{"paper_id":"8439a403-410f-45ee-b5c3-4dbedb1cf35b","body_text":"~ 30 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2018; 2(3): 30-33 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2018; 2(3): 30-33 \nReceived: 08-03-2018 \nAccepted: 09-04-2018 \n \nShruthi A \nJunior Resident, College-ESIC \nMedical College and PGIMSR, \nBangalore University- Rajiv \nGhandhi University of health \nSciences Department- OBG, \nKarnataka, India \n \nSreelatha S \nProfessor, College- ESIC Medical \nCollege and PGIMSR, Bangalore, \nUniversity- Rajiv Ghandhi \nUniversity of Health Sciences, \nDepartment- OBG, Karnataka, \nIndia \n \nSatish Kumar \nJunior Resident, College- ESIC \nMedical College and PGIMSR, \nBangalore, University- Rajiv \nGhandhi University of Health \nSciences, Department- OBG, \nKarnataka, India \n \nKavitha BL \nJunior Resident, College- ESIC \nmedical college and PGIMSR, \nBangalore, university- Rajiv \nGhandhi University of health \nsciences, department- OBG, \nKarnataka, India \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorrespondence \nShruthi A \nJunior Resident, College-ESIC \nmedical college and PGIMSR, \nBangalore university- Rajiv \nGhandhi University of health \nsciences department- OBG, \nKarnataka, India \n \nAdenomyosis in patients undergoing hysterectomy for \nleiomyomas: A retrospective study \n \nShruthi A, Sreelatha S, Satish Kumar and Kavitha BL \n \nAbstract \nAim: To identify the prevalence of Adenomyosis in patents who underwent hysterectomy f or fibroid \nuterus, and to correlate patient profile, clinical finding and reproductive characteristics. \nMethodology: This is a retrospective study conducted at ESIC Medical College and PGIMSR, Rajajinagar \nBangalore. Women who underwent abdominal or vagina l hysterectomy for proven uterine leiomyomas on \nultrasonography with or without oophorectomy in a 3 year period from 2013 to 2016 were included in the \nstudy. Retrospectively data was collected from medical records regarding age, parity, presenting \nsymptoms, histopathological report of hysterectomy specimen for evidence of concurrent adenomyosis. \nStatistical analysis of data was carried out using SPSS statistical software. Quantative data were analysed \nwith mean, median and standard deviation. Qualitative da ta (categorical) were analysed with percentages \nand frequencies. \nResults: We had 180 patients who underwent hysterectomy with or without oophorectomy for fibroid \nuterus in our study period. Out of which 108(60%) patients were found to have adenomyosis. Adenomyosis \nwas more commonly seen in patients with older age group than with patients with fibroid alone. The \npatients with concurrent adenomyosis significantly presented with dysmenorrhoea (P -0.001) and pelvic \npain (P-<0.001), also the size of the uterus a t the time of surgery was less than 12week in a significant \npopulation (P -0.243). Reproductive data between the two cohort, showed that significant patients with \nleiomyomas alone were nulliparous (P -0.015) and as parity increased to two or more the patient s were \nprone to have concurrent Adenomyosis (P-0.008). \nConclusion: Our study shows that 60% of patients who underwent hysterectomy for fibroid uterus had \nconcurrent Adenomyosis. Patients with concurrent Adenomyosis more frequently presented with \nDysmenorrhoea and pelvic pain than with patients with fibroid alone. As the parity increased the risk of \nhaving co existing adenomyosi s also increased significantly.  A detail history obtained from the patients \nwith reproductive history along with use of modern non -invasive diagnostic imaging modality like \ntransvaginal ultrasonography, magnetic resonance imaging and nuclear magnetic resonance can aid in the \ndiagnosis of Adenomyosis in patients prior to hysterectomy. \n \nKeywords: Leiomyomas, Adenomyosis, hysterectomy, dysmenorrhoea, pelvic pain, histopathology \n \nIntroduction \nAdenomyosis is a benign uterine condition characterized by the presence of endometrial glands \nand stroma deep in the myometrium. This haphazard location of endometrium deep in the \nmyometrium should be atleast 2.5mm below the endomyometrial junction f or the diagnosis of \nAdenomyosis [1]. Leiomyomas on the other hand are also benign myometrial neoplasms. These \nare monoclonal tumors of the smooth muscle cells of the myometrium and consists of large \namounts of extracellular matrix that contains collagen, fibronectin, proteoglycans and \nsurrounded by a pseudocapsule composed of areolar tissue and compressed muscle fibers [2]. \nThe main symptoms caused by Adenomyosis include abnormal uterine bleeding, \ndysmenorrhoea, chronic pelvic pain and dyspareunia [3]. And those caused by Fibroids include \nheavy menstrual cycles, mass per abdomen, pressure symptoms with bowel and bladder \nsymptoms and dysmenorrhoea. Since both these conditions often co -exist in the same uter us, \nmost of the times it is difficult to attribute the symptom to either condition alone and o verlap \neach other in most cases [4]. \nAlthough the two conditions  co exists the treatment option vary widely depending on the \npredominant condition and the present ing symptom. Fibroids are usually dealt with \nhysterectomy or myomectomy although medical line of treatment include oral contraceptive, \nprogestogens: oral or Intra Uterine Device and recently with nonsurgical alternatives such as \nUterine artery embolization and fibroid ablation [5].  \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology \n~ 31 ~ \nThe treatment options available for adenomyosis is limited due \nto its delayed diagnosis often after hysterectomy retrospectively. \nConservative management with progestogens, endomyometrial \nablation, laparoscopic myometrial electrocoagulation or excision \nis effective in >50% of cases and hysterectomy is needed in only \ndeep seated adenomyosis [6]. \nAdenomyosis was found concomitantly in hysterectomy \nspecimens of those undertaken for fibroid uterus with an \nincidence of 15 -57% [7]. Often the diagnosis of Adenomyosis \nwas made retrospectively from histopathological examination of \nhysterectomy specimen rather than pre operatively. This under \ndiagnosis of Adenomyosis is one of the reasons of treatment \nfailure and increased hysterectomy ra tes in patients with fibroid \nuterus. Thus this study aims to identify the prevalence of \nAdenomyosis in patents who underwent hysterectomy for \nfibroid uterus, and to correlate their clinical finding and \nreproductive characteristics to allow better clinical decision \nmaking regarding alternative to hysterectomy and decrease the \nrisk of treatment failure. \n \nMethodology \nThis is a retrospective study conducted at ESIC Medical College \nand PGIMSR, Rajajinagar Bangalore. Women who underwent \nabdominal or vaginal hyste rectomy for proven uterine \nleiomyomas on ultrasonography with or without oophorectomy \nin a 3 year period from 2013 to 2016 were included in the study. \nRetrospectively data was collected from medical records \nregarding age, parity, presenting symptoms, histo pathological \nreport of hysterectomy specimen for evidence of concurrent \nadenomyosis. Adenomyosis was diagnosis when the distance \nbetween the lower border of the endometrium and the affected \nmyometrial area was over one -half of a low power field \n(2.5mm). The patients in whom hysterectomy was performed for \nAdenomyosis alone were excluded from the study. \nStatistical analysis of data was carried out using SPSS statistical \nsoftware. Quantative data were analysed with mean, median and \nstandard deviation. Qualitat ive data (categorical) were analysed \nwith percentages and frequencies. The significance in difference \nbetween the two groups were assessed with cross tables, \nPearson’s chi square test and Fishers exact test were applied \nwhere ever necessary. \n \nResults \nWe ha d 180 patients who underwent hysterectomy with or \nwithout oophorectomy for fibroid uterus in our study period. Out \nof which 108(60%) patients were found to have adenomyosis \nidentified in histopathological report after hysterectomy. The \npatents were divided  into 2 cohort depending on presence or \nabsence of concurrent adenomyosis and retrospective analysis \nwas carried out. The mean age of patients with leiomyoma alone \nwas 43(SD- 4.2) years and those of leiomyoma and adenomyosis \nwas 45(SD- 4.5) years. \n \nTable 1: Clinical symptoms and uterine size of the cohort \n \n Leiomyoma n(%) Leiomyoma with Adenomyosis n(%) Pa/b (significance) \n1. Menorrhagia/metrorrhagia 23(31.9) 30(27.8) 0.548(NS)a \n2. Dysmenorrhoea 27(37.5) 68(63.0) 0.001(S)a \n3. Pelvic pain 13(18.1) 47(43.5) <0.001(S)a \n4. Uterus size >12weeks 27(37.5) 50(46.3) 0.243(S)a \n5. Pressure symptoms 12(16.7) 2(1.9) <0.001(S)a \n6. Dyspareunia 3(4.2) 5(4.6) 1.000(NS)b \nPa- Pearson’s chi square test. A P value of <0.005 was considered statistically significant difference. \nPb- Fishers test \nS- Significant statistically. \nNS- Not Significant statistically. \n \nThe patients records were analysed for presenting symptoms, \nand we found that patients with concurrent adenomyosis \nsignificantly presented with dysmenorrhoea (P-0.001) and pelvic \npain (P-<0.001). The size of the uterus at the time of surgery \nwas less than 12week in a significant population (P -0.243) \nindirectly indicating that the patients presented early to the clinic \nbecause of the distressing symptoms and surgery was \nundertaken because of symptomatic fibroid. [Table-1] \nThe patients with fibroid alone presented more with a pressure \nsymptoms (P-<0.001) and the size of uterus was more than 12 \nweeks in a significant population. However no difference was \nsee regarding symptoms like menorrha gia, metrorrhagia and \ndyspareunia. [Table-1] \n \n \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology \n~ 32 ~ \nTable 2: Reproductive characteristics of the 2 cohort \n \n Leiomyoma n(%) Leiomyoma with Adenomyosis n(%) Pa \n1. Nulliparity 13(18.1) 07(6.5) 0.015(S)a \n2. Parity >or= 2 38(52.8) 78(72.2) 0.008(S)a \n3. Spontaneous/medical abortions 24(33.3) 35(29.6) 0.599(NS)a \n4. Surgical abortions 6(8.3) 11(10.2) 0.677(NS)a \n5. Caesarean / uterine scar 22(30.6) 29(26.9) 0.589(NS)a \nPa- chi square test of significance, a P value of<0.05 is considered statistically significant. \nS- Significant statistically. \nNS- Not Significant statistically. \n \nFrom the analysis of reproductive data between the two cohort, \nwe found that significant patients with leiomyomas alone were \nnulliparous (P-0.015) and as parity increased to two or more the \npatients were prone to have concurrent Adenomyosis  (P-0.008). \nHowever significant difference were not found with the presence \nof spontaneous or surgical abortion nor the patients who \nunderwent caesarean section or laparotomy with uterine scar \nwith the occurrence of disease between the two cohort. \n \nDiscussion \nIn our current study we found the incidence of Adenomyosis in \nhysterectomy specimen performed in patients in view of fibroid \nuterus was about 60%. As our study is a retrospective study and \nbased on histopathological r eport, the then pathologist reporting \nthe specimen were unaware of the study. Thus there is a fair \nchance of the pathological condition to be over looked and the \nincidence being even more than what this study has concluded. \nThis can be justified according to previous studies by Bird et al. \nwhich states that the possibility of demonstrating Adenomyosis \non HPE is directly proportional to the pathologist awareness of \nthe condition, the number and site  of myometrial sample \nanalysed [8]. \nAdenomyosis was more com monly seen in patients with older \nage group than with patients with fibroid alone and the size of \nthe uterus was significantly less at the time of hysterectomy. \nThese findings goes well with the previous study results by \nTaran FA et al  in 2010  [7, 9]. This could be adenomyosis \ncoexisting with small fibroids which were failed to be picked up \non Transvaginal ultrasonography conducted pre operatively. The \nsymptoms in such fibroids cases can be attributed to either \nFibroids or adenomyosis. Thus by identifying s uch co existing \nadenomyosis with Magnetic resonance imaging and other recent \nimaging modalities, conservative line of management can be \nused with minimal treatment failure before planning \nhysterectomy. \nThe symptoms caused by adenomyosis and fibroids overlap each \nother making it difficult to attribute it to a single condition. \nHowever menorrhagia, dysmenorrhoea and chronic pelvic pain \nis significantly associated with adenomyosis and if present in a \npatient with fibroid uterus should alert the clinician to lo ok for \nconcurrent adenomyosis [9, 10]. This significance was also proven \nin our study. Although there was no significant difference in the \noccurrence of menorrhagia and dyspareunia between the two \ncohort in our study. Many other studies done previously als o \narrived at the same conclusion. A. Graziano et al also reported \nthat 70% of patients with adenomyosis are symptomatic and \nmainly present with menorrhagia, dysmenorrhoea and chronic \npelvic pain, while remaining 30% are asymptomatic [11]. \nOn our analysis o f obstetric history between the 2 cohorts. We \nfound multiparous patients are more prone to develop concurrent \nadenomyosis. Pregnancy might facilitate adenomyotic foci to be \nincluded in myometrium during trophoblastic inva sion of \nplacenta [4, 12]. In addition hyper estrogen state during pregnancy \nalso facilitate development of islands of endometrium at ectopic \nsites including uterine myometrium [13]. Thus as the parity of the \npatients increase also does the risk of adenomyosis. Shretha et \nal, in their study also found a significant increase in \nadenomyosis as the parity increase [10]. \nWe did not find a significant increase in concurrent adenomyosis \nwith prior abortions (spontaneous/surgical) or Caesarean / \nuterine scar. Previously done studies however shows a rise in \nadenomyosis rate in patients who undergo dilatation and \ncurettage, or previous disruption of endomyometrial - \nmyometrial border from surgical incision on  uterus as in \nCaesarean section [14, 15 ]. This deviation in our study may be \nbecause all caesare an were of lower segment with no incision \ninvolving upper segment (as in classical caesarean). A recent \nstudy done in 2012 by Taran FA et al also did not show a rise in \nadenomyosis in patients with prior uterine surgeries [7]. \nThus this study reinforces th e presence of distinct clinical \nfeatures in patients of fibroid uterus with coexisting \nadenomyosis. A detail history obtained from the patients with \nreproductive history along with use of modern non -invasive \ndiagnostic imaging modality like transvaginal ul trasonography, \nmagnetic resonance imaging and nuclear magnetic resonance \ncan aid in the diagnosis of Adenomyosis in patients prior to \nhysterectomy. \nWith early diagnosis of Adenomyosis, the disease can be \nmanaged with medial line alone or with conservative approach \nsuch as uterine artery embolization, endometrial ablation etc. \nAlso by detection of concurrent adenomyosis in patients with \nsmaller fibroid size, medical line of management and be \nexercised with minimal treatment failure and decrease the \nburden of surgery in such group of patients. \n \nConclusion \nOur study shows that 60% of patients who underwent \nhysterectomy for fibroid uterus had concurrent Adenomyosis. \nPatients with concurrent Adenomyosis more frequently \npresented with Dysmenorrhoea and pelvic pain  than with \npatients with fibroid alone. As the parity increased the risk of \nhaving co existing adenomyosi s also increased significantly.  A \ndetail history obtained from the patients with reproductive \nhistory along with use of modern non -invasive diagnostic \nimaging modality like transvaginal ultrasonography, magnetic \nresonance imaging and nuclear magnetic resonance can aid in \nthe diagnosis of Adenomyosis in patients prior to hysterectomy. \n \nReferences \n1. Azziz R . Adenomyosis: Current prespectives. Obstet \nGynecol Clin Nam. 1989; 16:221-35. \n2. Sankaran S, Manyonda IT. Medical management of \nfibroids. Best Pract Res Clin Obstet Gynaecol. 2008;  \n22(4):655-676. \n3. Stewert EA. Uterine fibroids. Lancet. 2001; 357:293-298. \n4. Weiss G, Maseelall P, Schott LL, Brockwell SE, Schocken \n\nInternational Journal of Clinical Obstetrics and Gynaecology \n~ 33 ~ \nM, Johnston JM. 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Obstet Gynecol. \n2000; 95:688-691. \n15. Panganamamula UR, Harmanli OH, Isik -Akbay EF et al. Is \nprior uterine surgery a risk factor of adenomy osis? Obstet \nGynecol. 2004; 104:1034-1038.","source_license":"CC0","license_restricted":false}