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Adenomyosis

Adenomyosis is a benign gynecological condition characterized by the presence of endometrial tissue (glands and stroma) within the myometrium (muscular wall of the uterus). This results in uterine enlargement, heavy menstrual bleeding, painful periods, and chronic pelvic pain. It often coexists with other uterine conditions like fibroids and endometriosis.

Types and Variants of Adenomyosis

1. Focal Adenomyosis

  • Localized areas of endometrial tissue within the myometrium forming discrete lesions.
  • Sometimes called adenomyoma when forming a mass.
  • Appears as a well-circumscribed lesion with indistinct margins on imaging.
  • Can cause localized pain and abnormal bleeding.

2. Globular Adenomyosis

  • Refers to a diffusely enlarged, globular-shaped uterus due to widespread adenomyotic infiltration.
  • The uterine contour remains smooth despite enlargement.
  • Associated with symptoms like heavy bleeding and dysmenorrhea.

3. Focal Adenomyosis of Outer Myometrium

  • Adenomyotic lesions located in the outer third of the myometrium.
  • Also referred to as extrinsic adenomyosis or Subtype II (extrinsic) per MRI classifications.
  • May disrupt the uterine serosa but spare the junctional zone.
  • Often associated with deep infiltrating endometriosis.

Microwave Ablation for Adenomyosis

  • A minimally invasive treatment option involving the use of microwave energy to thermally ablate adenomyotic tissue.
  • Performed under imaging guidance (ultrasound or MRI).
  • Aimed at reducing uterine volume and alleviating symptoms such as heavy bleeding and pelvic pain.
  • Offers an alternative to hysterectomy or hormonal therapy, particularly in women desiring uterine preservation.
  • Early studies show promising results with symptom relief and minimal complications.

Summary of Adenomyosis Features and Classification (Based on MRI and Imaging Studies)

  • Diffuse Adenomyosis: Widespread infiltration of endometrial tissue throughout the myometrium; most common form.
  • Focal Adenomyosis / Adenomyoma: Localized lesions/masses within the myometrium with or without cystic changes.
  • Cystic Adenomyosis: Rare variant with cystic spaces filled with blood products due to repeated hemorrhages.
  • Internal vs External Adenomyosis: Internal involves junctional zone thickening; external involves outer myometrium involvement.
  • Subtype I (Intrinsic): Lesions closely related to the junctional zone and endometrium.
  • Subtype II (Extrinsic): Lesions in the outer myometrium, often linked with deep endometriosis.

Clinical Presentation

  • Heavy or prolonged menstrual bleeding (menorrhagia)
  • Severe menstrual cramps (dysmenorrhea)
  • Chronic pelvic pain
  • Enlarged, tender uterus (globular shape)
  • Dyspareunia (painful intercourse)
  • Infertility or subfertility in some cases
  • Pressure symptoms (bladder or bowel)

Diagnosis

  • Physical exam: Enlarged, tender uterus.
  • Ultrasound: May show heterogeneous myometrium, myometrial cysts, or asymmetrical thickening.
  • MRI: Gold standard for detailed assessment; shows junctional zone thickening (>12 mm), myometrial cysts, and lesion extent.
  • Histopathology: Definitive diagnosis after tissue sampling.

Treatment Overview

  • Medical: Hormonal therapy (combined oral contraceptives, progestins, GnRH analogues) to control bleeding and pain.
  • Minimally invasive: Microwave ablation, uterine artery embolization.
  • Surgical: Conservative surgery (adenomyomectomy) or hysterectomy in severe/refractory cases.