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Adenomyosis

Definition
Adenomyosis is a condition characterized by the presence of endometrial tissue within the myometrium.
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Pathophysiology
The pathophysiology of adenomyosis involves the disruption of the endometrial-myometrial boundary, leading to the formation of ectopic endometrial glands and stroma in the myometrium.
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Epidemiology
Adenomyosis is a common condition, with prevalence estimated at 21.8% in patients undergoing surgery for endometriosis.
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Disease course
Clinically, adenomyosis is associated with heavy menstrual bleeding, pelvic pain, infertility, miscarriage, and adverse pregnancy outcomes. These symptoms can significantly impact a woman's QoL. Adenomyosis often coexists with other gynecological conditions, such as endometriosis or fibroids, which can complicate the clinical presentation.
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Prognosis and risk of recurrence
The prognosis of adenomyosis is generally benign, as it is not a malignant condition. However, it can significantly impact the QoL due to the associated symptoms.
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Key sources
The following summarized guidelines for the evaluation and management of adenomyosis are prepared by our editorial team based on guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC 2023), the European Society of Human Reproduction and Embryology (ESHRE 2023), and the Royal College of Obstetricians and Gynaecologists (RCOG 2012).
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Guidelines

1.Screening and diagnosis

Clinical presentation: recognize that adenomyosis is associated with heavy menstrual bleeding, pelvic pain, infertility, miscarriage, and adverse pregnancy outcomes.
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  • Indications for testing

2.Diagnostic investigations

Diagnostic imaging: as per SOGC 2023 guidelines, obtain a transvaginal ultrasound as first-line imaging of suspected adenomyosis in patients with heavy menstrual bleeding, pelvic pain, infertility, miscarriage, and adverse pregnancy outcomes.
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3.Medical management

Hormonal therapy: offer oral contraceptives, levonorgestrel-releasing intrauterine system, and dienogest as first-line therapy for pain and heavy menstrual bleeding in patients with adenomyosis.
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4.Therapeutic procedures

Uterine artery embolization: consider offering uterine artery embolization for heavy bleeding and pain associated with adenomyosis in patients completed child-bearing and wishing to preserve their uterus.
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  • Thermal ablation

5.Perioperative care

Correction of anemia: correct anemia (hemoglobin < 120 g/L) before adenomyomectomy given the substantial risk of intraoperative hemorrhage.
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6.Surgical interventions

Adenomyomectomy: perform adenomyomectomy as a treatment option in patients with symptomatic adenomyosis.
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  • Total hysterectomy

7.Patient education

Fertility counseling: counsel patients undergoing fertility treatments that the impact of adenomyosis on pregnancy outcomes is uncertain.
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  • Preoperative counseling