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Adenomyosis

Adenomyosis is characterized by the presence of endometrial glands and stroma in the myometrium and is often associated with local myometrial hypertrophy. Endometrial glands and stroma outside the uterus, or including the serosa but not the myometrium.

Histogenesis and Pathology

The most popular theory of the histogenesis of adenomyosis is that the basoendometrium invades the myometrium to give rise to foci of adenomyosis. Uterine trauma at the time of delivery, increased uterine pressure, or chronic endometritis may contribute to this invasion. Alternatively, preliminary evidence suggests that some lesions may be monoclonal and can exhibit the cytogenetic abnormalities seen in myomata. If adenomyosis proves to be clonal.

The normal endomyometrial junction is irregular, with endometrial glands and stroma dipping into the myometrium for a variable distance. Many pathologists define adenomyosis as the presence of endometrial glands and stroma in the myometrium more than 2-3 mm below the endomyometrial junction. The pathologic diagnosis of adenomyosis is highly dependent on the number of sections from the uterine specimen that are processed for analysis.

Microscopically, the glands in adenomyosis are lined by inactive endometria that resemble the glands from the basalis layer. Adenomyosis lesions seldom show a secretory effect, even if the overlying endometrium is secretory. In pregnant women, however, secretory changes and decidual transformation frequently occur. Under estrogen stimulus the glands and stroma can proliferate. Studies have demonstrated the presence of estrogen, progesterone, and androgen receptors in adenomyosis lesions. In some cases there is local myometrial hypertrophy that is exaggerated and completely encircles the adenomyosis lesion, resulting in an adenomyoma.

Numerous epidemiologic studies suggest that adenomyosis is seldom observed before menarche or after the menopause. Most studies report that parous women are at a slightly increased risk for developing adenomyosis.

Symptoms and Signs

The clinical diagnosis of adenomyosis usually is based on the triad of menorrhagia, dysmenorrhea, and a slightly enlarged, "boggy" uterus on physical examination. Most women are between 35 and 50 years.

Treatment

Hysterectomy is the only treatment that clearly is effective in the treatment of adenomyosis. Preliminary studies suggest that hormonal treatments effective in the treatment of myomata also can be used to successfully treat adenomyosis. In a small number of case reports, women with longstanding infertility and adenomyosis were treated successfully with leuprolide acetate depot. Many women with infertility and severe adenomyosis have distortion and partial or complete occlusion of the intramural portion.