{"paper_id":"c53217be-6f3d-4718-997e-77b453cfb033","body_text":"~ 411 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2021; 5(1): 411-415 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2021; 5(1): 411-415 \nReceived: 07-11-2020 \nAccepted: 13-12-2020 \n \nBoubacar Siddi Diallo \nUniversity Department of Gynecology \nObstetrics, Donka National Hospital, Conakry \nGuinea \n \nAbdoulaye Sylla \nUniversity Department of Anatomy \nPathology, Donka National Hospital, Conakry \nGuinea \n \nIbrahima Conte \nUniversity Department of Gynecology \nObstetrics, Ignace Deen National Hospital, \nConakry Guinea \n \nBoubacar Alpha Diallo \nUniversity Department of Gynecology \nObstetrics, Donka National Hospital, Conakry \nGuinea \n \nDiallo Yaya \nUniversity Department of Gynecology \nObstetrics, Ignace Deen National Hospital, \nConakry Guinea \n \nKK Bah \nUniversity Department of Anatomy \nPathology, Donka National Hospital, Conakry \nGuinea \n \nIbrahima Sory Balde \nUniversity Department of Gynecology \nObstetrics, Ignace Deen National Hospital, \nConakry Guinea \n \nMoussa Koulibaly \nUniversity Department of Anatomy \nPathology, Donka National Hospital, Conakry \nGuinea \n \nTelly SY \nUniversity Department of Gynecology \nObstetrics, Ignace Deen National Hospital, \nConakry Guinea \n \nYolande Hyjazi  \nUniversity Department of Gynecology \nObstetrics, Donka National Hospital, Conakry \nGuinea \n \nNamory Keita \nUniversity Department of Gynecology \nObstetrics, Donka National Hospital, Conakry \nGuinea \n \n \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nBoubacar Siddi Diallo \nUniversity Department of \nGynecology Obstetrics, Donka \nNational Hospital, Conakry Guinea \n \nGenital endometrioses: frequency and anatomo-\nhistoclinic aspects at Conakry University Teaching \nHospital Guinee \n \nBoubacar Siddi Diallo, Abdoulaye Sylla, Ibrahima  Conte, Boubacar Alpha \nDiallo, Diallo Yaya , K K Bah, Ibrahima Sory Balde,  Moussa Koulibal y, \nTelly SY, Yolande Hyjazi and Namory Keita \n \nDOI: https://doi.org/10.33545/gynae.2021.v5.i1g.846 \n \nAbstract \nObjectives: Calculate the frequency of genital endometriosis, describe the epidemiological profile and \ndescribe the anatomo -histoclinical aspects of genital endometriosis at the Conakry University teaching \nHospital. \nMethodology: this was a retrospective descriptive study lasting 10 years, from January 1, 2008 to \nDecember 31, 2018. It concerned all cases of lesions of the female genital system, the which documents \nwere examined in the anatomo -pathological laborato ry. It concerned all cases of lesions of the female \ngenital system whose parts were examined in the anatomo -pathological laboratory. The limitations or \nconstraints of the study were the absence of certain information on the anatomopathological examination \nrequest forms and the absence of imaging results (ultrasound, MRI). We carried out an exhaustive \nexamination of the data available in the registers of the anatomo -pathologies service of the Conakry \nUniversity Teaching Hospital. \nResults: The frequency of ge nital endometriosis was 13.09% (n = 111) among benign genital pathologies \n(n = 737). Female genital endometriosis cases represented 81.02% followed by digestive ones 9, 48%. The \nepidemiological profile was that of a woman in the 30 -39 age group (33.10%), h ousewife (45.54%), pauci \ngesture (26.67%), nulliparous (36%). The reasons for consultation are dominated by dysmenorrhea \n(54.05%) followed by menometrorrhagia (48.65%). The main presumptive clinical diagnoses were ovarian \ncysts (30%) and uterine myoma (27. 027%). The samples represented by the operative parts constituted the \nbulk of the samples examined (89.19%). The uterine endometriosis topography was the highest (53.15%) \nfollowed by ovarian one (35.14%). The cases of endometriosis with a firm consistency were the most \nobserved at 48.65% followed by cases with a soft consistency (16.22%). The cases of genital endometriosis \nof homogeneous consistency and reddish appearance represented 44.14% followed by whitish cases \n(27.03%). Endometriosis with heterologous  elements represented 37.84% followed by cases without \nassociated changes 24.32%. Endometriosis lesions with a mono focal location were the most represented \n63.06%. The histological position in the utero -cervical locations was deep in 49.21% followed by th e \nsuperficial location in 26.98%. Endometriosis cases without associated lesions represented 55.86 followed \nby cases associating inflammatory lesions 18.02%. \nConclusion: Endometriosis is a benign lesion affecting all segments of the female genital tract. I t \nconstitutes a polymorphic lesion in its non-specific symptomatology. It represents an affection of the young \nwoman in full genital activity which can compromise her fertility. The diagnosis of deep forms is complex \ninvolving clinical, imaging (ultrasound and magnetic resonance imaging) which must always be confirmed \nby pathological examination. \n \nKeywords: Genital endometriosis, frequency, anatomo-histoclinical aspects \n \nIntroduction  \nFemale genital endometriosis is one of the affections of women characteri zed by ectopia of the \nendometrial mucosa outside its usual site. These lesions are benign, organic, but can cause \nfemale infertility [1]. Their frequency is difficult to determine as a large number of these \nconditions remain asymptomatic [2]. They can affect all ages of life, but with a high frequency in \nwomen with full genital activity between the 3rd and 5th decade of life [3]. \nTheir prevalence is generally a function of the site of localization. Their prevalence in \nhysterectomy series is also very variab le, from 10 to 33% [2]. It is difficult to extrapolate to \ninfertile women, these prevalences being determined in the series of hysterectomy performed [2].  \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 412 ~ \nAll organs of the female genital system can be affected but with \na variable frequency depending on  the topography according to \nthe authors. Uterine involvement is most frequently encountered \non hysterectomy and autopsy specimens. Tubo -ovarian \ninvolvement is the most common in certain gynecological \nstatistics [4]. Multiparity is the main risk factor for  adenomyosis. \nTobacco, the intrauterine device (IUD), oral contraception, a \nhistory of cesarean section or curettage do not constitute a risk \nfactor for adenomyosis [5]. Although they constitute a benign \nuterine pathology, but they can compromise the obste trical \nfuture of the woman or cause other serious or fatal organic \nlesions of the genital tract (Cancer). Their diagnosis is often \ncomplex due to the many asymptomatic forms and the absence \nof pathognomonic symptoms in these conditions [6]. Their \ndiagnosis is based on clinical examination, imaging (ultrasound, \nMRI) but always confirmed by pathological examination of the \noperating part [2]. The objectives of this study were to calculate \nthe frequency of genital endometriosis, describe the \nepidemiological pro file and describe the anatomo -histoclinical \naspects of these genital endometriosis at the Conakry University \nTeaching Hospital. \n \nMethodology \nThis was a descriptive retrospective study lasting 10 years, from \nJanuary 1, 2008 to December 31, 2018. It concerne d all cases of \nlesions of the female genital system, with its parts examined in \nthe anatomo -pathological laboratory. It concerned all cases of \nlesions of the female genital system whose parts were examined \nin the anatomo -pathological laboratory. All cases of lesions of \nthe female genitalia diagnosis that had been ruled out \nhistologically were excluded. The limitations or constraints of \nthe study were the absence of certain information on the \nanatomopathological examination request form and the absence \nof im aging results (ultrasound, MRI). We carried out an \nexhaustive review of the available data in the registers of the \nanatomo-pathologies service of Conakry University teaching \nHospital. The variables studied were epidemiological \n(frequency, anatomical locati on, age, pregnancy, parity, socio -\nprofessional categories), clinical (reasons for consultation, \npresumptive clinical diagnosis), anatomopathological: \nmacroscopic (type of sample, topography, appearance, \nassociated rearrangements, consistency of the nodule)  and \nhistological (number of the nodule, associated lesions, \nhistological position in utero-cervical locations). \n \nResults \nI-1. Frequency: The frequency of genital endometriosis was \n13.09% (n = 111) among benign genital pathologies (n = 737). . \n \n \n \nI-2. Anatomical location : cases of endometriosis at female \ngenital locations represented 81.02% followed b y digestive \ncases 9.48%.  \n \n \nLocation Number Parentages \nGenital 111 81,02 \nDigestive 13 9,48 \nUrinary 6 4,37 \nCutaneous-mucosa 7 5,10 \nTotal 137 100 \n \nII. The epidemiological profile \n1. Age: the age group of 30 -39 years was the most concerned \n(33.10%) followed by that of 40 -49 years, 27 cases (25, \n71%). It is followed by the age group of 40 -49 years, 27 \ncases (25, 714%), then the age groups of 50 -59 years and  \n60-69 years, 11 cases of each, or 10, 48%. The average age \nwas 34.71 years with extremes of 13 and 64 years. \n2. Gesture: Pauci gestures were the most represented \n(26.67%) followed by nulligestes (25.33%) and then \nprimigestes (18.67%). \n3. Parity: The nulliparas constituted the majority of the cases \nobserved (35.13%) followed by first -time mothers \n(25.22%). \n4. Socio-professional categories: Housewives were the most \nconcerned (45.54%) followed by civil servants (30.69%). \n \nIII. Clinical \na) Reasons for consultation : Dysmen orrhea were the main \nreasons for consultation (54.05%) followed by \nmenometrorrhagia (48.65%). \nb) Presumptive clinical diagnosis : The main presumptive \nclinical diagnoses were ovarian cysts (30%) and uterine \nmyoma (27.027%). \n \nIV. Anatomo-pathology \nA. Macroscopy \n The type of sample : The samples represented by the \noperative documents constituted the bulk of the samples \nexamined (89.19%). \n Topography: The topography of endometriosis at uterine \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 413 ~ \nlocation was the highest (53.15%) followed by ovarian one \n(35.14%). \n Appearance: The cases of genital endometriosis of \nhomogeneous consistency and reddish appearance \naccounted for 49 44.14% followed by whitish cases 30 \ncases (27.03%). \n Associated rearrangements:  Endometriosis with \nheterologous elements represented 37.84%, followed by  \ncases without associated rearrangements 24.32% then cases \nof necrotic rearrangements 18.02%. \n The consistency of the nodule: The cases of endometriosis \nwith a firm consistency were the most observed, ie 48.65%, \nfollowed by cases with a soft consistency (16 .22%) then \ncases with a renitent consistency 16 cases (14.41%). \n \nB. Histology \n The number of the nodule : Endometriosis lesions with a \nmono focal location were the most represented 63.06%. \n Associated lesions: Endometriosis cases without associated \nlesions repre sented 55.86 followed by cases associating \ninflammatory lesions 18.02%.  \n \nAssociates lesions Number Parentage \nHyperplasia 16 14,41 \nInflammatory lesions 20 18,02 \nUterine myoma 19 17,12 \nWithout Associates Lesions 62 55,86 \nTumor 5 4,50 \nNoboth's eggs 10 9,01 \n \n The histological position in the utero -cervical locations: \nLesions of adenomyosis or uterine endometriosis of \nassociated anatomical position, that is to say superficial and \ndeep in relation to the endometrium, represented 49.21% \nfollowed by locations shallow 26.98%. \n \nDiscussion \nI-1. Frequency 1: The frequency of genital endometriosis was \n13.09% (n = 111) among benign genital pathologies (n = 737). \nOur observation is similar to that reported by C. DUPAS et Coll. \n[7], Jondet Michel [8] and Daraï E. and Coll. [9] ie 9%, 12% and \n13% respectively. On the other hand, Boutet Gerard and Coll. \n[10] reported that the exact frequency of adenomyosis is \nunknown, as there are many asymptomatic forms diagnosed \nduring routine autopsy. It is found in 7 -77% of hysterec tomy \nspecimens. \n \nI-2. Anatomical location : cases of endometriosis at female \ngenital locations represented 81.02% followed by digestive \ncases 9.48%. DARAÏ E. and Coll. [9] reported that the forms \nwith digestive localization were 12%. \n \nII. The epidemiological profile: \n1. Age: the age group of 30 -39 years was the most concerned \n(33.10%) followed by that of 40 -49 years, 27 cases (25, \n71%). It is followed by the group age 40 -49 years, 27 cases \n(25, 714%). Then in the age groups of 50 -59 years and 60 -\n69 years, 11 ca ses each, or 10.48%. This result shows that \nendometriosis constitutes a benign pathology of the \nendometrium that could be encountered at any age, but with \na high frequency in women in full genital activity. This \nresult is comparable to that found by BEN AI SSIA \nNIZAR.etColl. [11] with a frequency peak between 40 and 50 \nyears. \n2. Gesture: Pauci gestures were the most represented \n(26.67%) followed by nulligestes (25.33%) and then \nprimigestes (18.67%). PANEL P. et al. [6] reported in their \nseries that endometriosi s is often highlighted in women of \nchildbearing age, with a peak in frequency between 30 -40 \nyears. The same authors have reported that the increased \ntime between the age of the first menstruation and \npregnancy is a risk factor for endometriosis. \n3. Parity: Th e nulliparas constituted the majority of the \nobserved cases (35.13%) followed by first -time mothers \n(25.22%). This result is lower than that reported by \nCAMAGNA OLIVIER et Coll. [12] or 77% in nulliparas. On \nthe other hand BEN AISSIA NIZAR. Et Coll. [11] found in \ntheir study that adenomyosis mainly affects the multiparous \n74%. \n4. Socio-professional categories: Housewives were the most \nconcerned (45.54%) followed by civil servants (30.69%). \n \nIII. Clinic \na) Reasons for consultation : Dysmenorrhea were the main \nreasons for consultation (54.05%) followed by \nmenometrorrhagia (48.65%). This result is lower than that found \nby Camagna Olivier et Coll. [12] or 82.5% cases of \ndysmenorrhea. On the other hand BEN AISSIA NIZAR. et al. \n[11] and Boutet Gerard and Coll. [10] found 71% and 50% cases of \nmenometrorrhagia, respectively. \nb) Presumptive clinical diagnosis:  The main presumptive \nclinical diagnoses were ovarian cysts (30%) and uterine myoma \n(27.027%). C. Dupas. and Coll. [7] in their series reported that \nthe diagnosis of  endometriosis is most often made in women of \nchildbearing age but it can be difficult to establish, due to the \ndiversity of symptoms and diagnostic difficulties. In fact, there \nis no simple examination to confirm the diagnosis and it is only \nthe observati on of ectopic endometrial tissue by pathological \nexamination on a biopsy under laparoscopy or an operative \nspecimen to confirm the diagnosis with certainty. The other \nclinical and para clinical examinations are only times evoking \nthe diagnosis without conf irming it. G. Chene and Coll. [2] \nindicates that the diagnosis of endometriosis must be confirmed \nby a pathological examination, in practice, a biopsy of the lesion \ndiagnosed during laparoscopy. \n \nIV. Anatomo-Pathology \nA. Macroscopy \n The type of sample : The sam ples represented by the \noperative documents constituted the bulk of the samples \nexamined (89.19%). KDOUS M. et al . [5] reported that in \ncases of hysterectomies for various reasons (excluding \nprolapse), histological study of the surgical specimen \nrevealed t he presence of adenomyosis in 14.85%. G. \nCHENE et al . [2] who in their study affirms that the \ndiagnosis of endometriotic lesions is easy to study on the \norgan part than on diagnostic biopsies. This allows a \nclinical-histological correlation study to be car ried out in \norder to determine the specificity and diagnostic sensitivity. \nEndometriosis lesions are rarely evoked or confirmed on a \ndiagnostic biopsy specimen, especially endometrial ones. \nThis will always raise doubts about the diagnosis. To better \nconfirm these endometriosis lesions and assess the \nassociated lesions, surgical specimens seem to be the best \nindicated. This observation is classic, it is similar to that of \nother authors because endometriosis is a polymorphic lesion \nthat can be multifocal. \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 414 ~ \n Topography: The topography of endometriosis at uterine \nlocation was highest (53.15%) followed by ovarian one \n(35.14%). This observation is classic because the location of \nendometriosis called adenomyosis is the main location. This \nlocalization is often assoc iated with smooth muscle \nhyperplasia of the myometrium, hence the name \nadenomyomatosis. BRICOU. A. et al . [1] reported in their \nstudy that there is a distribution asymmetry between the \nright and left hemi -pelvis. The left hemi -pelvis is more \naffected than the right, regardless of the types of \nendometriotic lesions (superficial, cystic, ovarian and deep). \nSuperficial lesions are predominant in the left hemi cavity \ncompared to the right. Endometria are most often located on \nthe left ovary. \n Appearance: The cas es of genital endometriosis of \nhomogeneous consistency and reddish appearance \nrepresented 49 44.14% followed by cases with a whitish \nappearance 30 cases (27.03%). This observation shows that \nthe endometriotic lesions are benign lesions which vary in \nappearance depending on the organ which is the site of the \nlesion and the functional nature of the lesion. This statement \nis similar to that of JONDET MICHEL [8] who in his study \nmentioned that the macroscopic aspects depend on the \norgan and the age of the lesio n. These aspects make it \npossible to differentiate between red or bluish punctiform \nlesions, classically corresponding to endometriosis of recent \nformation, then the whitish forms correspond to the oldest \nlesions. The lesions can take on the form of nodule s or \ncysts, the most advanced form being represented by \nendometriotic cysts of sometimes respectable size (10 cm in \ndiameter or even more), with “chocolate or tar” liquid \ncontent. Adhesions can quite frequently be associated with \nthese different lesions. \n Associated rearrangements : Endometriosis with \nheterologous elements represented 37.84%, followed by \ncases without associated rearrangements 24.32% then cases \nof necrotic rearrangements 18.02%. This observation shows \nthat endometriosis lesions are rarely hom ogeneous; they are \nmost often associated with heterologous lesions which are \nthe functional activity of endometriosis. It joins that of \nJONDET MICHEL [8] who in his study reported that the \npresence of heterologous elements within endometriotic \nlesions are classic. Bleeding within foci of endometriosis, \nconcomitant with menstruation, results in hemorrhagic \nsuffisions in the cytogenic chorion and in the glandular \nlumen and is accompanied by a predominantly macro -\nphasic inflammatory reaction, this would explai n the \nnecrotic lesions. \n The consistency of the nodule: The cases of endometriosis \nwith a firm consistency were the most observed, ie 48.65%, \nfollowed by cases with a soft consistency (16.22%) then \ncases with a renitent consistency 16 cases (14.41%). This \nobservation is classic because most of our collected cases \nwere uterine. The endometriotic localization of the uterus \npromotes hypertonia of the uterine wall, which strengthens \nthe firmness of the endometriotic nodule. The endometriotic \nlesions of ovarian l ocalization if they are functional favor \nthe formation of cysts with hemorrhagic fluid content giving \na renitent consistency. Our study joins that of JONDET \nMICHEL [8] who reported in his study that the consistency \nof the endometriotic nodule depends on th e site or tissue \nlocation. The uterine localization gives a firm appearance \nsometimes hard, poorly limited, while the tubo -ovarian one \ngives a renitent or soft blood fluid collection. \n \nB. Histology \n The number of the nodule : Endometriosis lesions with a \nmono f ocal location were the most represented 63.06%. \nThis shows that the locations of genital endometriosis can \nbe single or multiple but are difficult to assess because some \nendometriosis lesions can be non -functional, that is to say \nwithout clinical expressio n. Our result is contrary to those \nreported by DEFFIEUX X. et al. [13] and by FERNANDEZ \nH. [14] who in their respective studies affirm that \nadenomyosis with multifocal or diffuse localizations is the \nmost frequent. \n Associated lesions: Endometriosis cases w ithout associated \nlesions represented 55.86 followed by cases associating \ninflammatory lesions 18.02% then cases associating uterine \nleiomyoma 17.12%. This observation shows that \nendometriosis lesions may be associated with other benign \nor malignant lesion s of a tumor or dystrophic nature. It is \nclassic and joins that of other authors: BEN AISSIA NIZAR \net Coll. [11] reported in their series that adenomyosis is rarely \nisolated, it is associated with fibromyoma in 62% of cases. \nKDOUS M. and Coll. [5] show in their series that \nadenomyosis on an operative specimen can be associated \nwith leiomyomas in 32.18% of cases, endometrial \nhyperplasia in 13.79%, polyps in 5.74%, and atrophy in \n3.44%. \n The histological position in the utero -cervical locations: \nLesions of ade nomyosis or uterine endometriosis of \nassociated anatomical position, that is to say superficial and \ndeep in relation to the endometrium, represented 49.21% \nfollowed by locations shallow 26.98%. This observation \nshows that lesions of uterine endometriosis o r adenomyosis \nare most often multifocal lesions superficial and deep in \nrelation to the endometrium. DEFFIEUX X. and Coll. [13] \nare of the same opinion and found during their study that \nadenomyosis with associated anatomical position, that is to \nsay superficial and deep, is the most commonly encountered \non hysterectomy specimens, 28% and 47.23%, respectively. \nThe same authors report that the number of foci is variable \nand there is a correlation between the depth of myometrial \ninvasion and the number of foci of adenomyosis. \n \nConclusion \nEndometriosis is a benign lesion affecting all segments of the \nfemale genital tract. It constitutes a polymorphic lesion with \nnon-specific symptoms. It represents an affection of the young \nwoman in full genital activity which c an compromise her \nfertility. The pathological examination is the fundamental part of \nthe diagnosis. \n \nReferences \n1. Bricou A, Borghese B, Batt RE, Piketty M, De Ziegler D, \nChapron C. Study of the anatomical distribution of \nendometriotic lesions: A major argume nt in favor of the \nparticipation of regurgitation theory in the pathophysiology \nof endometriosis. Gynecol. Obstet. Fertile 2009;37:325-333. \n2. Chene G, Jaffeux P, Lasnier C, Aublet-Cuvelier B, \nMatsuzaki S, Jardon K et al . Is there an anatomoclinical \ncorrelation between minimal endometriosis and severe \nendometriosis? Gynecol. Obstet. Fertile 2008;36:17-22. \n3. Bonte H, Chapron C, Vieira M, Fauconnier A, Barakat H, \nFritel X et al . Histologic appearance of endometriosis \ninfiltrating uterosacral ligaments in women wit h painful \nsymptoms. J. Am Assoc. Gynecol. Laparosc 2002;9: 419-\n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 415 ~ \n524. \n4. Fauconnier A, Chapron C, Dubuisson JB, Vieira M, \nDousset B, Breart G. Relation between pain symptoms and \nthe anatomic location of deep infiltrating endom etriosis. \nFertile Sterile 2002;78:719-26. \n5. Kdous M, Feerchiou M, Chaker A. Uterine adenomyosis. \nClinical and therapeutic study about 84 cases. Medical \nTunisia A 2002;80(7):373-379. \n6. Panel P, Renouvel F. Management of endometriosis: \nClinical and biological evaluation: Recommendations for \nclinical practice developed by the national college of French \ngynecologists and obstetricians (CNGOF): Management of \nendometriosis. Journal of Obstetric Gynecology an d \nReproductive Biology A. 2007;36(2):119-128. \n7. Dupas C, Christin-Maitre S. What is new about \nendometriosis? Annals of Endocrinology 2008;69:S53-S56. \n8. Jondet Michel . Endometriosis: the pathologist's point of \nview: Endometriosis. Human reproduction and hormon es A \n2006;19(7-8):352-358. \n9. Darai E, Bazot M, Rougier R. Rectal endometriosis and \nfertility. Gynecol Obstet Fertil A 2008;36(12):1214-1217. \n10. Boutet Gerard , Conrl Vanessa , Boucher Pauline . \nAdenomyosis. The practitioner's review. Gener al medicine \nA 2009;832:829-833. \n11. Ben Aissia Nizar , Berriri Habib , Gona Faouzi . \nAdenomyosis: analytical study o f 35 cases, L a Tunisie \nmédicale 2001;79(08/09):447-451. \n12. Camagna Olivier , Dupuis Olivier , Poncelet Christophe . \nContribution of complementary examinations to the \ndiagnosis and surgical prognosis of endometriosis of the \nrectovaginal septum: about a continuous series of 40  cases. \nThe practitioner's review. GynecolObstet A 2002;63:25-28. \n13. Deffieux X, Fernandez H. Physiopathological, diagnostic \nand therapeutic developments in the management of \nadenomyosis. Literature paper. Journal of Obstetric \nGynecology and Reproductive Biol ogy A 2004;33( 8):703-\n712. \n14. Fernandez H. Pathophysiological, diagnostic and \ntherapeutic evolutions for the management of adenomyosis. \nJournal of Obstetric Gynecology and Reproductive Bio logy \nA 2003;32(CAH2):423-427.","source_license":"CC0","license_restricted":false}