Adenomyosis: Clinical sciences

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Introduction0:00–0:37

Adenomyosis is a condition characterized by abnormal growth of endometrial glands and stroma into the myometrium. Often resulting in an enlarged and globular uterus.
Although adenomyosis can occur at any age, it's most commonly diagnosed in multiparous patients in their thirties and forties diagnosis can be challenging as the symptoms often mimic those of other gynecological conditions like endometriosis or uterine leiomyomas.
Treatment options vary depending on the severity of symptoms and the reproductive goals of the patient. When a patient presents with a chief concern, suggesting adenomyosis start by obtaining a focused history and physical exam.

History & Physical0:37–2:22

Commonly reported symptoms include heavy menstrual bleeding, dysmenorrhea or pain during menstruation, chronic pelvic pain and possibly dyspareunia which is pain during intercourse.
On physical exam, you may note an enlarged or globular uterus and possibly uterine tenderness. Based on these findings, you can suspect adenomyosis.
The next logical step is to confirm your diagnosis by obtaining some imaging studies. A pelvic ultrasound incorporating both transvaginal and transabdominal views is the first choice for identifying adenomyosis in some situations.
Like when you need a more detailed look or an ultrasound can't make the diagnosis. You can consider an MRI all right, characteristic findings on ultrasound include a heterogeneous myometrium with streaky shadowing, asymmetric myometrial thickness.
And often you can see myometrial cysts. Sometimes you will see only some but not all of these findings in this situation.
Adenomyosis should be high on your differential. So, proceed with this clinical diagnosis.
Heres a clinical pearl. The gold standard for diagnosis is histological examination of the uterus.
After hysterectomy. Obviously, this requires loss of the organ.
So usually adenomyosis is clinically diagnosed unless hysterectomy is indicated. All right, now that we've confirmed the diagnosis of adenomyosis.

Management2:22–8:22

Let's discuss. Treatment management is tailored to the patients.
Individual goals of therapy, especially taking into account their immediate and long term reproductive plans. First assess the patient's desire for pregnancy if your patient wants to become pregnant immediately.
Your first step in treatment is analgesia to address any pain they're experiencing from adenomyosis. Pain relief can be achieved with oral medications such as nsaids.
Be sure to tell them that nsaids should be taken only once Menzies occurs and preferably after a negative pregnancy test to avoid possible adverse outcomes during early pregnancy.
Next, consider pelvic floor physical therapy which can aid in strengthening and supporting the pelvic muscles. As many patients with adenomyosis will have coexisting pelvic floor dysfunction and pain.
Finally, think about an infertility, work up to assess factors that may affect the patient's ability to conceive and identify underlying issues that require targeted intervention.
Ok. Let's go back a step and talk about patients who express a future desire for pregnancy, as well as those who don't desire pregnancy in asymptomatic patients or those who do not desire intervention, you can proceed with expectant management.
Be sure to continue following these patients and assess their symptoms on a regular basis. On the flip side, if your patient has symptomatic adenomyosis, consider pelvic floor physical therapy to address dysfunction and pain.
Now, medical management is appropriate for symptomatic patients who desire intervention. First line therapy consists of analgesia with nsaids.
These can be used either alone or with combined oral contraceptive pills. Other first line treatments include progestins such as the levonorgestrel intrauterine system or the adeno gestyl implant.
After initiating management, follow up with your patient to assess their response if they have an adequate response and are happy with their management plan.
Continue routine follow up. However, some patients have an inadequate response, meaning that they continue to be symptomatic.
In this case, discuss both medical and procedural management options. Medical management includes gonadotropin releasing hormone agonists, simply known as GNRH agonists.
These work by interrupting the hypothalamic pituitary, ovarian hormonal access, which ultimately stops the menstrual cycle, thereby decreasing symptoms of adenomyosis.
It is important to counsel your patients on common side effects of GNRH agonists like bone loss and menopausal symptoms, specifically hot flashes, ad back therapy where progestins are used in addition to GNRH agonists is recommended to prevent long term bone loss due to these side effects.
GNRH agonists are generally used for short term symptom management. Often as a patient awaits more permanent surgical intervention.
Another option to consider is a GNRH antagonist which works similarly to disrupt the hypothalamic pituitary ovarian access GNRH antagonists are typically indicated for the treatment of endometriosis or leiomyomas but can be considered for adenomyosis as these gynecologic disorders often coexist.
Keep in mind that GNRH antagonists and agonists are not birth control. So you should always discuss family planning goals with your patient and prescribe contraception as indicated.
Switching gears. Let's talk about procedural management, specifically uterine artery embolization or UAE.
This procedure is performed by an interventional radiologist where small dissolvable particles are injected into the uterine arteries to decrease blood flow to the uterus and therefore reduce symptoms from adenomyosis.
This procedure can initially result in a flare of pain as disrupting the blood supply to the uterus causes necrosis of the organ.
So, pain management after the procedure is key, long term ues are thought to reduce pain. Overall, this is a good option for a patient who wants to avoid surgical intervention or desires uterine preservation.
However, the information about its effect on reproductive outcomes is limited. So it is not recommended for those who desire pregnancy in the future.
Finally, this procedure carries the risk of needing further intervention. Now, if the response to this treatment is inadequate, consider definitive surgical management with a hysterectomy, be sure your patient has completed childbearing or does not desire future pregnancy before electing for this option.
Additionally, have an open and thorough discussion with your patient about the potential risks and benefits of a hysterectomy taking into account their specific medical history and preferences.
All right, we've covered a lot, but let's take a moment to jump back to imaging. If a pelvic ultrasound does not reveal characteristic findings of adenomyosis.
Consider an alternative diagnosis for guidance. Refer to the palm coined mnemonic which categorizes causes of abnormal uterine bleeding into structural and nonstructural ones.
The palm portion refers to structural causes including polyps, adenomyosis, leiomyoma, and malignancy. While the coin category includes nonstructural causes such as coagulopathy, ovulatory dysfunction, endometrial iatrogenic and not yet classified.
Keep in mind that these are not mutually exclusive and may sometimes coexist. All right, as a quick recap adenomyosis is characterized by the presence of endometrial tissue.

Review8:22–9:17

In the myometrium diagnosis involves a focused history, a physical exam and usually an ultrasound treatment options depend on the patient's reproductive goals.
If your patient wants to become pregnant immediately, analgesia is recommended to manage pain for patients with future pregnancy plans or those who do not desire pregnancy, expectant management and medical management including nsaids, combined oral contraceptive pills or progestins.
If they don't respond to treatment, consider GNRH agonists and procedural management involving UAE. Finally, if this doesn't work surgical management with a hysterectomy is an option for those not planning future pregnancies
Adenomyosis: Video, Causes, and Symptoms | Osmosis