Approach To A Patient With Adenomyosis Final

Gynecology Case Correlates Barrera, Diana Jane Atanga, Pascal

E.E. 38 year-old housewife Chief Complaint

Increased amount and duration of menses with menstrual pains

History of Present Illness 27 months PTA • Increased in amount and duration of menses

– from 3 pads moderately soaked to 5 pads fully-soaked /day – from 3 days to 7 days • Accompanied by menstrual pain, grade 8/10, relieved by Mefenamic acid, 250 mg • NO consultation.

History of Present Illness 22 months PTA• There was persistence of above symptoms, not relieved by Mefenamic acid. • Consulted a gynecologist (Dr. Jimenez?) at Westmin Hospital (Mindoro) – Abdominal and pelvic exam: unremarkable – TVS: “makapal na matres” – Advised hysterectomy; Patient did not consent; lost to follow-up Since then, self-medicated with Naproxen Sodium( Flanax) 550mg/tab which afforded relief of dysmenorrhea.

History of Present Illness 2 weeks PTA

• Persistence of above symptoms – Further increased in amount of menses • From 5 pads fully soaked (regular napkin) to 5 pads fullysoaked (maternity napkins)

• Progressive dysmenorrhea, grade 10/10, not relieved by Naproxen Sodium( Flanax) 550mg/tab • Consulted at OPD, USTH – Abdominal/ pelvic exam: suprapubic tenderness on palpation, uterus enlarged to 2 1/2 m size – Laboratory work-up: CBC – Transvaginal Ultrasound was done. Results showed: Ultrasound

• Patient was admitted for hysterectomy. Admission: Admission

Review of Systems • General: No significant weight changes. No fatigue or body weakness. • Skin: No rashes or pigmentation. No pallor, generalized skin scaliness, excessive sweating, or pruritus. No easy bruising. • HEENT: No history of head injury. No blurring of vision. No eye redness or lacrimation. No hearing loss or tinnitus. No bleeding gums or sore throat. • Neck: No lumps, goiter, pain. No swollen glands. • Respiratory: No cough. No hemoptysis. No wheezing. • Cardiovascular: No hypertension. • Gastrointestinal: No change of appetite. No occasional vomiting. No hematemesis, dysphagia or indigestion. Regular bowel movements. No diarrhea or bleeding. No pain, jaundice, gallbladder or liver problems.

Review of Systems • Urinary: No oliguria. No frequency or urinary incontinence. No recent flank pain. • Peripheral Vascular: No history of phlebitis or leg pain. • Musculoskeletal: No muscle pain. No joint stiffness and pain. • Psychiatric: No history of depression or treatment for psychiatric disorders. • Neurologic: No seizures, fainting, motor or sensory loss. Has a good memory. • Hematologic: No bleeding gums. No bruises. No history of anemia. • Endocrine: No excessive sweating, heat or cold intolerance. No polyuria, polydipsia or polyphagia;

Personal ,Family and Social History • Patient: Religion: Born Again Occupation: fish vendor, house-wife – non-smoker – non-alcoholic drinker, – denied illicit drug use

Father : stroke, heart attack, and hypertension at 67.

Past Medical History • Childhood Illnesses: – Asthma; no other forms of allergy.

• Adult Illnesses: – Medical: UTI, 1996, treated. No bleeding problems.

• Psychiatric: None

Obstetric/Gynecologic History Menstruation history • • • • •

Menarche: 14 years old, Interval: 28-29 days Duration: 3 days Amount : 3 pads/day, fully-soaked Symptoms: no dysmenorrheal symptoms.

• LMP: February 12-18, 2009 • PMP: January 10-14, 2009

Sexual History • first sexual contact: at 18 • single partner, fisherman • No post coital bleeding or dyspareunia

Obstetric/Gynecologic History G5P4 (4016) • G1, January 1992, girl, 7lbs. term NSD, uncomplicated home delivery by TBA. • G2, August 1992, aborted at 3 months, dilatation and curettage was done (St. Joseph) • G3, 1994, girl ,10 lbs. term,NSD, uncomplicated home delivery by TBA. • G4, 1996, – – – –

caesarian section, triplets, 5.4, 5.7, 6.6 lbs. term At St. Joseph’s Hospital.. Pregnancy Complications: UTI, unknown medication, completely treated. Gestational hypertension, unknown medication, well-managed.

• G5, 1999, boy, 6.0 lbs. term, NSD, uncomplicated home delivery by TBA Family planning: none

Physical examination • • • • • • • • •

General: conscious, coherent, ambulatory, not in cardio-respiratory distress Vital Signs: Height: 163 cm Weight: 63 kg BMI: 24 BP: 110 60 supine, PR 80/min RR: 21 /min T-37.2 C Skin: Warm and smooth, no jaundice, no active dermatoses. Nails without clubbing or cyanosis HEENT: Pink palpebral conjunctiva, anicteric sclera No retained cerumen, no tragal tenderness, no hyperemic external auditory canal No nasal discharge, nasal septum midline Moist buccal mucosa, non-hyperemic posterior pharyngeal wall, tonsils not enlarged. Neck: Supple neck, no palpable cervical lymphadenopathy, thyroid not enlarged. Neck veins not distended.

Physical examination • Thorax and Lungs: Symmetric chest, no chest wall deformities, no retractions, no lagging, no tenderness, no palpable masses, equal tactile vocal fremiti, resonant on percussion, vesicular breath sounds, no crackles, no wheezes, no rhonchi. • Cardiovascular: JVP 3 cm at 30 degrees. CAP, rapid upstroke, gradual downstroke, Negative for carotid bruit. Adynamic precordium, AB 5th LICS AAL, no lifts, heaves or thrills, S1>S2 at apex, S2>S1 at the base. No murmurs. • Breast: symmetrical, no skin lesions, no dimpling; non-tender on palpation, no palpable masses or lumps. No discharge. • Abdominal: Flabby abdomen, with striae of pregnancy and vertical infraumbilical laparotomy scar; normoactive bowel sounds; with tenderness on low abdominal area on deep palpation; liver and spleen not palpable, no palpable intra-abdominal masses. tympanitic on percussion

Physical examination Pelvic Exam: • On External inspection: • pubic hair triangular distribution; • no gross lesions of external genitalia • On Speculum Examination: • the cervix is smooth, long, firm and closed with minimal whitish mucoid discharge. • On internal Examination: • Uterus is symmetrically enlarged to about 2 ½ month size,midline, movable, and anteverted, soft with slight tenderness on palpation. • No adnexal masses • No nodularities in cul de sac.

Physical examination Pelvic Exam: • On External inspection: • pubic hair triangular distribution; • no gross lesions of external genitalia • On Speculum Examination: • the cervix is smooth, long, firm and closed with minimal whitish mucoid discharge. • On internal Examination: • Uterus is symmetrically enlarged to about 2 ½ month size,midline, movable, and anteverted, soft with slight tenderness on palpation. • No adnexal masses • No nodularities in cul de sac.

Salient Features • 38 years old, G5P4 (4016) with multiple gestation • Menorrhagia

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Uterus symmetrically enlarged to 21/2 month size, midline and movable, soft, tender on palpation

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Tenderness on lower abdominal area in deep palpation.

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No signs and symptoms of anemia

• Progressive dysmenorrhea • No drug use especially hormones, OCP’s • Caesarian section • Dilatation and curettage • No GIT and urinary symptoms • No bleeding tendency/disorders

Differential Diagnosis Secondary Dysmenorrhea with Menorrhagia

Clinical Condition:

ADENOMYOSIS

ENDOMETRIOSIS •Reproductive age group •Earlier, 20-40

LEIOMYOMA

Age of onset

•Reproductive age group •30 and 50 •Median age 40 years

•Reproductive age group

Characteristic of pain

•Cyclic •usually premenstrual and menstrual

Signs

•Uterus is diffusely enlarged, •Uterus not enlarged •<14 cm in size, •Retro-verted uterus with •Soft and tender, at the time of •tender nodules in the uterosacral menses. region or thickening of the cul-de•Mobility not restricted, sac •No associated adnexal pathology •No rebound tenderness Adhesions •Direct tenderness are common

•Enlargement of uterus is asymmetric, pelvic mass •May occur singly but often are multiple.

Symptoms

•Excessively heavy or prolonged •Abnormal bleeding tends to be menstrual bleeding, premenstrual spotting •dysmenorrhea •dysmenorrhea •Associated GI symptoms

•Abnormal bleeding, pelvic pressure •BUT •Usually asymtomatic

Risk Factors

•Multiparity •Cesarean sections •D and C •tubal ligations

table

•Cyclic •Mostly asymptomatic •usually premenstrual and menstrual

•Obese women •Never given birth •Diet •Endometriosis in mother •menstrual cycles < 27 days •exercise • bleeding > 8 days •normal passage of menses. •the pelvis by previous •Being white or Asian

Impression Given a patient who is of the reproductive age group … with regular menstrual cycle… presenting with menorrhagia and secondary dysmenorrhea… and a symmetrically enlarged uterus…

ADENOMYOSIS

ADENOMYOSIS • a condition where endometrial glands and supporting tissues are found in the muscular wall of the uterus

Adenomyosis • The reported prevalence of adenomyosis in the literature ranges from 20% to 30% • This condition typically affects women in the fourth and fifth decades of life. • Menorrhagia and dysmenorrhea have been reported to occur in 40% to 50% and 15% to 30% of patients, respectively, • approximately one-third being asymptomatic. • Metrorrhagia, nonmenstrual pelvic pain, and dyspareunia may also be present. • Azziz R. Adenomyosis: current perspectives. Obstet Gynecol Clin North Am 1989;16:221–235.

Adenomyosis • The diagnosis is made histopathologically • Endometrial stroma and glands are observed at least 2 to 3 mm below the endometrial surface within the myometrium. • The cause of the pain associated with this condition is not known. • Ultrasonography and hysterosalpingography are not useful in the diagnosis of adenomyosis. • However, magnetic resonance imaging (MRI) can be used to diagnose adenomyosis. • Hysterectomy has consistently been shown to be successful in treating and controlling the symptoms associated with adenomyosis.

Azziz R. Adenomyosis: current perspectives. Obstet Gynecol Clin North Am 1989;16:221–235.

ADENOMYOSIS Incidence - 20.6 % of the specimen studied - total of 296 hysterectomy specimen (dysfunctional uterine bleeding)

Incidence of adenomyosis in hysterectomies. Anwar Ali. Department of Pathology, Saidu Medical College, Swat.Pakistan J. Med. Res.Vol. 44 No.1, 2005

Risk factors

ADENOMYOSIS

“Women who smoked tended to be at decreased risk of the condition: in comparison with women who had never smoked, the risk for current smokers was 0.7 (0.3- 1.3)” “The frequency of adenomyosis was higher in parous women: in comparison with nulliparae, the odds ratio of the disease were 1.8 [95% confidence interval (CI) 0.93.4] and 3.1 (95% CI 1.7-5.5) respectively in women reporting one and two or more births (chi2 trend 20.71, P < 0.01).” “ ..women reporting one or more spontaneous abortions had an odds ratio of 1.7 (95% CI 1.1-2.6) for adenomyosis, in comparison with those reporting no spontaneous abortion. Risk factors for adenomyosis. F Parazzini, P Vercellini, S Panazza, L Chatenoud, S Oldani and PG Crosignani Centro Medicina della Riproduzione,Clinica Ostetrico Ginecologica Universita di Milano, Italy.

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Others: uterine surgery

Work-ups • CBC • Transvaginal Ultrasound

Transvaginal Ultrasound Why do we request ? • • • •

confirm the cause of enlarged uterus location and extent of lesion assessment of endometrial lining assess the ovaries

Transvaginal Ultrasound

The subendometrial halos a thin hypoechoic band (arrows). The endometrium is uniformly echogenic

NORMAL

6-8cm

3-5 cm

714m m

Transvaginal Ultrasound ADENOMYOSIS characteristics • Heterogeneous myometrial echotexture • Ill defined hypoechoic areas • Small anechioc lakes • Symmetrical uterine enlargement • Indistinct endometrial-myometrial border • Posterior wall involvement

Transvaginal Ultrasound Brosens and coworkers assessed ultrasonographic details of adenomyosis such as:

Uterine dimensions Symmetry of myometrium Echogenicity of the myometrium

They found that the most predictive is the ill-defined heterogeneous echotexture within the myometrium.

BACK pix

Work-Up Results: TVS Cervix: 4.12 x 3.9 cm Uterine Corpus: 8.64 x 8.85 x 8.26 cm* Anteverted Inhomogenous Endometrium: 0.84 cm Isoechoic Ovaries Right: 2.75 x 1 x 1.94 cm Follicles: <10 mm Left: 2.59 x 2.06 x 2.4 cm Follicles < 10 mm Other Findings: Cul-de-sac: Minimal fluid *Coarse area noted at the anterior wall – 4.42 x4.03 cm (adenomyosis) *Hypoechoic nodule noted at the lower anterior wall – 1.33 x 1.03 x 1.14 cm REMARKS: ENLARGED UTERUS WITH ADENOMYOSIS AND INTRAMURAL MYOMA PROLIFERATVE ENDOMETRIUM NORMAL – SIZED OVARIES

Ultrasound Correlations

Management • Surgical Abdominal Hysterectomy – Age, no desire for child-bearing anymore – Definitive treatment • Medical - if young and desire for child bearing - poor surgical risk, with co morbidities, etc - hormones are mainstay of medical treatment - not definitive, signs and symptoms recur upon withdrawal

Management Problems

Goals

Adenomyosis - Menorrhagia and secondary dysmenorrhea

• Definitive removal of the lesion and relieve of symptoms

Anemia

• Correction of anemia (prior to operation)

Management

TOTAL ABDOMINAL HYSTERECTOMY

Management PREOPERATIVE • • • • • • • •

Informed consent Laboratory: CBC, BT, Blood typing and cross-matching ,RBS Kidney function test – urinalysis, BUN, Creatinine Liver Function Test - TPAG Chest X-ray ECG – cardio-pulmonary clearance Correct ANEMIA Bowel preparation (simple hysterectomy) - Light dinner, NP0 (8 hours) – Cleansing enema

• Prophylactic antibiotics (first gen. cephalosporin) • IV fluids

Intraoperative

back

Management Post-operative • • • • •

Vital signs monitoring IV fluids NPO to clear to soft diet Analgesics Prevent complications – Pneumonia – DVT – Bedsores – SSI

The diagnosis can only be proven by the pathologists But a good gynecologist may suspect adenomyosis based on the clinical factors, but the final diagnosis usually has to wait until hysterectomy is performed

THANK YOU

BACK UP SLIDES

Work-Up Results: CBC

BACK

Work-Up Results: TVS Cervix: 4.12 x 3.9 cm Uterine Corpus: 8.64 x 8.85 x 8.26 cm* Anteverted Inhomogenous Endometrium: 0.84 cm Isoechoic Ovaries Right: 2.75 x 1 x 1.94 cm Follicles: <10 mm Left: 2.59 x 2.06 x 2.4 cm Follicles < 10 mm Other Findings: Cul-de-sac: Minimal fluid *Coarse area noted at the anterior wall – 4.42 x4.03 cm (adenomyosis) *Hypoechoic nodule noted at the lower anterior wall – 1.33 x 1.03 x 1.14 cm REMARKS: ENLARGED UTERUS WITH ADENOMYOSIS AND INTRAMURAL MYOMA PROLIFERATVE ENDOMETRIUM NORMAL – SIZED OVARIES

Medical Management: Medical • GnRH- agonists is efficient in reducing the adenomyotic uterine size. • GnRH-alpha treatment before laparoscopic surgery greatly decreases surgical difficulties and blood loss in certain cases.

Gonadotropin releasing hormone agonists in the treatment of adenomyosis. Obstetricts and Gynecology Hospital, Shanghai Medical University, Shanghai 200011 Zhonghua Fu Chan Ke Za Zhi 1999 Apr; 34:214-6

BACK

Management: Uterine Artery Embolization UAE procedures were performed in 23 patients with adenomyosis. After treatment the symptoms and uterine volume of all patients were investigated.

All clinical symptoms of 23 patients relieved. •Dysmenorrhea completely disappeared in 19 patients, significantly alleviated in 2 patients. But in other 2 recurred. •The uterine volume shrunk significantly [(50 +/- 18)%] vs [(100 +/- 0)%]. •The blood flow within the uterine and lesions detect by color doppler flow imaging decreased immediately after UAE. •Low-abdominal pain and slight fever were seen after treatment and recovered within 1 - 2 weeks. Uterine arterial embolization in the treatment of adenomyosis .Chen C, Liu P, Lu J, Yu L, Ma B, Wang J, Liu P Zhonghua Fu Chan Ke Za Zhi 2002 Feb.

Management: Uterine Artery Embolization

UAE is an effective and safe method in the treatment of adenomyosis. BUT the recurrence rate is not yet evaluated.