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Occasionally, endometrial glands extend into the underlying uterine tissue, or myometrium, far below the surface endometrium where they are usually found.  This condition is benign but may lead to enlargement of the uterine wall with accompanying pain.  This condition is often found in association with endometriosis.

Under the microscope, endometrial glands in stroma are present in the underlying myometrium greater than 1/2 of a low-power field (about 2.5 mm) below the endometrium.

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Prevalence and risk factors of adenomyosis at hysterectomy.

Bergholt T, Eriksen L, Berendt N, Jacobsen M, Hertz JB.

Department of Obstetrics and Gynaecology and 2Department of Pathology, Gentofte University Hospital, Niels Andersens Vej 65, 900 Hellerup, Denmark.

Hum Reprod 2001 Nov;16(11):2418-21 Abstract quote

BACKGROUND: The present study was performed to evaluate the prevalence and possible associated risk factors for adenomyosis.

METHODS: Medical records were retrieved and histo-pathological material re-examined for 549 consecutive women undergoing hysterectomy in a two-year period from 1990-1991.

RESULTS: The prevalence of adenomyosis in the study varied from 10.0-18.2%, depending on different diagnostic criteria. The presence of endometrial hyperplasia at the time of hysterectomy was the only variable significantly associated with adenomyosis (OR = 3.0; 95% CI: 1.2-8.3). No statistically significant association was found between adenomyosis and previous caesarean section, endometrial curettage or evacuation of the uterus. Furthermore, we did not see any significant association between adenomyosis and pain-related symptoms, indication for hysterectomy, age, parity or number of myometrial samples.

CONCLUSIONS: Our study stresses the need for precise diagnostic criteria for adenomyosis, and furthermore indicates that endometrial hyperplasia and adenomyosis may have a common aetiology.

Adenomyosis at hysterectomy: prevalence and relationship to operative findings and reproductive and menstrual factors.

Vavilis D, Agorastos T, Tzafetas J, Loufopoulos A, Vakiani M, Constantinidis T, Patsiaoura K, Bontis J.

2nd Department of Obstetrics and Gynaecology, Aristotelian University of Thessaloniki, Greece.

Clin Exp Obstet Gynecol 1997;24(1):36-8 Abstract quote

In order to estimate the frequency and risk factors for adenomyosis, the clinical records of 594 women undergoing hysterectomy were retrieved.

Data were collected on indications for the intervention, age at surgery, age at menarche, parity, abortions, mode of delivery, abnormal uterine bleeding, dysmenorrhea, and menopausal status at surgery. Adenomyosis was found in 116 of the 594 patients (19.5%). A pathologic condition was present in 63 patients with fibroids (20.5%), 11 with genital prolapse (25.6%), 11 with benign ovarian tumors (17.8%), six with endometrial hyperplasia (13.6%), two with cervical cancer (18.2%), ten with endometrial cancer (16.1%), and 13 with ovarian cancer (21.3%). No relationship was found between adenomyosis and endometriosis. On the contrary, a strong relationship was found between adenomyosis and parity, cesarean section, induced abortions, dysmenorrhea, abnormal uterine bleeding, and late age at menarche.

These results show that adenomyosis is a common pathologic finding, significantly related to reproductive and menstrual characteristics of the patients.


Adenomyosis in endometriosis--prevalence and impact on fertility. Evidence from magnetic resonance imaging.

Kunz G, Beil D, Huppert P, Noe M, Kissler S, Leyendecker G.

Departments of Obstetrics and Gynaecology, Radiology I, Academic Teaching Hospital to the Universities of Frankfurt and Heidelberg/Mannheim, Klinikum Darmstadt, Darmstadt, Germany, and Present addresses: Department of Obstetrics and Gynecology, St.-Johannes-Hospital Dortmund, Germany.
Hum Reprod. 2005 May 26; [Epub ahead of print] Abstract quote  

BACKGROUND: The hypothesis is tested that there is a strong association between endometriosis and adenomyosis and that adenomyosis plays a role in causing infertility in women with endometriosis.

METHODS. Magnetic resonance imaging of the uteri was performed in 160 women with and 67 women without endometriosis. The findings were correlated with the stage of the disease, the age of the women and the sperm count parameters of the respective partners.

RESULTS: The posterior junctional zone (PJZ) was significantly thicker in women with endometriosis than in those without the disease (P<0.001). There was a positive correlation of the diameter of the PJZ with the stage of the disease and the age of the patients. The PJZ was thicker in patients with endometriosis with fertile than in patients with subfertile partners. The prevalence of adenomyotic lesions in all 160 women with endometriosis was 79%. In women with endometriosis below an age of 36 years and fertile partners, the prevalence of adenomyosis was 90% (P<0.01)

CONCLUSIONS: With a prevalence of up to 90%, uterine adenomyosis is significantly associated with pelvic endometriosis and constitutes an important factor of sterility in endometriosis presumably by impairing uterine sperm transport.



Immunohistochemical assessment of superoxide dismutase expression in the endometrium in endometriosis and adenomyosis.

Ota H, Igarashi S, Hatazawa J, Tanaka T.

Department of Obstetrics and Gynecology, Akita University School of Medicine, Akita-city, Japan.

Fertil Steril 1999 Jul;72(1):129-34 Abstract quote

OBJECTIVE: To determine the expression of superoxide dismutase (SOD) in the endometrium during the menstrual cycle in endometriosis and adenomyosis.

DESIGN: Immunohistochemical identification of SOD in endometrial tissues using the monoclonal antibody.

SETTING: Department of obstetrics and gynecology in a university hospital.

PATIENT(S): The subjects were divided into three groups: 36 patients with endometriosis, 38 patients with histologically proven adenomyosis, and 47 fertile control subjects.

INTERVENTION(S): Endometrium was biopsied throughout the menstrual cycle. MAIN

OUTCOME MEASURE(S): Semiquantitative immunostaining (evaluation nomogram) score for endometrial cells.

RESULT(S): The analyses revealed phase-dependent changes in the expression of SODs in the glandular and surface epithelia during the menstrual cycle in fertile controls. Specifically, the expression of copper, zinc SOD was weakest in the early and midproliferative phases, then gradually increased, and was most marked in the early and midsecretory phases. The expression of manganese SOD reached a peak in the late secretory phase. The expression of both SODs in endometriosis and adenomyosis was persistently higher than the control levels throughout the menstrual cycle.

CONCLUSION(S): The exaggerated expression of both SODs in the endometrium throughout the menstrual cycle suggests that superoxide plays a key role in infertility in endometriosis and adenomyosis.

Adenomyosis--a result of disordered stromal differentiation.

Parrott E, Butterworth M, Green A, White IN, Greaves P.

Medical Research Council Toxicology Unit, Hidgkin Building, Lancaster Rd., Leicester LE1 9HN, United Kingdom.

Am J Pathol 2001 Aug;159(2):623-30 Abstract quote

Adenomyosis is a fairly frequent disorder in adult women characterized by the haphazard location of endometrial glands and stroma deep within the myometrium of the uterus.

This study compared the effects on uterine development of the selective estrogen receptor modulators, tamoxifen, toremifene, and raloxifene with estradiol when given orally to female mice on days 2 to 5 after birth. Uterine adenomyosis was found in all (14 of 14) mice dosed with tamoxifen and most mice (12 of 14) treated with toremifene, but in none of the vehicle-dosed controls, in only one animal treated with raloxifene at 42 and 90 days after dosing and in none of the mice treated with estradiol at 42 days. At 6 days, the uterus in the groups that developed a high incidence of adenomyosis showed histological evidence of disturbed differentiation of the myometrium. Gene-expression XY-scatterplots using Clontech mouse 1.2 Atlas mouse cDNA expression arrays analyzing total uterine RNA showed nerve growth factor-alpha, preadipocyte factor-1, and insulin-like growth factor-2 were key genes differentially modified by tamoxifen or toremifene treatment, relative to the controls.

As these genes may play an important role in regulating differentiation and development of the myometrium, these data suggest that adenomyosis may be caused primarily by defects in the formation of the myometrium.

Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium.

Propst AM, Quade BJ, Gargiulo AR, Nowak RA, Stewart EA.

Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Menopause 2001 Sep-Oct;8(5):368-71 Abstract quote

OBJECTIVES: Basic fibroblast growth factor (bFGF) is an angiogenic growth factor present in human endometrium and myometrium. Women with leiomyoma-related abnormal uterine bleeding have local dysregulation of bFGF and its type 1 receptor (FGF-R). This study was designed to evaluate if adenomyosis expresses bFGF and FGF-R, and if present, to compare bFGF and FGF-R expression in adenomyosis and autologous endometrium.

DESIGN: Menopausal uteri containing endometrium and adenomyosis were analyzed using immunohistochemistry with monoclonal antibodies specific for bFGF, FGF-R, and proliferating cell nuclear antigen (PCNA), a marker of cellular proliferation. The expression and intensity of staining for bFGF, FGF-R, and PCNA were evaluated in the glandular epithelium and stroma of adenomyosis and endometrium.

RESULTS: Glandular epithelial staining was significantly greater in adenomyosis compared with autologous endometrium for bFGF and FGF-R. Stromal staining for bFGF and PCNA was significantly increased in adenomyosis compared with autologous endometrium.

CONCLUSIONS: Upregulation of the bFGF receptor/ligand system and increased cellular proliferation in adenomyosis may contribute to the pathogenesis of abnormal uterine bleeding associated with adenomyosis.




Adenomyosis: prospective comparison of MR imaging and transvaginal sonography.

Ascher SM, Arnold LL, Patt RH, Schruefer JJ, Bagley AS, Semelka RC, Zeman RK, Simon JA.

Department of Radiology, Georgetown University Medical Center, Washington, DC 20007.

Radiology 1994 Mar;190(3):803-6 Abstract quote

PURPOSE: To prospectively compare conventional spin-echo magnetic resonance (MR) imaging and transvaginal sonography for the diagnosis of adenomyosis.

MATERIALS AND METHODS: Twenty women with clinically suspected adenomyosis underwent MR imaging and transvaginal sonography performed within 3 months of each other. Pathologic proof was obtained in all cases.

RESULTS: Seventeen patients were proved to have adenomyosis. The correct diagnosis was achieved with MR imaging in 15 of 17 cases. One false-positive and two false-negative diagnoses were made with MR imaging. With transvaginal sonography, nine of 17 cases of adenomyosis were correctly diagnosed. One false-positive and eight false-negative diagnoses occurred. The most frequent cause of false-negative diagnoses with transvaginal sonography was the misinterpretation of adenomyosis as leiomyomas (seven cases).

CONCLUSION: MR imaging is significantly better (P < .02) than transvaginal sonography in the diagnosis of adenomyosis.

Transvaginal ultrasound in the diagnosis of diffuse adenomyosis.

Atzori E, Tronci C, Sionis L.

Department of Obstetrics and Gynecology, Ospedale S. Giuseppe, Isili, Italy.

Gynecol Obstet Invest 1996;42(1):39-41 Abstract quote

The purpose of this study is to evaluate the diagnostic capability of transvaginal ultrasound in detecting diffuse adenomyosis.

One hundred and seventy-five women, mean age 45.8 years (range 37-62), were studied by TV ultrasound before hysterectomy for benign uterine pathology. The sonographer diagnosed adenomyosis in 19 patients, whereas the pathologist diagnosed adenomyosis in 15 women making ex novo diagnoses in 2 cases. The sensitivity of TV ultrasound was 86.6%, the specificity 96.2%, the positive predictive value 68.4%, and the negative predictive value 98%.

In conclusion, this study showed that TV ultrasound is an important and advanced tool in the diagnosis of diffuse adenomyosis.

Magnetic resonance imaging and transvaginal ultrasonography for the diagnosis of adenomyosis.

Dueholm M, Lundorf E, Hansen ES, Sorensen JS, Ledertoug S, Olesen F.

Department of Gynecology and Obstetrics, Aarhus University and Aarhus University Hospital, Aarhus, Denmark.

Fertil Steril 2001 Sep;76(3):588-94 Abstract quote

OBJECTIVE: To compare the diagnostic potential of magnetic resonance imaging (MRI) and transvaginal ultrasonography (TVS) in the diagnosis of adenomyosis.

DESIGN: Double blind set-up.

SETTING: University medical school.

PATIENT(S): We studied 106 consecutive premenopausal women who underwent hysterectomy for benign reasons.

INTERVENTION(S): Transvaginal ultrasonography and MRI were compared with histopathologic examination as the golden standard.


RESULT(S): Twenty-two (21%) patients had adenomyosis. The sensitivity and specificity were as follows: sensitivity: MRI 0.70 (0.46-0.87) and TVS 0.68 (0.44-0.86) (P=.66); specificity: MRI 0.86 (0.76-0.93) and TVS 0.65 (0.50-0.77) (P=.03). The combination of MRI and TVS was most sensitive (0.89 [0.64-0.98]), but produced the lowest specificity (0.60 [0.44-0.73]). Adenomyosis was not detected by either MRI or TVS at uterine volumes >400 mL. Exclusion of uteri >400 mL from the analysis improved the diagnostic precision of MRI, but not that of TVS. The diagnostic accuracy at MRI was improved by calculating the maximum difference between the thinnest and thickest junctional zone (JZdif) (i.e., > or =5-7 mm).

CONCLUSION(S): Magnetic resonance imaging was superior to TVS for the diagnosis of adenomyosis. Magnetic resonance imaging had a higher specificity than TVS, but their sensitivities were in line. The diagnostic accuracy of MRI, as that of TVS, was at an intermediate level, but the diagnostic accuracy of the former improved by exclusion of uteri >400 mL. 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.

Ultrasonography compared with magnetic resonance imaging for the diagnosis of adenomyosis: correlation with histopathology.

Bazot M, Cortez A, Darai E, Rouger J, Chopier J, Antoine JM, Uzan S.

Departments of Radiology, Pathology and Obstetrics and Gynecology, Hopital Tenon, 4 rue de la Chine, 75020, France.

Hum Reprod 2001 Nov;16(11):2427-33 Abstract quote

BACKGROUND: The objective of this study was to compare the accuracy of transabdominal (TAUS) and transvaginal sonography (TVUS) and magnetic resonance imaging (MRI) for the diagnosis of adenomyosis, and to correlate imaging with histological findings.

METHODS: In a prospective study, 120 consecutive patients referred for hysterectomy underwent TAUS, TVUS and MRI. Results of these examinations were interpreted blindly to histopathological findings.

RESULTS: Histological prevalence of adenomyosis and leiomyomas was 33.0 and 47.5% respectively. Adenomyotic uteri were accompanied by additional pelvic disorders in 82.5% of cases. Sensitivity, specificity, and positive and negative predictive values of TAUS and TVUS were 32.5 and 65.0%, 95.0 and 97.5%, 76.4 and 92.8%, and 73.8 and 88.8% respectively. Myometrial cyst was the most sensitive and specific TVUS criterion. In MRI, the presence of a high-signal-intensity myometrial spot was as specific but less sensitive than a maximal junctional zone thickness (JZ(max)) >12 mm and a JZ(max) to myometrial thickness ratio >40%. Sensitivity, specificity, and positive and negative predictive values of MRI were 77.5, 92.5, 83.8 and 89.2% respectively. No difference in accuracy was found between TVUS and MRI, but sensitivity was lower with sonography in women with associated myomas.

CONCLUSIONS: TVUS is as efficient as MRI for the diagnosis of adenomyosis in women without myoma, while MRI could be recommended for women with associated leiomyoma.


ADENOMYOMA This describes a focus of adenomyosis within a leiomyoma (fibroid).  Both conditions are common so it is not suprising that this overlap or collision condition may occur.

Adenomyosis as a Major Cause for Laparoscopic-Assisted Vaginal Hysterectomy for Chronic Pelvic Pain

Carter JE, Kong I I.

Women's Health Center of South Orange County, 26732 Crown Valley Pkwy., Suite 541, Mission Viejo, CA 92691.

J Am Assoc Gynecol Laparosc 1994 Aug;1(4, Part 2):S6 Abstract quote

Ninety-three women in whom conservative surgical therapy for chronic pelvic pain failed required hysterectomy for control of their disabling condition. In 22 of these 93 patients (24%), adenomyosis was the major pathologic finding. In 10 of the 22 (45%) women who had adenomyosis and required hysterectomy for control of their pain, tubal ligation had been previously performed. Only 15% (11/71) of patients without adenomyosis had had a tubal ligation.

Over 23% of patients requiring hysterectomy for control of chronic severe pelvic pain had adenomyosis, and almost half of these women had had a tubal ligation performed. The possible relationship of adenomyosis to a previous tubal ligation has been explored.

Adenomyosis at hysterectomy: a study on frequency distribution and patient characteristics.

Vercellini P, Parazzini F, Oldani S, Panazza S, Bramante T, Crosignani PG.

Clinica Ostetrica e Ginecologica Luigi Mangiagalli, Department of Obstetrics and Gynaecology, University of Milano, Italy.

Hum Reprod 1995 May;10(5):1160-2 Abstract quote

To evaluate the prevalence and risk factors for adenomyosis, the clinical records of consecutive women undergoing hysterectomy during a 3 year period were retrieved.

Data were collected on indication for the intervention, general sociodemographic characteristics of the patients, age at menarche, parity, abortions, and menopausal status at surgery. Adenomyosis was diagnosed in 332 of the 1334 cases (24.9%). The condition was present in 146 of the 627 patients (23.3%) with fibroids and menorrhagia, 68 of the 265 (25.7%) with prolapse, 21 of the 98 (21.4%) with ovarian cysts, 19 of the 100 (19%) with cervical cancer, 31 of the 110 (28.2%) with endometrial cancer, 16 of the 57 (28.1%) with ovarian cancer, and 19 of the 77 (24.7%) with miscellaneous indications. These differences were not statistically significant (chi 2(6) = 11.14). In comparison with nulliparous women, the odds ratio was 1.3 and 1.5 respectively in women with one and > or = two births (chi 2(1) trend = 5.76 P < 0.05). No relationship was found between age at surgery, age at menarche, indications for surgery, menopausal status at intervention, and presence of endometriosis.

Our findings do not support the notion that adenomyosis is more frequently related to particular clinical conditions, and suggest that parity may be associated with an increased frequency of adenomyosis.



Pathologic findings from the Maryland Women's Health Study: practice patterns in the diagnosis of adenomyosis.

Seidman JD, Kjerulff KH.

Department of Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Baltimore, USA.

Int J Gynecol Pathol 1996 Jul;15(3):217-21 Abstract quote

Criteria for the diagnosis of adenomyosis vary widely in practice. The reported frequency of adenomyosis in hysterectomy specimens varies from 5-70% in published series.

In this study, 1252 pathology reports on hysterectomy specimens from women enrolled in the Maryland Women's Health Study were reviewed. The frequency of adenomyosis was calculated based on two subgroups: 1114 reports from 15 hospitals, and 705 reports signed by 25 pathologists. The frequency of diagnosis of adenomyosis ranged from 12% to 58% among the 15 hospitals, and 10% to 88% among the 25 pathologists. This wide variation could not be explained by differences in patient age or number of pregnancies, factors known to correlate with the frequency of adenomyosis.

These data suggest that adenomyosis may be overdiagnosed. Stringent and widely accepted criteria for the diagnosis of adenomyosis are needed, as epidemiologic studies of this common condition would be facilitated by the use of standard criteria in practice.

Pathogenetic role of the stromal cells in endometriosis and adenomyosis.

Mai KT, Yazdi HM, Perkins DG, Parks W.

Department of Laboratory Medicine, Ottawa Civic Hospital, Ontario, Canada.

Histopathology 1997 May;30(5):430-42 Abstract quote

Ten cases of endometriosis of bowel, ovaries, uterine serosa and 10 cases of adenomyosis were studied.

Blocks of tissue with areas of interest were submitted for serial sectioning of the entire block. Some sections were immunostained for oestrogen receptor, vimentin, Ber-EP-4 and cytokeratins. The common finding was the presence of type 1 nodules, consisting of isolated nodules of endometrial stromal cells without endometrial glands, along blood or lymphatic vessels. The stromal cells showed positive immunoreactivities for oestrogen receptor and vimentin, and negative reactivities for cytokeratins. Due to the absence of connection with adjacent endometriosis or adenomyosis, it is likely that these endometrial stromal nodules arise from the multipotential pericytes. In addition, in serosa of all cases of endometriosis, type 2 nodules, having adjacent mesothelium (Ber-EP4-) changing into epithelium (Ber-EP4+) and type 3 nodules, with non-endometrial epithelium (oestrogen receptor-) changing into endometrial gland (oestrogen receptor+) were identified. We believe that the formation of type 1 nodules from the pericytes and the transformation of the mesothelium into endometrial glands in type 2 and 3 nodules are accomplished through the process of induction by the endometrial stroma, and the proliferation is controlled by genetic, hormonal and immunological factors.

Type 1, 2 and 3 nodules are likely to represent a histological continuum in the development of early endometriosis. Subsequent to the formation of endometriosis in the serosa, the pathway of development of endometriosis and adenomyosis is similar. Through the processes of induction and proliferation there is an increase in size of the stroma of type 1 nodules and that of endometrial tissue with subsequent fusion of the stroma of type 1 nodules and that of foci of adenomyosis or endometriosis. Consequently, there is enlargement of the stroma of the foci of adenomyosis or endometriosis. The 'newly enlarged stroma' serves as 'new soil' for further growth of the endometrial glands in the endometrial tissue.


Adenomyosis with sparse glands. A potential mimic of low-grade endometrial stromal sarcoma.

Goldblum JR, Clement PB, Hart WR.

Department of Anatomic Pathology, Cleveland Clinic Foundation, OH 44195.

Am J Clin Pathol 1995 Feb;103(2):218-23 Abstract quote

Most cases of adenomyosis are easily recognized by the presence of intramyometrial aggregates of endometrial glands and endometrial stromal cells surrounded by hypertrophic smooth muscle.

The authors report seven cases of adenomyosis with sparse glands, which was a finding that initially caused difficulties in diagnosis and raised the question of low-grade endometrial stromal sarcoma (LGESS). The patients' ages ranged from 51 to 81 years. All were postmenopausal. Each had undergone hysterectomy for a variety of reasons unrelated to the adenomyosis. Microscopic examination of the uteri disclosed multiple intramural nests of adenomyotic endometrial stromal cells without endometrial glands, ranging from 0.5 mm to 8.0 mm in maximum dimension. The percentage of adenomyotic foci without glands in each case ranged from 40% to 94%. Two cases also had foci of intravascular intrusion by the gland-poor adenomyotic stroma.

The most useful features for differentiating adenomyosis with sparse glands from LGESS include: (1) its occurrence as an incidental finding in uteri removed for other reasons; (2) the microscopic size of the adenomyotic foci without grossly evident tumor nodules; (3) a distinctive concentric zonal organization of the gland-poor stromal aggregates, with less cellular pale centers surrounded by a thin rim of stromal or smooth muscle cells with increased cellularity, often with a thicker, but less well-defined, peripheral zone of hypertrophic myometrial smooth muscle; (4) the atrophic appearance of the stromal cells and absence of nuclear atypia and mitotic figures; (5) an absence of sclerotic areas, foam cells, sex cordlike structures, hemangiopericytoma-like vascular pattern, prominent vascular invasion and extrauterine extension commonly found in LGESS; (6) the presence of typical adenomyosis with glands elsewhere in the myometrium; and (7) the postmenopausal age of the patient.


Morphometric evaluation of stromal vascularization in the endometrium in adenomyosis.

Ota H, Igarashi S, Tanaka T.

Department of Obstetrics and Gynecology, Akita University School of Medicine, Japan.

Hum Reprod 1998 Mar;13(3):715-9 Abstract quote

A computerized morphometric investigation of stromal vascularization in the endometrium during adenomyosis was performed retrospectively.

Using a polyclonal antibody and a peroxidase-antiperoxidase method, formalin-fixed paraffin sections of the tissue were stained for von Willebrand factor, a marker for endothelium. The subjects were divided into two groups: 42 patients with histologically proven adenomyosis and 29 fertile control subjects, 12 in the proliferative phase and 17 in the secretory phase. Objective quantitative colour image analysis was used to assess the staining intensity and hence the degree of vascularization. In the control group, stromal vascularization increased in the secretory phase.

In adenomyosis, vascularization increased markedly, up to 11.6 times that of the controls, in terms of the in total surface area of capillaries per mm2 in the endometrium in the proliferative phase. These findings suggest clinical relevance to severe functional disturbances such as hypermenorrhoea or iron deficiency anaemia.


Adenomyosis with a sex cord-like stromal element.

Fukunaga M.

Department of Pathology, The Jikei University School of Medicine, Tokyo, Japan.

Pathol Int 2000 Apr;50(4):336-9 Abstract quote

A case of adenomyosis with a sex cord-like stromal element is described. The element was an incidental, solitary, microscopic finding in a focus of adenomyosis. It was characterized by cord and trabecular arrangements of round to polygonal shaped cells in the endometrioid stroma. The cells were immunohistochemically positive for desmin and alpha-smooth muscle actin but negative for sex cord markers (alpha-inhibin and O13).

The element appears to originate from the endometrial stromal cells through smooth muscle metaplasia.



CD10 Immunostaining Does Not Distinguish Endometrial Carcinoma Invading Myometrium From Carcinoma Involving Adenomyosis.

Srodon M, Klein WM, Kurman RJ.

Am J Surg Pathol. 2003 Jun;27(6):786-9. Abstract quote

The distinction of involvement of adenomyosis by endometrial carcinoma from endometrial carcinoma invading the myometrium can at times be difficult. This distinction, however, is important from the standpoint of staging, treatment, and prognosis because the outcome of carcinoma invading the myometrium as compared with involving adenomyosis is significantly worse. CD10 has been recently reported to be expressed by normal and neoplastic endometrial stromal cells. We therefore hypothesized that CD10 may be helpful in distinguishing carcinoma within adenomyosis from endometrial carcinoma directly invading the myometrium.

Twenty-two cases of invasive endometrioid adenocarcinoma were identified from the surgical pathology files of the Johns Hopkins Hospital and consultation files of one of the authors (R.J.K.) and immunostained for CD10, desmin, and caldesmon. The pattern of staining was compared with five cases in which carcinoma was confined to adenomyosis. As a control, 14 cases of adenomyosis unassociated with carcinoma were included in the analysis.

All 22 endometrial carcinomas that invaded the myometrium expressed CD10 to some extent in cells immediately surrounding the neoplastic glands. In 18, all of the invasive nests displayed CD10 in surrounding cells, but in four cases the staining was patchier, involving the surrounding cells of approximately 50-75% of the invasive nests. In four cases of myoinvasive carcinoma, the CD10-positive cells surrounding the nests of invasive carcinoma were also positive for desmin and caldesmon. In the remaining 18 cases with myoinvasive carcinoma, the cells surrounding the carcinomas failed to react with desmin and caldesmon. All five endometrial carcinomas involving adenomyosis displayed CD10 positivity in what appeared to be endometrial stromal cells surrounding the neoplastic glands. The stromal cells were negative for desmin and caldesmon. The control cases of adenomyosis were all positive for CD10, although in four cases the staining was patchy compared with 10 cases in which it was diffuse. Desmin and caldesmon were negative in all of these cases.

Although CD10 identifies endometrial stromal cells in the endometrium and in adenomyosis and endometriosis, this study demonstrates that CD10 does not aid in distinguishing myometrial invasion of endometrial carcinoma from involvement of adenomyosis by endometrial carcinoma because the cells surrounding the tumor in the myoinvasive group express CD10.



Successful pregnancy in a series of patients with adenomyosis.

Nezhat CH, Kane L, Abolfathian P, Nezhat FR, Nezhat CR.

Stanford University School of Medicine, Atlanta, GA, USA

Obstet Gynecol 2001 Apr;97(4 Suppl 1):S22 Abstract quote

Objective: To report the surgical technique and pregnancy outcome in a series of patients with adenomyosis.

Methods: This is an observational study of patients who underwent laparoscopy or laparoscopically assisted cytoreductive surgery for symptomatic enlarged uterus due to uterine myoma or adenomyosis or both who desired to preserve their reproductive system.

Results: We present a series of nine patients-mean age 36.2 years (range, 31-41 years), mean gravida 1.7, para 0.3, with histologically confirmed adenomyosis or ademyoma-who achieved pregnancy. The average length of time from surgery to conception was 6.9 months (range, 3-14). One patient was treated preoperatively with danazol (case 1); one with nafarelin acetate (case 2); and two with oral contraceptive pills (cases 4, 6). Five patients conceived spontaneously (cases 2, 4, 5, 7, 9). Two patients used clomiphene citrate and intrauterine insemination (cases 1, 3); one used clomiphene citrate and timed intercourse (case 8). Case 6 had in vitro fertilization. Five patients carried to term (cases 1, 2, 3, 4, 8); one had a cesarean birth at 36 weeks, delivering twins (case 6); one is currently in the second trimester (case 5); and two patients had missed abortion at 12 and 9 weeks (cases 7, 9). The most common associated pathologies were endometriosis (56%), adhesions (56%), and leiomyomata (22%).

Conclusion: Adenomyosis theoretically is associated with infertility, and hysterectomy has been considered the treatment of choice. However, previous anecdotal case reports and our series indicate that in patients with adenomyosis who desire pregnancy, there is a good chance for successful pregnancy after cytoreductive surgery.

Adenocarcinomas Arising from Uterine Adenomyosis: A Report of Four Cases

Masafumi Koshiyama; Akira Suzuki; Mitsuru Ozawa; Kohei Fujita; Atsuko Sakakibara; Makoto Kawamura; Shugen Takahashi; Haruko Fujii; Takeshi Hirano; Atsuhiko Okagaki; Tadayoshi Nagano; Chiaki Ban

From the Department of Obstetrics and Gynecology (M.K., A.S., M.O., K.F., A.S., M.K., S.T., H.F., T.H., A.O., T.N., C.B.), Osaka National Hospital, Chuoku, Osaka 540-0006, Japan, and the Department of Obstetrics and Gynecology (M.Ko.), Himeji National Hospital, Himeji City, Hyogo 670-8520, Japan.

Int J Gynecol Pathol 2002 Jul;21(3):239-45 Abstract quote

Adenocarcinomas arising from adenomyosis uteri are rare.

This study reports four such cases and characterizes them clinically and microscopically. In all four patients, the endometrial cytology was negative, and MR imaging and ultrasound sonography did not detect the tumors preoperatively.

The histological subtypes of the four tumors were endometrioid (one grade 1, one grade 3), serous, and clear cell. In three cases, the adenocarcinomas were present exclusively in the myometrium, and a transition between the carcinomas and the adenomyotic glands was observed in all cases. The eutopic endometrium was normal except in one case in which there was a small focus of invasive carcinoma. In two of four cases, pelvic or paraaortic lymph node metastases were present. In the carcinomas, ER immunoreactivity was not found in any tumor and PR positivity was found in only one tumor. In contrast, p53 immunopositivity was found in three of four carcinomas.

Adenocarcinomas arising from adenomyosis are difficult to diagnose preoperatively, and their aggressive behavior in some cases seems to be related to the histological subtype.

Endometrioid adenocarcinoma arising from adenomyosis: report and immunohistochemical analysis of an unusual case.

Sasaki T, Sugiyama T, Nanjo H, Hoshi N, Murakami M, Sugita A, Takahashi M, Kawamura K, Ono I, Masuda H.

Department of Pathology, Nakadori General Hospital, Yokohama, Japan.

Pathol Int 2001 Apr;51(4):308-13 Abstract quote

A case of endometrioid adenocarcinoma arising from adenomyosis is reported. The patient was a 53-year-old woman who complained of vulvar itching.

Smear cytology of the endometrium revealed adenocarcinoma. Magnetic resonance imaging of the pelvis revealed a lesion with a slightly high intensity in the uterine fundus on a T2-weighted image. Semiradical total hysterectomy and bilateral adnexectomy were performed, followed by chemotherapy. Histologically, the lesion in the uterine fundus was composed mostly of adenocarcinoma with stromal invasion. There were many adenomyotic foci in and around the carcinoma, including some showing transition to adenocarcinoma. There was no malignant finding in the normally situated endometrium. The carcinoma invaded in the myometrium, involving the uterine serosa, but no dissemination to the peritoneal cavity was found.

The carcinoma was, therefore, considered to be endometrioid adenocarcinoma arising from adenomyosis. Immunohistochemistry showed expression of p53 oncoprotein and Ki-67 antigen in the carcinoma cells. The value of immunohistochemistry in predicting prognosis is discussed.

Endometrioid adenocarcinoma arising from adenomyosis.

Takai N, Akizuki S, Nasu K, Etoh Y, Miyakawa I.

Department of Obstetrics and Gynecology, Oita Medical University, Hasama-machi, Oita, Japan

Gynecol Obstet Invest 1999;48(2):141-4 Abstract quote

In spite of many references to carcinoma arising from endometriosis at extrauterine sites, there are few documented cases of carcinoma developing in association with adenomyosis.

We present 2 rare cases of adenocarcinoma arising from adenomyosis. The relationship between prior frequent estrogen use and carcinogenesis and the possible effects of chemotherapy and radiation therapy are reviewed.


Live birth after conservative surgery for severe adenomyosis following magnetic resonance imaging and gonadotropin-releasing hormone agonist therapy.

Ozaki T, Takahashi K, Okada M, Kurioka H, Miyazaki K.

Department of Obstetrics and Gynecology, Shimane Medical University, Izumo, Japan.

Int J Fertil Womens Med 1999 Sep-Oct;44(5):260-4 Abstract quote

This is a report of a live birth after conservative surgery for severe adenomyosis following diagnosis by MRI and therapy with GnRH-a.

A 33-year-old gravida 1 para 1 woman with a 5-year history of secondary infertility received a gonadotropin-releasing hormone agonist (GnRH-a), leuprolide acetate, for 16 weeks to control symptoms of severe adenomyosis and to treat infertility. However, severe dysmenorrhea recurred after the discontinuation of therapy. Because an elevated serum level of CA-125 and MRI findings suggested that she was experiencing a relapse of adenomyosis, GnRH-a therapy was re-instituted. After 24 weeks of the second therapy, her uterus decreased to normal size and an MRI revealed a localized low-signal-intensity myometrial mass with well-defined borders.

We easily resected the localized lesion of adenomyosis using the same technique used to treat uterine leiomyoma. The patient became pregnant after 12 weeks of additional danazol therapy. A healthy male infant was delivered at term by cesarean section.

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