Abstract
Uterine adenomyosis is a common gynecologic disorder in women of reproductive age, characterized by the presence of ectopic endometrial glands and stroma within the myometrium. Dysmenorrhea, abnormal uterine bleeding, chronic pelvic pain, and deep dyspareunia are common symptoms of this pathological condition. However, adenomyosis is often an incidental finding in specimens obtained from hysterectomy or uterine biopsies. The recent evolution of diagnostic imaging techniques, such as transvaginal sonography, hysterosalpingography, and magnetic resonance imaging, has contributed to improving accuracy in the identification of this pathology. Hysteroscopy offers the advantage of direct visualization of the uterine cavity while giving the option of collecting histological biopsy samples under visual control. Hysteroscopy is not a first-line treatment approach for adenomyosis and it represents a viable option only in selected cases of focal or diffuse “superficial” forms. During office hysteroscopy, it is possible to enucleate superficial focal adenomyomas or to evacuate cystic haemorrhagic lesions of less than 1.5 cm in diameter. Instead, resectoscopic treatment is indicated in cases of superficial adenomyotic nodules > 1.5 cm in size and for diffuse superficial adenomyosis. Finally, endometrial ablation may be performed with the additional removal of the underlying myometrium.
Highlights
Adenomyosis is defined as the presence of endometrial tissue within the myometrium; heterotopic endometrial tissue foci are associated with a variable degree of smooth muscle cell hyperplasia [1]
Endometrial glands and/or stroma are extensively intermingled with myometrial muscle fibers with an increase in uterine volume; focal adenomyosis is generally a single nodular aggregate located in the myometrium, which may have a histologic spectrum from mostly (“adenomyoma”) solid to mostly cystic (“adenomyotic cyst”) [2, 3]
The exact mechanisms of how adenomyosis develops are still unknown, but the current trend in thought is that adenomyosis or adenomyoma originate from the deep part of the endometrium that invaginates between the bundles of smooth muscle fibers of the myometrium itself, mainly after uterine traumatic events [5, 6]
Summary
Adenomyosis is defined as the presence of endometrial tissue (glands and stroma) within the myometrium; heterotopic endometrial tissue foci are associated with a variable degree of smooth muscle cell hyperplasia [1]. Endometrial glands and/or stroma are extensively intermingled with myometrial muscle fibers with an increase in uterine volume (proportionally correlated with the extent of lesions); focal adenomyosis is generally a single nodular aggregate located in the myometrium, which may have a histologic spectrum from mostly (“adenomyoma”) solid to mostly cystic (“adenomyotic cyst”) [2, 3]. The incidence rate of adenomyosis, generally defined on the basis of hysterectomy specimens, is extremely variable (ranging between 5% and 70%) mainly because of the lack of widely accepted criteria for histopathological diagnosis [4]. It is usually diagnosed in fertile-age women and possible risk factors appear to be pregnancy and previous operative procedures on the uterus. For uterine adenomyotic cysts—a cystic structure lined with endometrial tissue and surrounded by myometrial tissue that, in most cases, contains haemorrhagic material—direct proliferation of metaplastic myometrial cells of endometrial tissue is supposed to be a possible pathogenetic mechanism, considering the common embryological origin from the Mullerian ducts of the endometrium and the subjacent myometrium [6, 8]
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