Addressing adenomyosis: Implications beyond we actually know

Ganesh Kumar, Purnima Pachori
In: International Journal of Reproduction, Contraception, Obstetrics and Gynecology · 2019 · vol. 8(9) , pp. 3644 · doi:10.18203/2320-1770.ijrcog20193790 · W2970017633
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This study compared hysterectomy specimens and found adenomyosis was present in 49% of cases, often co-occurring with leiomyoma, but was less frequently diagnosed pre-operatively via ultrasound than fibroids.

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This retrospective study analyzed 1,646 hysterectomy specimens to compare the prevalence of adenomyosis and leiomyoma, finding that adenomyosis was present in 49% of cases, often co-occurring with fibroids. The authors noted a significant diagnostic gap, as pre-operative ultrasonography identified only 32% of adenomyosis cases compared to 87% for fibroids, despite similar clinical presentations like abnormal uterine bleeding and pelvic pain. The paper concludes that adenomyosis requires higher clinical suspicion for accurate diagnosis and highlights its broader implications beyond middle age, including impacts on infertility and pregnancy outcomes. This paper is centrally about adenomyosis — specifically examining its histopathological frequency relative to leiomyoma and the challenges in pre-operative diagnosis.

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Abstract

Background: Hysterectomy is one of the commonest gynecological surgeries being performed in India for various pelvic pathologies like fibroid uterus, endometrial hyperplasia, dysfunctional uterine bleeding, etc. But pre-operative diagnosis of adenomyosis and making it an indication for hysterectomy is not as common as pathologists find it in histo-pathology of hysterectomized specimens. The aim of the study was to study the frequency of adenomyosis in comparison to leiomyoma as a uterine pathology in hysterectomized specimens and correlate them clinically.Methods: A retrospective comparative study was carried out on 1646 hysterectomy specimens, during January 2014 to December 2016, which showed either adenomyosis or leiomyoma or both. Clinical records of these cases were retrieved and histo-pathology was correlated to clinical presentations and pre-operative ultrasonography.Results: Of the 1646 specimens taken for comparision between adenomyosis and leiomyoma, 49% showed only adenomyosis, 37% only leiomyoma and 14% had dual pathology showing findings of both. The peri-menopausal age group (45-54 years) accounted for the maximum number of patients undergoing hysterectomy (37.12%). But adenomyosis was found maximum in 35 - 44 years age group (38.04%). The clinical presentations for these two pathologies were similar and maximum patients presented with abnormal uterine bleeding and pelvic pain. Ultrasonography was able to diagnose only 32% cases of adenomyosis pre-operatively whereas this figure was 87% for fibroids.Conclusions: Adenomyosis and leiomyoma both account for the most frequent findings in hysterectomy specimens. Fibroids are easily diagnosed pre-operatively, but adenomyosis needs to be diagnosed pre-operatively by high index of clinical suspicion and imaging techniques. Adenomyosis is not just a disease of middle age, it needs to be addressed for infertility, recurrent pregnancy loss (RPL), bad obstetric history, IVF failures and adherent placenta as well.
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Background

Hysterectomy is one of the commonest gynecological surgeries being performed in India for various pelvic pathologies like fibroid uterus, endometrial hyperplasia, dysfunctional uterine bleeding, etc. But pre-operative diagnosis of adenomyosis and making it an indication for hysterectomy is not as common as pathologists find it in histo-pathology of hysterectomized specimens. The aim of the study was to study the frequency of adenomyosis in comparison to leiomyoma as a uterine pathology in hysterectomized specimens and correlate them clinically.

Methods

A retrospective comparative study was carried out on 1646 hysterectomy specimens, during January 2014 to December 2016, which showed either adenomyosis or leiomyoma or both. Clinical records of these cases were retrieved and histo-pathology was correlated to clinical presentations and pre-operative ultrasonography.

Results

Of the 1646 specimens taken for comparision between adenomyosis and leiomyoma, 49% showed only adenomyosis, 37% only leiomyoma and 14% had dual pathology showing findings of both. The peri-menopausal age group (45-54 years) accounted for the maximum number of patients undergoing hysterectomy (37.12%). But adenomyosis was found maximum in 35 - 44 years age group (38.04%). The clinical presentations for these two pathologies were similar and maximum patients presented with abnormal uterine bleeding and pelvic pain. Ultrasonography was able to diagnose only 32% cases of adenomyosis pre-operatively whereas this figure was 87% for fibroids.

Conclusions

Adenomyosis and leiomyoma both account for the most frequent findings in hysterectomy specimens. Fibroids are easily diagnosed pre-operatively, but adenomyosis needs to be diagnosed pre-operatively by high index of clinical suspicion and imaging techniques. Adenomyosis is not just a disease of middle age, it needs to be addressed for infertility, recurrent pregnancy loss (RPL), bad obstetric history, IVF failures and adherent placenta as well. Metrics

References

Azziz R. Adenomyosis: current perspectives. Obstet Gynecol Clin North Am. 1989;16:221-35. Book chapter: Abnormal Uterine Bleeding. Wolter Kluwer. Marc A. Fritz, Leon Speroff Clinical Gynecologic Endocrinology and Infertility. Eighth ed. South Asian ed: 2011; 592. Menstrual disorders. Wolter Kluwer. Marc A. Fritz, Leon Speroff: Clinical Gynecologic Endocrinology and Infertility. Eighth ed. South Asian ed: 2011;579. Purandare CN. Adenomyosis and Reproduction. J Obstet Gynecol India. 2006;5:387-9. Brosens I, Pijnenborg R, Vercruysse L, Romero R. The “Great Obstetrical Syndromes” are associated with disorders of deep placentation. Am J Obstet Gynecology. 2011;204(3):193-201. Juang CM, Chou P, Yen MS, Twu NF, Horng HC, Hsu WL. Adenomyosis and risk of preterm delivery. Brit J Obstet Gynecol. 2007;114:165-9. Fernando S, Breheny S, Jaqques AM, Halliday JL, Baker G, Healy D. Preterm birth, ovarian endometriomata, and assisted reproduction technologies. Fertil Steril. 2009;91:325-30. Stephansson O, Kieler H, Granath F, Falconer H. Endometriosis, assisted reproduction technology, and risk of adverse pregnancy outcome. Hum Reprod. 2009;24:2341-7. Rizvi G, Pandey H, Pant H, Chufal SS, Pant P. Histopathological correlation of adenomyosis and leiomyoma in hysterectomy specimens as the cause of abnormal uterine bleeding in women in different age group in the Kumaon region: A retrospective study. J Mid Life Health. 2013;4:27-30. Taran FA, Stewart EA, Brucker S. Adenomyosis: epidemiology, risk factors, clinical phenotype and surgical and interventional alternatives to hysterectomy. Geburtshilfe Frauenheilkd. 2013;73(9):924-31.

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