Pattern and frequency of endometrial and ovarian pathologies with adenomyosis uteri in patients who attended the tertiary care hospital among rural population of North India

Adenomyosis is a myometrial lesion which is characterized by the presence of ectopic endometrial tissue with or without hyperplasia of the surrounding myometrium. It remains in continuity with the endometrium presumably signifying down growth of endometrial tissue into and between the smooth muscle fascicles of the myometrium. Rokitansky first described adenomyosis in 1860. The term adenomyosis uteri was used by Frank, first in 1925. The synonyms of adenomyosis are "endometriosis interna," "uterine endometriosis," and "internal endometriosis." Adenomyosis has long been regarded as a close cousin of endometriosis although two conditions behave quite differently. Coexisting pathologies such as leiomyomata, endometriosis, endometrial hyperplasia, endometrial polyp, and endometrial carcinoma are commonly seen with adenomyosis. Patients with adenomyosis clinically present with dysfunctional uterine bleeding, predominantly menorrhagia and pelvic pain. However, other related pathologies such as leiomyoma, endometriosis, endometrial hyperplasia, and endometrial carcinoma are usually seen, therefore, there is often uncertainty about the causal relationship of symptoms with adenomyosis itself, as it does not have the clinical symptoms of its own. Progressive dysmenorrhea is the chief complaint in the cases of adenomyosis and a clinical diagnosis is only presumptive. Ultrasound findings using sophisticated machines are also only suggestive and not conclusive. The final diagnosis is made by the histopathologist. The preoperative diagnosis of adenomyosis may be made by means of symptoms, ultrasonography, and magnetic resonance imaging. Hysterectomy is the only diagnostic and therapeutic modality. The diagnosis of adenomyosis is made in well-oriented hysterectomy specimens and essentially, never in curetting and hysteroscopic specimens. Currently, there is insufficient and scanty data regarding the ovarian and endometrial changes with adenomyosis. So, this study was planned to determine the prevalence, clinical symptoms, and coexisting endometrial and ovarian pathologies that are associated with adenomyosis uteri.

This is a tertiary care hospital based cross-sectional study carried out at the Rural Institute of Medical science and Research, Saifai, Etawah (Uttar Pradesh), from January 2008 to December 2014. Women who had undergone abdominal, vaginal, or laparoscopic hysterectomy with or without salpingo-oophorectomy were included. All the hysterectomy specimens received in the histopathology section of pathology department were examined grossly. Formalin fixed hysterectomy specimens were cut, sectioned, and at 3–4 µm sections were taken. Hematoxylin and eosin stain was applied, if required, additional sections were taken and examined. Other relevant details such as clinical symptoms, menstrual and reproductive factors, and contraceptive use history were also included. Ethical clearance was taken from the local ethical committee, and informed consent was obtained from each patient.

A total 353 patients were included. The common age group among these histopathologically diagnosed adenomyosis patients was 41–50 years (44.75%). Menorrhagia (70.25%) was the prime clinical symptom followed with abdominal and pelvic pain (35.41%), dysmenorrhea (27.76%), dyspareunia (21.52%), bulky uterus (15.29%), and polymenorrhea (3.39%). Among endometrium pathologies and changes, proliferative phase was more (44.47%), followed by secretory phase (25.21%), endometrial hyperplasia (12.46%), atrophy (11.89%), endometritis (5.09%), tuberculosis, clear cell carcinoma, and decidua each was accounting (0.28%). Common pathologies seen in the ovary were simple serous cyst (39.58%), corpus luteal cyst (27.08%), follicular cyst (10.41%), chocolate cyst (6.25%), dermoid cyst (8.33%), endometriosis (4.16%), hemorrhagic cyst with endometriosis, serous cystadenoma each was occupying 2.08%. Among polyps, endometrial polyp was commonly seen (40.74%), followed with endocervical polyp (33.33%), cervical polyp (18.51%), and finally hyperplastic endometrial polyp (7.40%).

Adenomyosis is an estrogen-dependent, chronic gynecologic disorder. It is defined as a localized or diffuse presence of ectopic endometrial glandular or stromal tissue in myometrium.[] Rokitansky first described this condition in 1860.[] The term adenomyosis uteri was first used by Frank in 1925.[] Adenomyosis was rarely diagnosed correctly, preoperatively, and still largely under diagnosed as it has no symptoms of its own. The preoperative diagnosis of adenomyosis may be made by means of symptomatology, ultrasonography, and magnetic resonance imaging.[] It is diagnosed in well-oriented hysterectomy specimens and essentially never in curettage and hysteroscopy specimens. Currently, the most reliable way to diagnose adenomyosis is the histopathological examination of hysterectomy specimens.[] The exact prevalence in the normal population is unknown. The percentage of hysterectomy specimens which contain adenomyosis varies from 5% to 70%.[] In the present study, prevalence of adenomyosis was (23.13%). The wide variation may be partly explained by the histological criteria which are used or by the number of tissue blocks which are examined. The youngest female diagnosed with adenomyosis was of 25 years of age and oldest was of 75 years. The maximum number of adenomyosis patients belonged to 41–50 years age group (44.75%) [Table 1], which is consistent with the other studies.[] Patients are usually pre- or peri-menopausal women who present with AUB and dysmenorrhea.[] Clinical observations related with adenomyosis were menorrhagia, abdominal and pelvic pain, dysmenorrhea, dyspareunia, bulky uterus, polymenorrhea, and pressure effects [Table 2]. Menorrhagia was a significant clinical symptom. It can be a consequence of the increased surface area of the enlarged uterine cavity. In addition, extensive involvement of the myometrium can interfere with the normal contraction of the uterine musculature and can lead to excessive bleeding.[] Endometrium of adenomyosis usually has a proliferative appearance and consistent with its basal layer nature. When the normally located endometrium is in the secretory phase, this is also true for one-fourth of the foci of an adenomyosis.[] Our results were also similar that proliferative phase endometrium was accounting for 44.47% and secretory phase was accounting for 25.21% [Table 3]. The pathogenesis is unexplained. Adenomyosis is not seen in children and uncommon in young women. Estrogen stimulation may be an important etiological factor. It does seem to occur more frequently in women with endometrial hyperplasia or endometrial carcinoma.[] Parazzini et al.[] found the significant association between adenomyosis and endometrial hyperplasia. Our study also confirms this [Table 3]. Koshiyama et al.[] showed that the adenocarcinoma ratio was 16% in cases of adenomyosis. In the present study, one case of clear cell carcinoma was diagnosed with adenomyosis forming a ratio of (0.28%). The risk factors remain unclear, including heredity factors, uterine trauma from childbirth or abortion, chronic endometritis, and hyperestrogenemia.[] In the present study, 5.09% cases of endometritis and 0.28% cases of pregnancy were seen with adenomyosis justifying the chronic endometritis and pregnancy as a risk factor of adenomyosis. Adenomyosis has long been regarded as a close cousin of endometriosis, although the two conditions behave quite differently. As a result of repeated hemorrhages, ovary is converted into a chocolate cyst. Not infrequently, repeated hemorrhages have totally destroyed the endometrial tissue; it is diagnosed as hemorrhagic cyst, consistent with endometriosis.[] Ovarian pathology seen with adenomyosis was 13.59%. Endometriosis change in ovary was 12.5% [Table 4]. During reproductive life, follicular cyst may be associated with endometrial hyperplasia and metrorrhagia.[] In this study, a case was presented with complex endometrium hyperplasia in endometrium and follicular cyst ovary in the reproductive period. Indraccolo demonstrated an association between adenomyosis and uterine polyp.[] At present, in adenomyosis uteri (7.64%) polyp was diagnosed and endometrial polyp was in majority (40.74%) [Table 5]. Coexisting pathologies were leiomyomata, endometriosis, endometrial hyperplasia, endometrial polyp, salpingitis isthmica nodosa, and even endometrial carcinoma.[] Two cases of hyperplastic endometrial polyp were diagnosed in which one was seen with endometrial hyperplasia. This signifies that hyperplastic endometrial polyp may develop in association with endometrial hyperplasia and responsible for the growth effect of estrogen.

Adenomyosis is a common uterine pathology seen predominantly in peri- and pre-menopausal women which clinically presents with menorrhagia. Proliferative phase endometrium, secretory phase endometrium, endometrial hyperplasia, and endometritis were common endometrial changes and pathologies seen with adenomyosis. Simple serous cyst was common ovarian pathology associated with adenomyosis. Endometriosis changes in the ovary were also seen confirming an association of adenomyosis with endometriosis. Polyp was also seen with adenomyosis, the majority was endometrial polyps, but hyperplastic endometrial polyp was found in association with endometrial hyperplasia, further signifying correlation between endometrial hyperplasia and adenomyosis. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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