1. Sun-Wei Guo Shanghai OB/GYN Hospital Fudan University
Adenomyosis
Sun-Wei Guo
Shanghai OB/GYN Hospital
Fudan University

2. Parsing the word…
“Adeno-”: glands
“myo-”: muscle
“-osis”: condition

3. Adenomyosis Definition: A common gynecologic disorder
A disorder that is characterized by the benign invasion of endometrial glands and stroma deep and haphazardly into the myometrium
Used to be called “endometriosis interna”
A common gynecologic disorder
with a poorly understood pathogenesis

6. Symptomology a soft and diffusely enlarged uterus
About 1/3 of women with adenomyosis are asymptomatic
Cyclic and non-cyclic pelvic pain
Intense debilitating pain all the time and/or
Acute & increasing pain at menstration and ovulation
Strong 'contraction' feel of uterus
Abdominal cramps
A 'bearing' down feeling
Pressure on bladder
Dragging sensation down thighs and legs
Abnormal uterine bleeding
Heavy bleeding and flooding
Large blood clots
Prolonged bleeding i.e.; up to 8–14 days
Subfertility
Hall mark:
a soft and diffusely enlarged uterus

7. Two subtypes Focal adenomyosis Diffuse adenomyosis Less common: ~ 1/3
More common: ~2/3
Diffusely spread throughout the uterus
Even or uneven
symmetric or asymmetric

8. Diagnosis Gynecological examination (not definite)
Transvaginal sonography (TVS)
Accuracy of ~85%
Highly dependent on experience
MRI
Similar to or slightly higher accuracy than ultrasound
Less dependent on experience

9. Adenomyosis: TVS

10. Focal adenomyosis: MRI

12. Diffuse adenomyosis: MRI

13. Diffuse adenomyosis.
Sagittal T2-weighted image shows indistinct zonal anatomy. Widening of the junctional zone is clearly seen in the region around the distorted endometrium (arrowheads). The myometrium has decreased signal intensity with tiny spots of high signal intensity (arrows).

16. Epidemiology Incidence Prevalence Risk factors Unknown
Mostly from women who underwent hysterectomy
Ranges from 14%-66%
In our hospital, ~ 43%
Risk factors
Parity, age (older than those with endometriosis), number of abortions, endometrial surgery, endometrial hyperplasia, menorrhagia

17. Some known facts
No consensus on diagnostic criteria to define presence, depth of penetration, degree of extension, and configuration of adenomyosis
Menorrhagia and dysmenorrhea are associated with severe forms of adenomyosis
Often co-exists with
Endometriosis
Uterine leiomyomas

18. Treatment Medical Surgical GnRH agonists Progestins
Oral contraceptives
Progestin-containing IUDs
Danazol
Surgical
Uterine artery embolization (UAE)
Hysterectomy

19. Some considerations Drug treatment has
a high rate of recurrence
Side-effects
Hysterectomy can be very traumatic
Especially for women who still desire a family

20. Some known molecular aberrations
Increased local production of estrogens
Increased production of proinflammatory cytokines
TNFalpha, IL-6, IL-8
Increased gene and protein expression of COX-2
Increased angiogenesis
Increased uterine contractility

21. Novel treatment on the horizon
Histone deactylase inhibitors
Valproic acid
GnRH antagonists
Aromatase inhibitors

22. Current state
More research is needed

23. Questions
As with eutopic endometrium, endometriotic lesions also experience cyclic bleeding. Some authors argue that by stopping bleeding, one can relieve endometriosis-associated symptoms. Does this argument has any merit at all? Why?

24. Questions
Many endometriotic lesions are often found to contain fibrotic tissues. In fact, adhesion is one cause for pain.
How do you think they come into being? Why?
What would be the best approach to eliminate the fibrotic tissues? Why?

25. Questions
In many hospitals in China, traditional Chinese medicine (TCM) is practiced and for endometriosis in particular, TCM medications are prescribed to patients. However, a recent systematic review indicates that, despite well over 150 publications—all in Chinese journals, no affirmative conclusion can be reached regarding the efficacy, indications, and side-effects of TCM in treating endometriosis, due mostly to poor quality in study design, execution, analysis, or reporting.
If you or your loved one had endometriosis, would you consider using TCM? Why?
Why no single TCM study could show the efficacy of TCM?
Why many physicians are still prescribing TCM even though there is no well-established evidence?
Would ancient medicine books sufficient for the TCM practice?