2.
Adenomyosis is a myometrial lesion
characterized by the presence of ectopic
endometrium with or without hyperplasia of
the surrounding myometrium.
Prevalence in women <35 yrs
A)9% in fertile women
B) 79% in women with coexisting
endometriosis(based on MRI data)
3.
4.
5.
Risk factors for adenomyosis are age,
multiparity, surgical disruptions of the
endometrial–myometrial border, elevated
levels of both FSH and prolactin (PRL),
smoking habits and history of depression.
6.
Adenomyosis has been shown to be
significantly associated with peritoneal
endometriosis in infertile patients.
Directed sperm transport is significantly
impaired in infertile women with pelvic
endometriosis which may be caused by the
destruction of the myometrial architecture by
adenomyotic lesions.
Therefore, it could be that uterine
adenomyosis could constitute a major cause
of infertility in pelvic endometriosis.
7.
8. (a) The JZ in the non-pregnant uterus
Brosens, I. et al. Hum. Reprod. 2010 0:dep474v1-474; doi:10.1093/humrep/dep474
Copyright restrictions may apply.
9.
Very variable phenotypes of adenomyosis as
documented by MRI can be obtained such as
enlargement of the AJZ and/or PJZ or focal
protrusions of variable size and location into
the outer myometrium.
10.
11.
it is mainly the posterior wall that is affected
and only exhibits, with respect to the
enlargement of the junctional zone.
12.
it is mainly the posterior wall that is affected
and only exhibits, with respect to the
enlargement of the junctional zone.
Posterior junctional zone thickness>10mm is
considered significant.
13.
Measurements obtained from MRI scans of uteri
with and without endometriosis With
endometriosis , Without endometriosis
Significance (P)
Diameter of the anterior junctional zone 10.1±4
9.2±5.1 >0.05
Diameter of the anterior total myometrium
17.1±3.6 18.2±4.2 0.03
Diameter of the posterior junctional zone
11.5±5.3 8.3±2.6 <0.001
Mean values in mm±SD.
14.
The mean diameter of the normal junctional
zone, representing the innermost myometrial
layer, or archimyometrium, has been
established to be in the range of 7–8 mm.
The diagnosis of adenomyosis by MRI is
considered to be established with a thickness
of the junctional zone of 12 mm.
15.
Within a thickness of 8–12 mm, the diagnosis
of adenomyosis requires specific secondary
criteria such as
A) relative thickening of the junctional zone in
a localized area,
B) poor definition of borders or high signal
intensity foci.
16.
Presence of focal areas with ill defined
borders or abnormal echo texture
When these areas are present, the following
criteria for adenomyosis :
A) presence of heterogeneity,
B) increased or decreased areas of
echogenicity,
C) presence of myometrial cysts.
17.
MRI superior to TVS for the diagnosis of
adenomyosis.
Magnetic resonance imaging have a higher
specificity(0.86 vs 0.65) than TVS, but their
sensitivities are similar (0.87 vs 0.86).
The diagnostic accuracy of MRI, as that of
TVS, was at an intermediate level, but the
diagnostic accuracy of MRI improved by
exclusion of uteri >400 mL.
18.
The combination of MRI and TVS produced
the highest level of accuracy for exclusion of
adenomyosis, but the low specificity may
necessitate further investigation of positive
findings.
Measurement of the difference in junctional
zone thickness may optimize the diagnosis of
adenomyosis at MRI (>5-7mm).
19.
OBJECTIVES: To establish the effect of
adenomyosis on IVF/ICSI outcomes in infertile
patients with endometriosis who were pretreated
with long-term (>/=3 months) GnRH-agonist
prior to IVF/ICSI.
STUDY DESIGN: Retrospective study in 74 infertile
patients with surgically proven endometriosis
who were treated with IVF/ICSI.
The diagnosis of adenomyosis was based on
transvaginal ultrasound criteria.
All patients were pretreated with long-term
(>/=3 months) GnRH-agonist prior to IVF/ICSI.
20.
RESULTS: 90.4% pts endometriosis rASRM stages IIIIV.
Adenomyosis in 27% of them . Predominantly in the
posterior wall of the uterus.
IVF/ICSI outcomes : a mean duration of GnRH-agonist
use prior to IVF/ICSI of 5.35 months (3-26);
a mean dosage of FSH used of 208IU (75-450);
the mean number of oocytes retrieved was 8.73 (130);
the mean number of embryos obtained was 3.86 (016);
the mean number of embryos transferred was 1.6; a
mean implantation rate of 26.3%;
21.
a mean miscarriage rate of 24.3%;
and a clinical pregnancy rate of 31.7%.
No significant differences were found for any
of the IVF/ICSI outcomes between women
with and without adenomyosis.
CONCLUSIONS: Adenomyosis had no adverse
effects on IVF/ICSI outcomes in infertile
women with proven endometriosis who were
pretreated with long-term GnRH-agonist.
22.
Thirty-eight women with symptomatic
adenomyosis with or without uterine
leiomyomas were treated with UAE with
calibrated tris-acryl gelatin microspheres.
Based on MR findings, women were
categorized as having pure adenomyosis
(group A; n = 15),
adenomyosis dominance with fibroid tumors
(group B; n = 14),
or fibroid tumor dominance with
adenomyosis (group C; n = 9).
23.
RESULTS: Heavy menstrual bleeding, pain,
and bulk-related symptoms at last follow-up
at a median of 16.5 months (range, 3-38
months) were compared with baseline
symptoms.
With follow-up MR imaging at a median of 12
months (range, 3-36 months), changes in
uterine volume, leiomyoma volume,
junctional zone thickness, and contrast
enhancement of adenomyosis were assessed.
24.
After embolization, adenomyosis infarction
could be depicted on contrast mediumenhanced MR in 44.1% of cases.
Median reductions of uterine volume, fibroid
tumor volume, and junctional zone thickness
were 44.8%, 77.1%, and 23.9%, respectively.
In group A, three patients needed additional
surgery after UAE, in addition to two in group
B and one in group C.
25.
In the remaining 32 patients, except for one
patient in group C, all preexisting symptoms (eg,
bleeding, pain, bulk-related symptoms) improved
or resolved after UAE.
Overall, 84.2% of women were satisfied with the
results of UAE.
CONCLUSION: In this study, midterm results (at a
median of 16.5 months) showed that UAE in
symptomatic adenomyosis with or without
uterine leiomyomas is effective. Hysterectomy
was avoided in the vast majority of patients. MR
imaging showed reduction of uterine volume and
junctional zone thickness.
26.
Twelve women (mane age 40.3 years) with
adenomyosis and uterine cavity depth over
11 cm received injections of GnRH-a, every 4
weeks, and after the uterine cavity depth was
reduced to below 10 cm, LNG-IUS was
deployed.
VAS pain score, PBAC bleeding score, uterine
volume, and hemoglobin levels of the women
were measured before the treatment and at 6
and 12 months after LNG-IUS placement.
27.
RESULTS: The VAS pain score was significantly
lowered at 6 and 12 month after LNG-IUS
placement (P<0.05), and the PBAC bleeding
score also showed significant reductions
(P<0.05).
The uterine volume decreased significantly at
6 and 12 months after LNG-IUS placement as
compared with that before the treatment.
28.
Serum hemoglobin levels underwent
significant increments after LNG-IUS
placement (P<0.05).
CONCLUSION: LNG-IUS combined with GnRH
analogue injection can be effective in the
treatment of adenomyosis with dysmenorrhea
and hypermenorrhea.
CHINESE MED JOUR MAR 2010
29.
The LNG-IUS was inserted into 94 women who
had moderate or severe dysmenorrhea associated
with adenomyosis diagnosed by transvaginal
sonography during Cycle Days 5-7.
A visual analogue scale (VAS) of dysmenorrhea,
uterine volume and serum CA125 levels were
used to assess the efficacy of the treatment at
baseline and 3, 6, 12, 24 and 36 months after
the LNG-IUS insertion. Side effects were recorded
at every follow-up visit.
30.
RESULTS: The VAS of dysmenorrhea dropped
continuously and significantly from the baseline
score of 77.9+/-14.7 to 11.8+/-17.9 after 36
months of the LNG-IUS insertion (p<.001).
The uterine volume decreased significantly from
113.8+/-46.9 mL to 94.5+/-40.1 mL (p=.003)
at 6 months and to 87.7+/-35.8 mL (p<.001) at
12 months and then rose slightly, but the
variables at 24 and 36 months still decreased
significantly in comparison with the baseline
variable (p<.001
31.
The serum CA125 levels reduced significantly
starting from 6 months after device insertion
(p<.001).
The most common side effects were weight gain
(28.7%), simple ovarian cyst formation (22.3%)
and lower abdominal pain (12.8%).
At 36 months, the overall satisfaction rate of the
treatment was 72.5%.
CONCLUSIONS: The LNG-IUS appears to be an
effective method in alleviating dysmenorrhea
associated with adenomyosis during 3 years. It
may be a valuable long-term alternative for the
treatment of adenomyosis.
32.
Adenomyosis is not uncommon in women< 35
years.
It probably contributes to infertility by altering
sperm trasnsport due to changes induce in the
junctional zone.
MRI and TVS-similar sensitivity, MRI-higher
specificity.
Not enough evidence found for its role in
reducing endometrial receptivity.
Medical treatment with GnRH@ depot for atleast
3 months prior to IVF appears to minimise any
inhibitory effect on implantation.
33.
LN-IUS appears to be a promising method to
study prior to IVF if time is available(atleast 6
months).Not enough evidence.
Not enough evidence found regarding High
intensity focussed ultrasound or MRFocussed ultrasound.
Not enough evidence regarding efficacy or
safety of adenomyomectomy.
