2015 Month : June Volume : 2 Issue : 26 Page : 3958-3961
1. Associate Professor, Department of Obstetrics & Gynecology, Andhra Medical College, Visakhapatnam.
NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:
Dr. C. Amulya,
Flat No. 403,
M. K. Royals, Opp. Grand Bay Hostel,
ABSTRACT: Adenomyosis is a benign condition defined as growth of the endometrial glands and stroma deep into the myometrium. It is difficult to diagnose. It usually does not cause significant uterine enlargement. Here we present a case of third degree utero-vaginal prolapse with grossly enlarged uterus (24 weeks), the clinical and MR findings of which was mimicking sarcoma. Final diagnosis was established after hysterectomy based on histo-pathological features.
KEYWORDS: Adenomyosis, Uterine Leiomyoma, Hysterectomy, Utero-Vaginal Prolapse.
C. Amulya. A Case Report of Adenomyosis with Utero-Vaginal Prolapse. Journal of Evidence based Medicine and Healthcare; Volume 2, Issue 26, June 29, 2015; Page: 3958-3961.
INTRODUCTION: Adenomyosis refers to the presence of islands of endometrial glands and stroma within the myometrium. When adenomyosis is focal, it mimics a leiomyoma as intramural, space-occupying lesion. It differs from leiomyoma as the mass cannot be shelled out easily from the uninvolved myometrium. So adenomyosis, cannot be usually diagnosed accurately and differentiated from leiomyoma before the pathological examination of the uterus.
CASE REPORT: A 45 year old parous woman, a known case of rheumatic heart disease and hypothyroidism on treatment presented with mass per vagina of two years duration. Clinical examination revealed third degree utero-vaginal prolapse with cystocele and rectocele (Fig. 1). Uterus was enlarged up to twenty-four weeks. Trans-abdominal ultrasound showed uterine enlargement of 16x10x11 cms with large ill-defined intramural fibroid. She was further evaluated with MRI pelvis which showed a bulky uterus with altered signal pattern and poor endometrial demonstration suggestive of sarcoma (Fig. 2). A provisional diagnosis of sarcoma of uterus with prolapse was made and she was planned for surgery under high risk. Intra-operatively uterus was uniformly enlarged (17x14x10 cm) and both ovaries and tubes were normal. She underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy with pelvic floor repair. Cut section of uterus revealed normal endometrial cavity with extreme myo-hyperplasia and cervical elongation (Fig. 3). Histopathological examination was suggestive of diffuse adenomyosis (Fig 4). Her post-operative recovery was good and she was discharged on tenth postoperative day.
DISCUSSION: Uterine adenomyosis is characterized by the presence of heterotopic endometrial glands and stroma within the myometrium, more than 2.5 mm in depth or more than one microscopic field at 10 times magnification from the endometrium–myometrium junction. Previously, it was called endometriosis interna.
The exact cause of this condition is unknown. It is hypothesized that an origin from the deep part of the endometrium would invaginate between the smooth muscle fibers of the myometrium and its spreading may be facilitated by the relative hyper-estrogenic states. The myometrium responds to this intrusion with muscular overgrowth. Epidemiological data indicate that parity, caesarean section, induced abortion, dilatation and curettage, uterine malformation and late age at menarche may be the risk factors for adenomyosis development. The need for hysterectomy to diagnose adenomyosis means that many cases go undetected, and limits our understanding of the prevalence and clinical impact.
Symptoms typically occur in women between 40 and 50 years old. Menorrhagia (91.2%), dysmenorrhoea (84.2%), lower abdominal pain (84.2%) beginning later in reproductive life is the classic presentation. The uterus is often enlarged and boggy on physical exam. About one-third of women will have no symptoms. Adenomyosis commonly co-exists with other gynecologic problems, such as endometriosis, fibroids and endometrial polyps. It is diagnosed in 20% of uterine specimens removed due to fibroids and 35-55% of all cases are found together with leiomyomas.
Adenomyosis is difficult to diagnose. Trans-vaginal sonography shows asymmetrical uterine enlargement with heterogenous myometrial echotexture, ill-defined hypo echoic areas and indistinct endometrial-myometrial border. Diffuse adenomyosis is best demonstrated on MRI T2 weighted images characterized an irregular and diffuse thickening of the junctional zone with underlying high signal foci. It is the smooth muscle changes that are easily recognized rather than foci of heterotropic glandular epithelium and stroma. A definitive diagnosis of adenomyosis can only be made from a microscopic examination of a hysterectomy specimen. Adenomyosis commonly appears within the myometrium as clusters of small cystic spaces filled with blood that have rarely a diameter greater than 5 mm. In rare cases, the lesion maybe seen as a single cyst, with a diameter ≥1 cm, filled with a chocolate-brown-coloured fluid.
Medical treatment include agents that create a hypoestrogenic (GnRH agonists, aromatase inhibitors), hyperandrogenic (danazol, gestrinone) or hyperprogestogenic (oral contraceptives, progestin’s) environment, with suppression of endometrial cell proliferation. However, medical treatments are symptomatic and not cytoreductive and are associated with adverse events impacting long-term use and adherence.
Since no medical treatment for endometriosis is universally effective, hysterectomy is a “gold standard” and definitive therapy for uterine adenomyosis, and many cases of adenomyosis have been diagnosed by pathological review retrospectively.
Review of literature shows only few case reports of such huge uterine enlargement with complete prolapse, most of which are due to uterine fibroids. Adenomyosis usually causes menstrual abnormalities with mild to moderate enlargement (Usually up to 12-14 weeks). But as in our case it can be asymptomatic with gross enlargement of uterus.
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Fig. 1: Picture showing third degree utero-vaginal prolapse
Fig. 2: MRI pelvis showing bulky uterus with altered signal pattern and poor endometrial demonstration occupying entire pelvis
Fig. 3: Cut section of uterus revealed normal endometrial cavity with extreme myo-hyperplasia and cervical elongation
Fig. 4: Histopathological slide suggestive of diffuse adenomyosis