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Management of Adenomyosis : Current concepts in management:

Shobhana Mohandas:  TOGS, Vol 1 No1 March 2005.

 

 

Adenomyosis: Current concepts in management:

The term “adenomyosis uteri” was first used by Frankl .  Cullen distinguished between adenomyoma, an intramyometrial tumor-like condition constituted by endometrial glands and stroma, and diffuse adenomyoma, in which both elements were distributed throughout the myometrium. The focally involved uterus with adenomyosis resembles a leiomyoma; Typically, adenomyoma does not have definite margins because they are mixed with the surrounding normal myometrium. In contrast, leiomyomata compress the surrounding myometrium and have clear-cut, well-circumscribed margins. The latter can be enucleated, whereas the former cannot.    

Clinical features: Approximately 35% of adenomyotic cases are asymptomatic . In the remaining cases, the most frequently cited profile comprises the triad of abnormal uterine bleeding (50%), secondary dysmenorrhea (30%), and enlarged, tender uterus. Other symptoms, such as dyspareunia and chronic pelvic pain, present less commonly.  Adenomyosis is said to contribute to infertility. Abnormal immune responses in patients with adenomyosis are said to stimulate macrophages or endometrial cells to produce large amounts of nitric oxide and impede fertilization and implantation. Excess of nitric oxide, may further predispose to early miscarriage.   

Treatment: The mainstay of treatment of adenomyosis remains hysterectomy.  Hormonal administration of progestins or gonadotropin-releasing hormone analogs may be effective, as in endometriosis  . Enlargement of the uterus and recurrence of symptoms usually reappear within 6 months after the cessation of therapy. Conservative surgery using endomyometrial ablation, laparoscopic myometrial electrocoagulation, or excision of adenomyosis has been helpful in some patients, although follow-up has been restricted to 3 years.  In a retrospective study Yap.C  et al performed laser excision of adenomyomas in 52 patients.  Instead of suturing they used adhesion prevention barriers.  They reported a pregnancy rate of 23.1%  .

Case history: Mrs X came to me with history of severe dysmenorrhoea since one year.  She was married for   9 years and had no children. Ultrasonography revealed a 7 cm ?fibroid  ? adenomyoma.  Laparoscopy revealed the mass to be an adenomyoma  .  On incising the mass with a unipolar cautery there was no clear cut margin.  Since the adenomyoma was of a large size and it was my first attempt at adenomyoma resection   I decided to do a laparotomy so that suturing could be done properly.   Adenomyoma was resected and the uterine muscle layers approximated.  The patient continued to have dysmenorrhoea for 2 more months  but when she came after 1 year she said she was totally relieved of her symptoms though conception could not be achieved as her husband visited her only for 2 months in a year.  I have performed one more excision of adenomyoma but follow up is awaited.  On speaking to many leading gynaecologists  many of them admit to having performed excision of adenomyoma sometimes with a proper preoperative diagnosis and sometimes with a surprise diagnosis of adenomyoma at the time of laparotomy/laparoscopy,   the preoperative diagnosis being leiomyoma.  The general opinion is that adenomyoma resection can relieve dysmenorrhoea  though for the possibility of conception after the procedure we have to rely on published literature reporting 23% success rate.  Although one remains skeptical about the possibility of conception after excision of an adenomyoma , the decision to undergo hysterectomy can be mentally devastating for an infertile woman .  Adenomyomectomy can definitely offer succor to this population of women.   

Mirena in adenomyosis: Yoke-Fai Fong et al, have described a patient with severe menorrhagia and dysmenorrhoea with a uterus of 16weeks size.  Her siblings suffered from malignant hyperpyrexia.   (Malignant hyperpyrexia is a condition, inherited as an autosomal dominant trait, that causes a severe uncontrollable fever during anesthesia or while using muscle relaxants, which precipitate a hypermetabolic state. If not detected immediately it can be fatal.) For this patient, they inserted an Levonorgestrel Intra Uterine Device(Marketed as Mirena in India)  as surgery was unacceptable to her.  After the initial 3 months during which there was some irregular menstrual bleeding, they report that the patient resumed regular cyclical menses, which were normal in flow and duration and was painfree. Nine months after the initial insertion, pelvic examination revealed diminution of uterine size to 10 weeks.. This represented a 27% decrease in the size of the uterus.  Though we have no Indian reports, in patients with unacceptable surgical risk at least, it may be worth a try. 

Conclusion: Excision of adenomyoma and insertion of progesterone IUD’s are some of the evolving strategies in the management of adenomyosis and needs further evaluation before being accepted as the standard therapy. 

 

 

 

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