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
• Anticoagulants
• Selective Serotonin Reuptake Inhibitors (SSRIs)
• Hypothyroidism
• Polycystic Ovary Syndrome
• Secondary anovulation

Reproductive Tract Causes

• Adenomyosis
• Atrophic endometrium
• Dysfunctional uterine bleeding
• Endometriosis
• Fibroids
• Foreign Body
• Infection (vaginitis, PID)
• IUD
• Neoplasia (especially in women >45 years old or in younger women with other risk factors)
• 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
• Definitive diagnosis relies on histology, and so it is usually made during pathology examination of the uterus after a hysterectomy

Management

• Hysterectomy is the definitive treatment
• Alternative options include
  • Hormonal therapy such as with a levonorgestrel IUD
• Uterine artery embolization
• Uterus sparing resection

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)