation - Hysteroscopic procedures such as endomyometrial excision and endometrial ablation - An ultrasound or MRIHigh-intensity focused ultrasound (HIFU)-guided high-frequency ultrasound ablation - The embolisation of the uterine artery (EAU) – The following other reported methods are among them: Radiofrequency ablation (focal adenomyosis) and alcohol instillation (cystic adenomyosis) Ablation by microwave Diffuse adenomyosis (thermoablation) ● The most hopeful outcomes appear to be provided by HIFU and UAE among the non-excisional methods. Excisional USOT, which includes uterine wedge resection, adenomyomectomy, and hysteroscopic excision, may possibly improve fertility, however the optimum surgical approach is still to be determined. This is according to a systemic review of USOT for adenomyosis in reproductive-aged women. Hysterectomy, UAE, and endometrial ablation are only alternatives if future fertility is not sought; nonexcisional USOT may increase fertility with HIFU and radiofrequency ablation. PROGNOSIS Adenomyosis is a benign growth of endometrial tissue; hysterectomy is the recommended treatment; symptoms typically go away during menopause. To ascertain the effect of untreated adenomyosis and USOT on fertility and reproductive outcomes, more research is still required. A consensus on the criteria for diagnosing adenomyosis needs to be developed, and more research is also required to understand the function of medical treatment in women with the condition. COMPLICATIONS Anaemia brought on by blood loss brought on by heavy periods Although it has been suggested that people with adenomyosis are more likely to develop malignancies, there is currently little morphologic, genetic, or epigenetic evidence to support this claim.
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