{"paper_id":"a062b59f-9c0f-48dd-87cc-3482d5dfcc29","body_text":"- Visibility 1.6k Views\n- Downloads 262 Downloads\n- Permissions\n- CrossMark\n- Citation\nA retrospective analysis of spectrum of presentation of adenomyosis in tertiary centre\n- Author Details:\n-\nRashmi K\n-\nRadhika\n-\nAnitha G S *\n-\nSukanya S\n-\nSavitha C\nAbstract\nIntroduction: Benign invasion of endometrial tissue into the myometrium of uterus is known as adenomyosis. It is found typically between the age of 35-50 years. Prevalence is 6- 39%. Modern imaging techniques, both ultrasound (TAS, TVS) and MRI have made possible, for the first time, a non-invasive identification of adenomyosis.\nAims & Objectives: To analyse the spectrum of presentation of adenomyosis and to determine the accuracy of clinical examination and imaging modalities in the diagnosis.\nMaterials and Methods: It is a retrospective study done at hospitals attached to Bangalore Medical College & Research Institute during august 2016-august 2017. The HPE reports and case records of all the hysterectomy specimens were reviewed. Data regarding age, parity, symptoms, obstetric history, examination, co morbidities, investigation findings, associated pathology and treatment modality were noted. They were tabulated and analysed.\nResults: Out of the 50 patients, 56% were in the age group of 41-50 years. The prevalence of adenomyosis in our study was only 10% in post-menopausal women when compared to the age group 41-50yrs (56%). Multiparous women had 94% incidence of adenomyosis. 26% of women had prior uterine surgeries. 22% of cases had history of infertility in this study. 56% had menstrual disturbances. Dysmenorrhea & Dyspareunia were the next common symptoms. Fibroid was the commonest associated pathology (38%). 34% had hyperplasia of endometrium whereas 66% had no pathology. Imaging picked up only 40% of cases contrary to 36% of clinical diagnosis and was raised to 66% with gross examination of specimen and 100% with HPE.\nConclusion: Adenomyosis has a varied presentation. Ultrasound fails to diagnose all the cases. Clinical examination is a better modality. Associated pathology may mask the clinical features of adenomyosis, and diagnosis may be missed. Presently HPE is probably the gold standard for diagnosing adenomyosis.\nIntroduction\nBenign invasion of endometrial tissue into the myometrium of uterus is known as Adenomyosis. It is found typically between the age of 35-50 years.[1] Prevalence is 6- 39%. This wide range is due to the different diagnostic methods used.[2] Microscopically, adenomyosis exhibits ectopic, non-neoplastic, endometrial glands and stroma surrounded by the hypertrophic and hyperplastic myometrium.[3]\n|\nSymptoms |\nSigns |\n|\n35% of patients are Asymptomatic |\nP/A- uterus just palpable |\n|\n30% Dysmenorrhoea |\nP/V- Halban’s sign- |\n|\nMenorrhagia |\n(during cycles) - bulky, soft, diffuse boggy and tender |\n|\n15% Dyspareunia |\n|\n|\n15- 20% chronic pelvic pan |\n|\nDiagnosis\nModern imaging techniques, both ultrasound (TAS, TVS) and MRI have made possible, for the first time, a non-invasive identification of adenomyosis.[4]\n|\nTVS------ Sensitivity—65- 68% |\nSpecificity- 65-98% |\n|\nMRI------- Sensitivity—70- 78% |\nSpecificity- 86 -93% |\nAims and Objectives\nTo analyse the spectrum of presentation of adenomyosis.\nTo determine the accuracy of clinical examination and imaging modalities in the diagnosis.\nMaterial and Methods\nIt is a retrospective study done at hospitals attached to Bangalore Medical College & Research Institute during august 2016-august 2017.\nThe HPE reports of all the hysterectomy specimens were reviewed and was found that 50 cases showed evidence of adenomyosis.\nCase records were reviewed.\nData regarding age, parity, symptoms, obstetric history, examination, co morbidities, investigation findings, associated pathology and treatment modality were noted.\nThey were tabulated and analysed with chi square test.\n|\nTAH |\n16 (32%) |\n|\nTAH + BSO |\n25 (50%) |\n|\nVH |\n1 (2%) |\n|\nTAH + RSO |\n3 (6%) |\n|\nNDVH |\n4 (8%) |\n|\nTAH + LSO |\n1 (2%) |\n90% of the cases underwent abdominal hysterectomy. 2% underwent vaginal hysterectomy and 2% NDVH.\nResults\n|\n<30 |\nNIL |\n|\n30-40 |\n14 cases (28%) |\n|\n41-50 |\n28 cases (56%) |\n|\n>50 |\n4 cases (8%) |\n|\nPostmenopausal |\n4 cases (8%) |\nMajority of patients were in 40-50 years of age. 28 cases were in the age group of 30-40 years.\n4 patients were postmenopausal. 4 patients were more than 50yrs of age. None were less than 30years.\n|\nMultiparous |\n47 cases (94%) |\n|\nNulligravida |\n2 cases (4%) |\n|\nNulliparous |\n1 case (2%) |\n94% were multigravida while 4% were nulligravida. The least incidence was in nullipara with 2%.\n|\n40-60kg |\n43 cases (86%) |\n|\n>60kg |\n7 cases (14%) |\nMajority of the cases were between 40- 60kgs. 7 patients are of weight more than 60kg.\nPresenting symptoms\nThere was varied presentation of complaints with menstrual disturbances being the most common.\n|\nHeavy menstrual bleeding |\n5 cases (10%) |\n|\nIncreased frequency of cycles |\n10cases (20%) |\n|\nIntermenstural bleeding |\n3 cases (6%) |\n|\nContinuous bleeding PV |\n4 cases (8%) |\n|\nDecreased frequency with menorrhagia |\n3 cases (6%) |\n|\nPost menopausal bleeding |\n1 case (2%) |\n|\nAmenorrhoea f/b menorrhagia |\n2 cases (4%) |\n|\nPost coital bleeding |\n1 case (2%) |\n|\nSpotting PV |\n1 case (2%) |\n|\nCongestive dysmenorrhea |\n3 (6%) |\n|\nSpasmodic dysmenorrhea |\n4 (8%) |\n|\nContinuous pain |\n6 (12%) |\n|\nDyspareunia |\n4 (8%) |\n|\nRetention of urine |\n1 (2%) |\n|\nIncomplete voiding of urine |\n1 (2%) |\n|\nMass per vaginal |\n2 (4%) |\n|\nAbdominal distension |\n1 (2%) |\nAmong the menstrual complaints, increasing frequency of menstrual cycles was the most common followed by heavy menstrual bleeding.\nPain was another complaint which affected the lifestyle of patients. Most of the patients complained of continuous pain. The second most common type was dyspareunia and spasmodic dysmenorrhea.\nHistory of infertility was present in 11 cases out of 50 cases (22%).\nAge of menarche- majority of patients had menarche after 12 years with no evidence of prolonged oestrogen stimulation.\nMost of them presented within 6 months of duration of illness- 58%.\nPrevious history of dilatation & curettage present in 13 cases out of 50 cases (26%).\nHistory of previous operative procedures.\n|\nOvarian cystectomy |\n1 (2%) |\n|\nDiagnostic lap |\n1 (2%) |\n|\nMyomectomy |\n1 (2%) |\n|\nNormal delivery |\n32 (64%) |\n|\nPrevious 1 section |\n8 (16%) |\n|\nPrevious 2 section |\n7 (14%) |\n|\nTubectomy |\nLTO- 16 (32%) BAT-18 (36%) 16 (32%) cases- non tubectomised |\n|\n<3 months |\n14 (28%) |\n|\n3-6 months |\n15 (30%) |\n|\n7m-1yr |\n7 (14%) |\n|\n1yr-2yr |\n11 (22%) |\n|\n>2yr |\n3 (6%) |\n14 patients had recent history of onset of symptoms from 3 months. Maximum patients had symptoms from one year. Very few of them had from 2 years.\n|\nEndometrium |\n|\n|\nSecretory |\n13 (26%) |\n|\nProliferative |\n20 (40%) |\n|\nHyperplastic |\n17 (34%) |\nThe most common type of endometrial histopathology was proliferative followed by hyperplastic. This indicates the role of oestrogen in the pathophysiology of adenomyosis.\nOther associated pathology\n|\nSimple cystic hyperplasia without atypia |\n13 (26%) |\n|\nSecretory phase of endometrium |\n11 (22%) |\n|\nProliferative phase of endometrium |\n13 (26%) |\n|\nPolypoidal endometrium |\n3 (6%) |\n|\nSenile cystic atrophy |\n3 (6%) |\n|\nNon secretory endometrium |\n2 (4%) |\n|\nBasal endometrium with superficial adenomyosis |\n4 (8%) |\n|\nShedding endometrium |\n1 (2%) |\nMost of the endometrial reports were normal. 13 patients had simple cystic hyperplasia without atypia.\n|\nAdenomyosis + TO mass |\n1 (2%) |\n|\nAdenomyosis + fibroid + ovarian cyst |\n3 (6%) |\n|\nAdenomyosis + fibroid |\n12 (24%) |\n|\nAdenomyosis + fibroid + polyp |\n3 (6%) |\n|\nAdenomyosis |\n21 (42%) |\n|\nAdenomyosis + ovarian cyst |\n5 (10%) |\n|\nAdenomyosis + polyp |\n5 (10%) |\nMajority patients had other associated pathology along with adenomyosis like fibroid, polyp, ovarian cyst. 21 patients were found to have only adenomyosis.\n|\nCervicle fibroid |\n1(2%) |\n|\nCervical polyp |\n1(2%) |\n|\nAdenomyosis |\n18(36%) |\n|\nPID |\n8(16%) |\n|\nFibroid |\n17(34%) |\n|\nAUB(o) |\n6(12%) |\n|\nCA endometrium |\n1(2%) |\nIn 36% of cases, clinical diagnosis of adenomyosis was made. In the rest, the co- existing pathology was adenomyosis, but primary pathology was as mentioned above.\n|\nUt normal size |\n3(6%) |\n|\nUt normal with ovarian cyst |\n6(12%) |\n|\nUt bulky |\n6(12%) |\n|\nFibroid |\n13(26%) |\n|\nFibroid + adenomyosis |\n5 (10%) |\n|\nAdenomyosis |\n14(28%) |\n|\nCA endometrium |\n1(2%) |\n|\nFibroid + ovarian cyst |\n1(2%) |\n|\nFibroid + ovarian cyst + adenomyosis |\n1(2%) |\n28% were reported as normal uterus\nAdenomyosis was picked up in 40% of cases and in the rest Adenomyosis was not reported\n|\nClinically |\n18(36%) |\n|\nUSG |\n20(40%) |\n|\nGross |\n33(66%) |\n|\nHPE |\n50(100%) |\nThe most reliable method of diagnosis of adenomyosis was by histopathological examination of the specimen while clinical diagnosis has the least sensitivity of diagnosis of adenomyosis.\nDiscussion\nOut of the 50 patients, 56% were in the age group of 41-50 years, which is the usual age of occurrence as similarly found in Bird et al. study.[5] The prevalence of adenomyosis in our study was only 10% in post-menopausal women when compared to the age group 41-50yrs (56%). This indicates adenomyosis regresses after menopause but remains detectable. Kitawaki et al., conducted a similar study showing diagnosis of adenomyosis in post-menopausal women.[6] In our study, multiparous women had 94% incidence of adenomyosis in correlation with high incidence in Wallwiener et al. study.[7] Harmanli O H et al., study stated that prior uterine surgeries could be a risk factor for adenomyosis. In our study only 26% women had this history.[8] There is no evidence of adenomyosis directly causing infertility. 22% of cases had history of infertility in this study. Chapron et al., also showed less correlation.[9] Symptom wise, 56% had menstrual disturbances which were also seen in Vercellin e al., study.[10] Dysmenorrhea & Dyspareunia were the next common symptoms. Fibroid was the commonest associated pathology (38%). Vercillin et al., study also had the same pathology as commonest.[11] 34% had hyperplasia of endometrium whereas 66% had no pathology. Similar results were seen in Cullen et al., study[12] showing that no hyperplasia was present as there was absence of prolonged oestrogen exposure.\nImaging picked up only 40% of cases contrary to 36% of clinical diagnosis and was raised to 66% with gross examination of specimen and 100% with HPE. This shows that a good gynaecologist may suspect adenomyosis on clinical basis, stated Aziz et al., as he found similar outcome in his study.[2]\nConclusion\nAdenomyosis has a varied presentation. Ultrasound fails to diagnose all the cases. Clinical examination is a better modality. Associated pathology may mask the clinical features of adenomyosis, and diagnosis may be missed. Presently HPE is probably the gold standard for diagnosing adenomyosis.\nProspects\nA prospective study needs to be conducted. Pre op myometrial biopsy may be an option in the diagnosis. Other imaging modalities like MRI need to be evaluated. Hysterectomy audit to be done. Severity of adenomyosis could be related to the symptom complex.\nSource of Funding\nNone.\nConflict of Interest\nThe authors declare that there is no conflict of interest.\nReferences\n- Brosens I, SG, Habiba M, Benagiano G. Uterine Cystic Adenomyosis: A Disease of Younger Women. J Pediatr Adolesc Gynecol. 2015;28(6):420-6. [Google Scholar]\n- Azziz R. Adenomyosis: Current perspectives. Obstet Gynecol Clin North Am. 1989;16:221-35. [Google Scholar]\n- Shrestha A. adenomyosis at hyterectomy: prevalence, patient characteristics, clinical profile and histopathological findings. Kathmandu Univ Med J(KUMJ). 2012;10(37). [Google Scholar]\n- Champaneria R, Abedin P, Daniels J, Balogun M, Khan K. Ultrasound scan and magnetic resonance imaging for the diagnosis of adenomyosis: systematic review comparing test accuracy. Acta Obstet Gynecol Scand. 2010;89(11):1374-84. [Google Scholar]\n- Bird C, McElin T, Manalo-Estrella P. The elusive adenomyosis of the uterus—revisited. 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Endocrinology: Gonadotrophins and prolactin rise after bilateral oophorectomy for benign conditions. Hum Reprod. 1995;10:2277-9. [Google Scholar]\n- Cullen T. The distribution of adenomyomata containing uterine mucosa. Arch Surg. 1920;1(2):215-83. [Google Scholar]\nHow to Cite This Article\nVancouver\nK R, Radhika , S AG, S S, C S. A retrospective analysis of spectrum of presentation of adenomyosis in tertiary centre [Internet]. Indian J Obstet Gynecol Res. 2021 [cited 2026 Jun 07];8(1):77-81. Available from: https://doi.org/10.18231/j.ijogr.2021.015\nAPA\nK, R., Radhika, , S, A. G., S, S., C, S. (2021). A retrospective analysis of spectrum of presentation of adenomyosis in tertiary centre. Indian Journal of Obstetrics and Gynecology Research, 8(1), 77-81. https://doi.org/10.18231/j.ijogr.2021.015\nMLA\nK, Rashmi, Radhika, , S, Anitha G, S, Sukanya, C, Savitha. \"A retrospective analysis of spectrum of presentation of adenomyosis in tertiary centre.\" Indian J Obstet Gynecol Res, vol. 8, no. 1, 2021, pp. 77-81. https://doi.org/10.18231/j.ijogr.2021.015\nChicago\nK, R., Radhika, , S, A. G., S, S., C, S.. \"A retrospective analysis of spectrum of presentation of adenomyosis in tertiary centre.\" Indian J Obstet Gynecol Res 8, no. 1 (2021): 77-81. https://doi.org/10.18231/j.ijogr.2021.015","source_license":"CC0","license_restricted":false}