Adenomyosis

ADENOMYOSIS

Q. 1

Infertility is seen in :

 A

Fibroid uterus

 B

Endometriosis

 C

Adenomyosis and PID both

 D

All Correct

Q. 1

Infertility is seen in :

 A

Fibroid uterus

 B

Endometriosis

 C

Adenomyosis and PID both

 D

All Correct

Ans. D

Explanation:

Ans. is a, b, c  i.e. Fibroid uterus; Endometriosis; Adenomyosis; and PID

Before going into the details of the causes of Infertility, lets first have a look at the prevalence of various causes.

    Etiology of Inlertility

Male W                              25%

Ovulatory                         27%

Tubal / Uterine                 22%

Others                              9%

Unexplained                     17%

Common causes of female Infertility are :

a.     Decreased ovarian reserve

b.     Ovarian Factor It is the most easily diagnosed and most treatable cause of infertility°. It includes :

Anovulation / Dysovulation

  • Like in case of hypothalamic dysfunction°, Kaltman syndrome
  • Hyperprolactinemia (due to drugs, pituitary adenoma°)
  • Primary hypothyroidism°
  •  
  • Sub clinical adrenal failure
  • Diabetes mellitus

Luteinized unruptured follicle Luteal phase defect

c. Tubal Factors : Partial or Complete Bilateral tubal obstruction resulting from previous salpingitis / PID. It could be : — Postabortal°

—  Gonococcal°

—  Chlamydial°

—  Tuberculous°

  • Tubal inflammation related to endometriosis
  • Following Inflammatory bowel disease
  • Following surgical trauma

d.   Peritoneal Factors : — Pelvic adhesions — Endometriosis

e.   Uterine Factors :

  • Uterine absence, atrophy
  • Congenital malformations (Among all congenital uterine abnormalities, septate uterus is the M/C and most highly associated with reproductive failure and obstetrics complications).
  • Intrauterine adhesions (Asherman’s syndrome)°
  • Endometrial polyps
  • Leiomyomas (most common with sub mucous variety)°
  • Chronic endometritis (TB)°
  • Exposure to DES in utero

f. Cervical Factors :

  • Impenetrable cervical mucus or poorly penetrable cervical mucus due to presence of local sperm antibodies.
  • Loss of mucus due to amputation of cervix, cone biopsy or over enthusiastic cervical diathermy.
  • Faulty direction of cervix as seen in retroversion or severe prolapse.
  • Cervical stenosis.

g. Others : Anxiety / apprehension use of contraceptives; anorexia nervosa.

As such adenomyosis is not given as a cause of infertility but if you go through the chapter of adenomyosis: (In chapter on Adenomyosis) : “The patient may also complain of infertility”. So, I am including it in the correct options


Q. 2

True regarding adenomyosis is :

 A

Most common in nullipara

 B

Progestin are agents of choice for medical man­agement

 C

Presents with menorrhagia, dysmenorrhea and an enlarged uterus

 D

More common in young women

Q. 2

True regarding adenomyosis is :

 A

Most common in nullipara

 B

Progestin are agents of choice for medical man­agement

 C

Presents with menorrhagia, dysmenorrhea and an enlarged uterus

 D

More common in young women

Ans. C

Explanation:

 Ans. is c i.e. Presents with menorrhagia, dysmenorrhea and an enlarged uterus 

Adenomyosis is a condition where there is ingrowth of endometrium (both gland + stroma) directly into the myometrium°.

Age group :        • Elderly patients > 40 years°

Parity :               • Multiparous°

Symptoms : • Most common symptom : Menorrhagia°

  • 2nd most common symptom : Dysmenorrhea°
  • Others : Pelvic discomfort, Backache, Dyspareunia.

On per vaginal examination : Painful symmetrical enlargement of uterus° (not more than 12-14 weeks of pregnancy)°.

Diagnosis :            • Diagnostic hysteroscopy combined with curettage is the best diagnostic modality°.

Management :       • TOC – Surgery (Total hysterectomy)° in most of the patient, as most of the patients are elderly.

  • In younger women – localized excision can be tried.

Q. 3

Symptoms of adenomyosis :

 A

Menorrhagia

 B

Dysmenorrhea

 C

Abdominal lump

 D

Option A and B both

Q. 3

Symptoms of adenomyosis :

 A

Menorrhagia

 B

Dysmenorrhea

 C

Abdominal lump

 D

Option A and B both

Ans. D

Explanation:

Option A and B both


Q. 4

Treatment of adenomyosis :

 A

Estrogens

 B

Estrogens and progesterones

 C

Total hysterectomy

 D

Laser

Q. 4

Treatment of adenomyosis :

 A

Estrogens

 B

Estrogens and progesterones

 C

Total hysterectomy

 D

Laser

Ans. C

Explanation:

Total hysterectomy


Q. 5

A 45 year old G2P2 presents with a chief complaint of pelvic pain that is worse immediately before and during her period. A bimanual exam and Pap smear are performed and are unremarkable. An ultrasound of her pelvic organs is performed and shows non-focal thickening of the myometrium with unremarkable ovaries. Which of the following is most likely to be the cause of this patient’s complaint?

 A

Adenomyosis

 B

Endometrial polyps

 C

Endometritis

 D

Leiomyoma

Q. 5

A 45 year old G2P2 presents with a chief complaint of pelvic pain that is worse immediately before and during her period. A bimanual exam and Pap smear are performed and are unremarkable. An ultrasound of her pelvic organs is performed and shows non-focal thickening of the myometrium with unremarkable ovaries. Which of the following is most likely to be the cause of this patient’s complaint?

 A

Adenomyosis

 B

Endometrial polyps

 C

Endometritis

 D

Leiomyoma

Ans. A

Explanation:

Adenomyosis is characterized by the presence of endometrial glands within the myometrium of the uterus in addition to their normal location in the endometrium.
These glands undergo cyclic changes with the menstrual cycle in response to the same stimuli as the normal endometrial glands.
The cause of adenomyosis is not known but this condition may be found in up to 20% of uteruses.
Grossly, it may be inapparent if it is limited to a small focus, or it may cause expansion of the uterine wall and have a glassy appearance. Microscopically, the aberrant glands must be separated from the endometrium by 2-3mm to be diagnostic.
Clinically pain is caused by the glands breaking down and bleeding within the confines of the myometrium.
The ultrasound shows non-circumscribed thickening.
Endometrial polyps , if symptomatic, could cause bleeding but not pain.
The Pap smear may show a few shed polyp cells, while an ultrasound would detect an intra-cavity polyp.
 It could also be clinically silent. An endometrial curettage is needed for diagnosis.
Endometritis  is an infection of the endometrium that may present with pain or bleeding. Diagnosis is made by endometrial biopsy.
A Pap smear might not sample high enough to detect infection in the uterine cavity.
There is no uterine wall thickening and a bimanual exam may elicit some pain.

Leiomyoma a benign smooth muscle tumor of the myometrium also referred to as a fibroid, may be asymptomatic even when it reaches a large size. Submucosal leiomyomas may cause bleeding and infertility.
Other problems include urinary frequency due to bladder pressure.
Pain is rare but may happen if the leiomyoma infarcts. Fibroids are usually detected with
bimanual exam if they are large or protuberant, and they are seen on ultrasound as well- circumscribed masses.
 
Ref: Wyatt C., Butterworth IV J.F., Moos P.J., Mackey D.C., Brown T.G. (2008). Chapter 17. Pathology of the Male and Female Reproductive Tract and Breast. In C. Wyatt, J.F. Butterworth IV, P.J. Moos, D.C. Mackey, T.G. Brown (Eds),Pathology: The Big Picture.

 


Q. 6

32 year old lady presented with menorrhagia and dysmenorrhea. What is the definitive treatment of adenomyosis?

 A

Mifepristone

 B

Oral progestins

 C

Hysterectomy

 D

Conservative resection

Q. 6

32 year old lady presented with menorrhagia and dysmenorrhea. What is the definitive treatment of adenomyosis?

 A

Mifepristone

 B

Oral progestins

 C

Hysterectomy

 D

Conservative resection

Ans. C

Explanation:

Hysterectomy is the definitive treatment and as with other conditions, the type of surgical procedure depends on uterine size and associated uterine or abdominopelvic pathology.

Endometrial ablation or resection using hysteroscopy has been used to successfully treat dysmenorrhea and menorrhagia caused by adenomyosis.

Ref: Hoffman B.L., Schorge J.O., Schaffer J.I., Halvorson L.M., Bradshaw K.D., Cunningham F.G., Calver L.E. (2012). Chapter 9. Pelvic Mass. In B.L. Hoffman, J.O. Schorge, J.I. Schaffer, L.M. Halvorson, K.D. Bradshaw, F.G. Cunningham, L.E. Calver (Eds), Williams Gynecology, 2e.



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