The Roentgen Findings in Adenomyosis

Adenomyosis is defined as the heterotopic occurrence of islands of endometrium within the myometrial layer of the uterine wall. Its detailed histopathology was first described by Rokitansky (8) in 1860. Von Recklinghausen (7), in 1896, in a monograph on the subject, identified these endometrial inclusions in the wall of the uterus as misplaced embryonal remnants derived from the mesonephros or wolffian body. Cullen (2), in 1908, utilizing serial sections, demonstrated in 56 of 73 cases studied, an anatomical continuity between the endometrium and the intramural “islands” of endometrial elements. It was subsequently demonstrated that a tubular communication could be identified in all cases provided the adenomyotic glands were located in the inner third of the uterine wall. Where endometrial implants were present in the outer muscle wall, no continuity was demonstrable (1). Pathology The uterus is usually slightly enlarged—in extreme cases to as much as five times its normal weight—in the absence of other disease. This enlargement is attributed to hyperplasia of the myometrium in the region of the implants. Ordinarily the thickening is uniform, but it may be irregular in those instances where the implants are irregularly distributed. There is a frequent association with pelvic endometriosis, including endometrial implants on the serosal surface of the uterus. The endometrium is usually smooth. On occasion, pit-like depressions, representing the openings of the adenomyotic channels, are seen. In approximately 10 to 15 per cent of cases there is endometrial hyperplasia (3). The cut surface (Fig. 1) shows whorl-like condensations of muscle surrounding tiny pale translucent areas which consist of uterine mucosa. Occasionally these central areas are cystic, measuring from 1 to 9 mm. in diameter and containing blood and desquamated epithelium. These central areas may contain chocolate-colored material resulting from menstrual hemorrhage, analogous to the chocolate fluid in endometrial cysts of the ovaries. Associated leiomyomas are frequently seen, occurring in 30 to 70 per cent of the reported cases (3). In this series their incidence was 20 per cent (Fig. 10). Microscopically (Figs. 2 and 3), islands of endometrium comprising epithelial, glandular, and stromal elements surrounded by hyperplasia of the adjacent smooth musculature are seen. These are not set off from the adjacent tissue by a capsule or basement membrane but lie free in the smooth muscle interstices. When they are located in the superficial layers of the myometrium, duct-like communications with the endometrial surface are readily demonstrated by serial section. The diameter of the channels may vary from not more than a hair breadth to as much as 5 mm. The tubular glands pursue a branching tortuous course, winding in all directions, but always directed toward the serosal surface, running between muscle bundles. Adenomyosis of the cervix is uncommon.