# Adenomyosis Adenomyosis Adenomyosis is a benign uterine disorder characterised by the presence of ectopic endometrium or endometrium-like struc - tures within the myometrium accompanied by smooth muscle hypertrophy or hyperplasia. The ectopic endometrium can be present either di ff usely or focally within the myometrium. The complexity of the condition is contrib uted to by its variable presentation and di ffi culty in making an accurate diagnosis, and, subsequently , its management. The true prevalence of the condition is unknown because of variable diagnostic criteria, and ranges from 1% to 70%. Table 87.4 outlines the presenting characteristics, recommended investigations and management options. /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Joseph (Gustav) Asherman , 1889–1968, Czech–Israeli gynaecologist. This syndrome was first described by Heinrich Fritsch in 1894, Asherman further characterised it in 1948. Presenting characteristics Non-speci /f_i c Symptoms Dysmenorrhoea Abnormal uterine bleeding Chronic pelvic pain Subfertility Presentation in the fourth and /f_i fth decades of life Asymptomatic Dyspareunia Uterine enlargement Signs Uterine tenderness Abnormalities identi /f_i ed at hysteroscopy (irregular endometrium with endometrial defects, cystic haemorrhagic lesions, altered vascularisation) Increased/longer oestrogen exposure (early menarche [ ≤ 10 years of age], short menstrual cycles [ ≤ 24 days in Risk factors length], elevated body mass index, oral contraceptive use, increasing age, tamoxifen use) Spontaneous miscarriage and multiple pregnancies Increasing parity Uterine instrumentation/incision (caesarean sections, surgical termination of pregnancy, SMM, endometrial curettage) Endometrial hyperplasia Leiomyomas that breach the endometrial–myometrial interface Endometriosis Smoking Diagnosis The Morphological Uterus Sonographic Assessment (MUSA) group recommends commenting on eight Ultrasound morphological features in its classi /f_i cation of adenomyosis (presence, location, differentiation, cystic or non- cystic, myometrial layer, the extent of disease, size of the lesion and vascularity). Typical features include an enlarged globular uterus with asymmetrical thickening of the myometrium, myometrial cysts, echogenic subendometrial lesions, hyperechogenic islands, fan-shaped shadowing, an irregular junctional zone and vascularity on colour Doppler ( Figures Three or more sonographic criteria are usually required to make a diagnosis of adenomyosis Can help differentiate an adenomyoma from /f_i broids Magnetic resonance imaging Historically obtained at the time of hysterectomy; considered the gold standard Histology Limited in those wishing to preserve their fertility Management Analgesia (i.e. NSAIDs) Medical management Hormonal preparations (i.e. levonorgestrel IUS [off-label use]; combined oral contraceptive pill; progestogens, i.e. dienogest; GnRH agonists and antagonists; danazol; aromatase inhibitors, i.e. letrozole; selective progesterone receptor modulators) HIFU or MRgFUS: adverse effects include abdominal pain, skin burns and leg pain secondary to thermal injury Radiological of the sciatic nerve, intestinal perforation and temporary acute renal failure interventions/ UAE: postembolisation syndrome is reported, which consists of pelvic pain, nausea, fever secondary to minimally invasive necrosis and haematoma formation at the femoral artery puncture site. In addition, complications such as those treatment options associated with radiation exposure, haemorrhage, unplanned surgery, infections and an age-related impairment of ovarian reserve have also been reported Different techniques: Surgical management Non-excisional surgical techniques (thermal coagulation of diseased myometrium) (uterus preserving) Partial reduction surgeries (i.e. for diffuse adenomyosis including wedge resections, wedge-shaped uterine wall (adenomyomectomy) removal, modi /f_i ed reductive surgery and transverse H incisions) Complete adenomyotic excision (i.e. for focal adenomyosis including the double- or triple- /f_l ap method and asymmetric dissection method) Hysterectomy: a total hysterectomy is preferred over a subtotal procedure as recurrence of the disease has Surgical management been reported within the cervical stump and rectovaginal septum (non-uterine Endometrial ablation/resection preserving) Uterine rupture (6% [>1% following an adenomyomectomy versus 0.26% following a myomectomy]), silent Postoperative uterine rupture complications Higher incidence of placenta accreta, increta and percreta compared with caesarean sections and myomectomies Asherman’s syndrome Disease recurrence GnRH, gonadotropin-releasing hormone; HIFU, high-intensity focused ultrasound; IUS, intrauterine system; MRgFUS, magnetic resonance- guided focused ultrasound; NSAID, non-steroidal anti-in /f_l ammatory drug; SMM, surgical management of miscarriage; UAE, uterine artery embolisation. 87.14–87.17 ) Figure 87.14 Ultrasound features of adenomyosis. Asymmetry between the anterior and posterior uterine wall and hyperechoic islands (arrow). Figure 87.15 Ultrasound features of adenomyosis. Myometrial cysts (arrows).