A CLINICOPATHOLOGICAL STUDY ON ADENOMYOSIS UTERI

Hysterectomy, Adenomyosis, Menorrhagia.

Adenomyosis is a myometrial lesion which is characterized by the presence of ectopic endometrium within the myometrium with or without hyperplasia of the surrounding myometrium. The study which was carried out from January 2010 to December 2011 over a period of 2 years to study the clinical profile of all the patients whose hysterectomy specimens showed adeno¬myosis. Three hundred and ninety (390) patients were studied. The prevalence of adenomyosis was 24.43%. 86% of the patients were seen in the age group of 31-50 years. 94.3% of the patients were multiparous. The dominant symptom was menorrhagia (75.6%), followed by dys¬menorrhoea (33.3%). DUB was clinically suspected in 33.9% of the cases followed by fibroid (24.6%) and adenomyosis (22.3%). The occurrence of adenomyosis was mostly seen in the age group of 31-50 years in the present study, which was contrary to that which was observed in some other stud¬ies, which showed the maximum occurrence after 40 years. The parity and the clinical symptoms correlated with those of other studies.

Adenomyosis is a myometrial lesion which is characterized by the presence of an ectopic endometrium within the myome- trium with or without hyperplasia of the surrounding myome- trium. The endometrial tissue should be at least 100x field or one low power field (about 2.5 mm) deep from the endomy- ometrial junction The endometrial glands may be inactive or hormonally responsive. In some cases, the glands are scant or absent and such cases may be mistaken for low-grade en- dometrial stromal sarcoma. A majority of the cases are diag- nosed following the histological examination of hysterectomy specimens, but the exact prevalence in the ‘normal’ popula- tion is unknown. The percentage of hysterectomy specimens which contain adenomyosis varies from 5–70% [1]. This wide variation may be partly explained by the histological criteria which is used and/or by the number of tissue blocks which are examined. The specificity of the pre-operative diagnosis which is based on the clinical picture is poor, ranging from 2.6–26% [2]. A majority of the cases are reported in women who are aged 40–50 years and there is a positive association with the parity also. The patients with adenomyosis present with men- orrhagia (40–50%), dysmenorrhoea (10–30%) and metrorrha- gia (10–12%) and, occasionally, dyspareunia [3, 4, 5].

In the period from January 2010- December 2011, 1596 hys- terectomy specimens were received and studied at the De- partment of pathology, GMC Jammu. Adenomyosis was diag- nosed when the distance from the endo-myometrial junction to the foci of the adenomyosis was more than one low pow- er field (Fig. 1). For the study, the paraffin sections of all the hysterectomy specimens were examined. 390 patients were diagnosed to be having adenomyosis. The medical records in which the histopathological report was adenomyosis were re- viewed and information regarding age, parity, the chief com- plaints, and the clinical diagnosis was obtained. The data was entered in simple tables and was analyzed.

Of the 390 patients, 46.9% were in the age group of 41- 50 years, 39.2% were in the age group of 31-40 years and 10.8% were in the age group of 51-60 years. In the extremes of age, the prevalence decreased to 2.1% in the age group of 21-30 years and 1.0% were above 60 years of age (Table 1). 94.3% of the patients were multiparous. A majority of them were of parity 2 and 3. In nulliparous and uniparous women, the prevalence was 2.6% and 3.1% respectively. In women with a parity of ≥ 5 also, the prevalence was found to be decreased (4.3%)(Table 2). The dominant symptom was menorrhagia (75.6%), followed by dysmenorrhoea (33.3%). Only 8.9% of the patients had chronic pain in the abdomen. Adenomyosis was also diagnosed in patients who had com- plaints of a mass descending per vagina, post-menopausal bleeding and a mass in the abdomen (Table 3). The pre-opera- tive clinical diagnosis was dysfunctional uterine bleeding(DUB) in 33.9% , fibroid uterus in 24.6%, adenomyosis in 22.3%, uterovaginal prolapse in 15.9%, post-menopausal bleeding in 2.8% and benign ovarian tumours in 0.5% of patients(Table 4).

Various aetiologies have been proposed for the development of adenomyosis, including genetic factors [6], increased intra- uterine pressure as seen in the multipara, prior uterine surgery [7,8], tamoxifen use [9] and hyperprolactinaemia. The true prevalence of adenomyosis is still unknown. The prevalence of adenomyosis in a study which was done by by Shaikh was 20.6 % [10] and it was 20.6% in a study which was done by Ali [11]. Its incidence was shown to be 26 % in India by Sharqill et al [12], 24.9% in Italy by Vercellin [13] and 6% in West Indies by Raju et al [14]. In our study, the prevalence was 24.43%. In a study by Anwar Ali, 73.7% of the patients were found to be between 41-50 years of age,16.3% were between 31- 40 years of age, 1.6% were between 21-30 years of age and 8.1% were of >50 yrs of age [11]. In Swan’s study, the mean age of the patients was 49.5± 3.4 [15]. In a study which was done by Sabin, the percentage of the patients in the age group of 41-50 years was found to be 70% and those in the age group of 31-40 years was found to be 25.5%. Only 2% of the patients were diagnosed with adenomyosis between the ages of 21-30 years and 51-60 years [16]. In a study which was done by Khresiat et al, 94% of the patients were found to be more than 40 years of age [17]. These studies were found to vary from our study in that almost equal num- Volume : 4 | Issue : 3 | Mar 2015 ISSN - 2250-1991 7 | PARIPEX - INDIAN JOURNAL OF RESEARCH bers of patients were diagnosed with adenomyosis in the age group of 31-40 years and 41-50 years. In a study by Weiss G et al, 58% of the patients were found to have complaints of abnormal vaginal bleeding and 10% had prolapse [15]. In Khreisat’s study, 64.71% of the pa- tients had dysmenorrhoea, 70.5% had menorrhagia, 3.92% had post-menopausal bleeding, 74.5% had dyspareunia, and 62.75% had chronic pelvic pain [17]. But in our study, men- orrhagia was the predominant symptom in 75.6% of the pa- tients and it was dysmenorrhoea in 33.3% of the patients. In our study, adenomyosis was seen in 18.2% of patients with prolapse and in 3.1% of patients with post-menopausal bleeding. The menorrhagia may have been due to the dys- functional contractility of the myometrium in patients with ad- enomyosis. In a study which was done by Khreisat, 96% of the patients with adenomyosis had a parity of more than 3 [17]. The max- imum occurrence was seen in patients with a mean parity of 3.8±2.3SD in a study [7] and it was 2.7 ±1.6 in another study [8]. In our study, a majority of the patients were of parity 2 or 3. This correlated with the hypothesis that pregnancy may facilitate the formation of adenomyosis by allowing the ade- nomyotic foci to be included in the myometrium due to the invasive nature of the trophoblasts on the extension of the myometrial fibers. According to Reinhold, the specificity of the preoperative diagnosis based on the clinical picture was poor, ranging from 2.6–26% [2]. In our study, the clinical diagnosis was DUB in 33.9%, fibroid in 24.6% and adenomyosis was suspected in 22.3% of the patients.

The prevalence of adenomyosis is found to be 24.43% in this study. Adenomyosis was diagnosed frequently in the age group of 40-50 years in other studies while in our study wom- en in the age group of 31-40 years and 41-50 years were equally affected. The data which was obtained from interna- tional studies were in consistence with those of our study re- garding the parity and the symptoms of adenomyosis. Adenomyosis is not a rare histopathological finding. Due to di- agnostic and therapeutic methods which are being developed as an alternative to hysterectomy, the clinical effects of ade- nomyosis and its association with other gynaecological con- ditions, adenomyosis appears to be an issue which should be more intensively investigated in the future. TABLES TABLE1 AGE DISTRIBUTION OF ADENOMYOSIS UTERI AGE NUMBER %AGE 21-30 8 2.1 31-40 153 39.2 41-50 183 46.9 51-60 42 10.8 >60 4 1.0 TOTAL 390 100 TABLE 2 PARITY DISTRIBUTION OF ADENOMYOSIS UTERI PARITY NUMBER %AGE 0 10 2.6 1 12 3.1 2 145 37.2 3 160 41.0 4 46 11.8 5 17 4.3 TOTAL 390 100 TABLE 3 SYMPTOMS IN PATIENTS WITH ADENOMYOSIS UTERI (There is overlap of symptoms) SYMPTOMS NUMBER %AGE Menorrhagia 295 75.6 Dysmenorrhoea 130 33.3 Pain Lower Abdomen 35 8.9 Mass Descending PV 71 18.2 Postmenopausal Bleeding 12 3.1 Mass Abdomen 3 0.8 TABLE 4 CLINICAL DIAGNOSIS DIAGNOSIS NUMBER %AGE Fibroid 96 24.6 DUB 132 33.9 Adenomyosis 87 22.3 Postmenopausal Bleeding 11 2.8 Uterovaginal Prolapse 62 15.9 Ovarian Cyst 2 0.5 Total 390 100 (Fig. 1) Ectopic endometrial glands and stroma lying with- in myometrium. H&E(40x10)

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