Surgical Techniques

A patient with severe adenomyosis requests uterine-sparing surgery

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References

Two-pronged route to diagnosis and a differential

Histology

Adenomyosis is definitively diagnosed based on histologic findings of endometrial-like tissue within the myometrium. Historically, histologic analysis was performed on specimens following hysterectomy but, more recently, has utilized specimens obtained from hysteroscopic and laparoscopic myometrial biopsies.19 Importantly, although hysteroscopic and laparoscopic biopsies are taken under direct visualization, there are no pathognomonic signs for adenomyosis; a diagnosis can therefore be missed if adenomyosis is not present at biopsied sites.1 The sensitivity of random biopsy at laparoscopy has been found to be as low as 2% to as high as 56%.20

Imaging

Imaging can be helpful in clinical decision making and to guide the differential diagnosis. Transvaginal ultrasonography (TVUS) is often the first mode of imaging used for the investigation of abnormal uterine bleeding or pelvic pain. Diagnosis by TVUS is difficult because the modality is operator dependent and standard diagnostic criteria are lacking.5

The most commonly reported ultrasonographic features of adenomyosis are21,22:

  • a globally enlarged uterus
  • asymmetry
  • myometrial thickening with heterogeneity
  • poorly defined foci of hyperechoic regions, surrounded by hypoechoic areas that correspond to smooth-muscle hyperplasia
  • myometrial cysts.

Doppler ultrasound examination in patients with adenomyosis reveals increased flow to the myometrium without evidence of large blood vessels.

3-dimensional (3-D) ultrasonography. Integration of 3-D ultrasonography has allowed for identification of the thicker junctional zone that suggests adenomyosis. In a systematic review of the accuracy of TVUS, investigators reported a pooled sensitivity and specificity for 2-dimensional ultrasonography of 83.8% and 63.9%, respectively, and a pooled sensitivity and specificity for 3-dimensional ultrasonography of 88.9% and 56.0%, respectively.22

Magnetic resonance imaging (MRI) is also used in the evaluation of adenomyosis. Although MRI is considered a more accurate diagnostic modality because it is not operator dependent, expense often prohibits its use in the work-up of abnormal uterine bleeding and chronic pelvic pain.2,23

The most commonly reported MRI findings in adenomyosis include a globular or asymmetric uterus, heterogeneity of myometrial signal intensity, and thickening of the junctional zone24 (FIGURE 1). In a systematic review, researchers reported a pooled sensitivity and specificity of 77% and 89%, respectively, for the diagnosis of adenomyosis using MRI.25

Approaches to treatment

Medical management

No medical therapies or guidelines specific to the treatment of adenomyosis exist.9 Often, nonsteroidal anti-inflammatory drugs (NSAIDs) are employed to combat cramping and pain associated with increased prostaglandin levels.26 A systematic review found that NSAIDs are significantly better at treating dysmenorrhea than placebo alone.26

Moreover, adenomyosis is an estrogen-dependent disease; consequently, many medical treatments are targeted at suppressing the hypothalamic–pituitary–ovarian axis and inducing endometrial atrophy. Medications commonly used (off-label) for this effect include combined or progestin-only oral contraceptive pills, gonadotropin-releasing hormone (GnRH) agonists, levonorgestrel-releasing intrauterine devices, danazol, and aromatase inhibitors.

Use of a GnRH agonist, such as leuprolide, is limited to a short course (<6 months) because menopausal-like symptoms, such as hot flashes, vaginal atrophy, and loss of bone-mineral density, can develop.16 Symptoms of adenomyosis often return upon cessation of hormonal treatment.1

Novel therapies are under investigation, including GnRH antagonists, selective progesterone-receptor modulators, and antiplatelet therapy.27

Although there are few data showing the effectiveness of medical therapy on adenomyosis-specific outcomes, medications are particularly useful in patients who are poor surgical candidates or who may prefer not to undergo surgery. Furthermore, medical therapy has considerable use in conjunction with surgical intervention; a prospective observational study showed that women who underwent GnRH agonist treatment following surgery had significantly greater improvement of their dysmenorrhea and menorrhagia, compared with those who underwent surgery only.28 In addition, preoperative administration of a GnRH agonist or danazol several months prior to surgery has been shown to reduce uterine vascularity and, thus, blood loss at surgery.29,30

Key practice points in managing adenomyosis
  • Adenomyosis is common and benign, but remains underdiagnosed because of a nonspecific clinical presentation and lack of standardized diagnostic criteria.
  • Adenomyosis can cause significant associated morbidity: dysmenorrhea, heavy menstrual bleeding, chronic pelvic pain, and infertility.
  • High clinical suspicion warrants evaluation by imaging.
  • Medical management is largely aimed at ameliorating symptoms.
  • A patient who does not respond to medical treatment or does not desire pregnancy has a variety of surgical options; the extent of disease and the patient’s wish for uterine preservation guide the selection of surgical technique.
  • Hysterectomy is the definitive treatment but, in patients who want to avoid radical resection, techniques developed for laparotomy are available, to allow conservative resection using laparoscopy.
  • Ideally, surgery is performed using a combined laparoscopy and minilaparotomy approach, after appropriate imaging.

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