{"paper_id":"46fd853e-be27-40c0-a147-3aa4bf6980bc","body_text":"Volume : 4 | Issue : 3 | Mar 2015 ISSN - 2250-1991\n6  | PARIPEX - INDIAN JOURNAL OF RESEARCH\nResearch Paper\nA Clinicopathological Study on Adenomyosis \nUteri\nMedical Science\nDR. RAJAT GUPTA Pathologist, Md Pathplgy Government Hospital Gandhi Nagar, \nJammu\nDr.Deepika Dewan Senior Resident, Department of Community Medicine, GMC,Jam-\nmu.\nKEYWORDS Hysterectomy, Adenomyosis, Menorrhagia.\nABSTRACT\nAdenomyosis is a myometrial lesion which is characterized by the presence of ectopic endometrium within the myometrium \nwith or without hyperplasia of the surrounding myometrium. The study which was carried out from January 2010 to \nDecember 2011 over a period of 2 years to study the clinical profile of all the patients whose hysterectomy specimens showed \nadeno¬myosis. Three hundred and ninety (390) patients were studied. The prevalence of adenomyosis was 24.43%. 86% \nof the patients were seen in the age group of 31-50 years. 94.3% of the patients were multiparous. The dominant symptom \nwas menorrhagia (75.6%), followed by dys¬menorrhoea (33.3%). DUB was clinically suspected in 33.9% of the cases \nfollowed by fibroid (24.6%) and adenomyosis (22.3%). The occurrence of adenomyosis was mostly seen in the age group \nof 31-50 years in the present study, which was contrary to that which was observed in some other stud¬ies, which showed \nthe maximum occurrence after 40 years. The parity and the clinical symptoms correlated with those of other studies.\nINTRODUCTION \nAdenomyosis is a myometrial lesion which is characterized by \nthe presence of an ectopic endometrium within the myome-\ntrium with or without hyperplasia of the surrounding myome-\ntrium. The endometrial tissue should be at least 100x field or \none low power field (about 2.5 mm) deep from the endomy-\nometrial junction The endometrial glands may be inactive or \nhormonally responsive. In some cases, the glands are scant \nor absent and such cases may be mistaken for low-grade en-\ndometrial stromal sarcoma. A majority of the cases are diag-\nnosed following the histological examination of hysterectomy \nspecimens, but the exact prevalence in the ‘normal’ popula-\ntion is unknown. The percentage of hysterectomy specimens \nwhich contain adenomyosis varies from 5–70% [1]. This wide \nvariation may be partly explained by the histological criteria \nwhich is used and/or by the number of tissue blocks which are \nexamined. The specificity of the pre-operative diagnosis which \nis based on the clinical picture is poor, ranging from 2.6–26% \n[2]. A majority of the cases are reported in women who are \naged 40–50 years and there is a positive association with the \nparity also. The patients with adenomyosis present with men-\norrhagia (40–50%), dysmenorrhoea (10–30%) and metrorrha-\ngia (10–12%) and, occasionally, dyspareunia [3, 4, 5].\nMATERIAL AND METHODS\nIn the period from January 2010- December 2011, 1596 hys-\nterectomy specimens were received and studied at the De-\npartment of pathology, GMC Jammu. Adenomyosis was diag-\nnosed when the distance from the endo-myometrial junction \nto the foci of the adenomyosis was more than one low pow-\ner field (Fig. 1). For the study, the paraffin sections of all the \nhysterectomy specimens were examined. 390 patients were \ndiagnosed to be having adenomyosis. The medical records in \nwhich the histopathological report was adenomyosis were re-\nviewed and information regarding age, parity, the chief com-\nplaints, and the clinical diagnosis was obtained. The data was \nentered in simple tables and was analyzed. \nRESULTS\nOf the 390 patients, 46.9% were in the age group of 41-\n50 years, 39.2% were in the age group of 31-40 years and \n10.8% were in the age group of 51-60 years. In the extremes \nof age, the prevalence decreased to 2.1% in the age group \nof 21-30 years and 1.0% were above 60 years of age (Table \n1). 94.3% of the patients were multiparous. A majority of \nthem were of parity 2 and 3. In nulliparous and uniparous \nwomen, the prevalence was 2.6% and 3.1% respectively. In \nwomen with a parity of ≥ 5 also, the prevalence was found \nto be decreased (4.3%)(Table 2). The dominant symptom was \nmenorrhagia (75.6%), followed by dysmenorrhoea (33.3%). \nOnly 8.9% of the patients had chronic pain in the abdomen. \nAdenomyosis was also diagnosed in patients who had com-\nplaints of a mass descending per vagina, post-menopausal \nbleeding and a mass in the abdomen (Table 3). The pre-opera-\ntive clinical diagnosis was dysfunctional uterine bleeding(DUB) \nin 33.9% , fibroid uterus in 24.6%, adenomyosis in 22.3%, \nuterovaginal prolapse in 15.9%, post-menopausal bleeding in \n2.8% and benign ovarian tumours in 0.5% of patients(Table \n4).\nDISCUSSION\nVarious aetiologies have been proposed for the development \nof adenomyosis, including genetic factors [6], increased intra-\nuterine pressure as seen in the multipara, prior uterine surgery \n[7,8], tamoxifen use [9] and hyperprolactinaemia. The true \nprevalence of adenomyosis is still unknown. The prevalence \nof adenomyosis in a study which was done by by Shaikh was \n20.6 % [10] and it was 20.6% in a study which was done \nby Ali [11]. Its incidence was shown to be 26 % in India by \nSharqill et al [12], 24.9% in Italy by Vercellin [13] and 6% in \nWest Indies by Raju et al [14]. In our study, the prevalence was \n24.43%.\nIn a study by Anwar Ali, 73.7% of the patients were found \nto be between 41-50 years of age,16.3% were between 31-\n40 years of age, 1.6% were between 21-30 years of age and \n8.1% were of >50 yrs of age [11]. In Swan’s study, the mean \nage of the patients was 49.5± 3.4 [15]. In a study which was \ndone by Sabin, the percentage of the patients in the age \ngroup of 41-50 years was found to be 70% and those in the \nage group of 31-40 years was found to be 25.5%. Only 2% \nof the patients were diagnosed with adenomyosis between \nthe ages of 21-30 years and 51-60 years [16]. In a study \nwhich was done by Khresiat et al, 94% of the patients were \nfound to be more than 40 years of age [17]. These studies \nwere found to vary from our study in that almost equal num-\n\nVolume : 4 | Issue : 3 | Mar 2015 ISSN - 2250-1991\n7  | PARIPEX - INDIAN JOURNAL OF RESEARCH\nbers of patients were diagnosed with adenomyosis in the age \ngroup of 31-40 years and 41-50 years.\nIn a study by Weiss G et al, 58% of the patients were found \nto have complaints of abnormal vaginal bleeding and 10% \nhad prolapse [15]. In Khreisat’s study, 64.71% of the pa-\ntients had dysmenorrhoea, 70.5% had menorrhagia, 3.92% \nhad post-menopausal bleeding, 74.5% had dyspareunia, and \n62.75% had chronic pelvic pain [17]. But in our study, men-\norrhagia was the predominant symptom in 75.6% of the pa-\ntients and it was dysmenorrhoea in 33.3% of the patients. \nIn our study, adenomyosis was seen in 18.2% of patients \nwith prolapse and in 3.1% of patients with post-menopausal \nbleeding. The menorrhagia may have been due to the dys-\nfunctional contractility of the myometrium in patients with ad-\nenomyosis.\nIn a study which was done by Khreisat, 96% of the patients \nwith adenomyosis had a parity of more than 3 [17]. The max-\nimum occurrence was seen in patients with a mean parity of \n3.8±2.3SD in a study [7] and it was 2.7 ±1.6 in another study \n[8]. In our study, a majority of the patients were of parity 2 \nor 3. This correlated with the hypothesis that pregnancy may \nfacilitate the formation of adenomyosis by allowing the ade-\nnomyotic foci to be included in the myometrium due to the \ninvasive nature of the trophoblasts on the extension of the \nmyometrial fibers. According to Reinhold, the specificity of the \npreoperative diagnosis based on the clinical picture was poor, \nranging from 2.6–26% [2]. In our study, the clinical diagnosis \nwas DUB in 33.9%, fibroid in 24.6% and adenomyosis was \nsuspected in 22.3% of the patients.\nCONCLUSION\nThe prevalence of adenomyosis is found to be 24.43% in \nthis study. Adenomyosis was diagnosed frequently in the age \ngroup of 40-50 years in other studies while in our study wom-\nen in the age group of 31-40 years and 41-50 years were \nequally affected. The data which was obtained from interna-\ntional studies were in consistence with those of our study re-\ngarding the parity and the symptoms of adenomyosis.\nAdenomyosis is not a rare histopathological finding. Due to di-\nagnostic and therapeutic methods which are being developed \nas an alternative to hysterectomy, the clinical effects of ade-\nnomyosis and its association with other gynaecological con-\nditions, adenomyosis appears to be an issue which should be \nmore intensively investigated in the future.\nTABLES\nTABLE1\nAGE DISTRIBUTION OF ADENOMYOSIS UTERI\nAGE NUMBER %AGE\n21-30 8 2.1\n31-40 153 39.2\n41-50 183 46.9\n51-60 42 10.8\n>60 4 1.0\nTOTAL 390 100\nTABLE 2\nPARITY DISTRIBUTION OF ADENOMYOSIS UTERI\nPARITY NUMBER %AGE\n0 10 2.6\n1 12 3.1\n2 145 37.2\n3 160 41.0\n4 46 11.8\n5 17 4.3\nTOTAL 390 100\nTABLE 3\nSYMPTOMS IN PATIENTS WITH ADENOMYOSIS UTERI\n(There is overlap of symptoms)\nSYMPTOMS NUMBER %AGE\nMenorrhagia 295 75.6\nDysmenorrhoea 130 33.3\nPain Lower \nAbdomen 35 8.9\nMass Descending \nPV 71 18.2\nPostmenopausal \nBleeding 12 3.1\nMass Abdomen 3 0.8\nTABLE 4\nCLINICAL DIAGNOSIS\nDIAGNOSIS NUMBER %AGE\nFibroid 96 24.6\nDUB 132 33.9\nAdenomyosis 87 22.3\nPostmenopausal \nBleeding 11 2.8\nUterovaginal \nProlapse 62 15.9\nOvarian Cyst 2 0.5\nTotal 390 100\n(Fig. 1) Ectopic endometrial glands and stroma lying with-\nin myometrium. 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