Algorithm for diagnosis, treatment and obstetric implications of adenomyosis

C. Grigoriu, I.A. Horhoianu, G. Călinescu, M.A. Bălan, D. Câmpean, T. Georgescu, M. Mitran, R.E. Bohîlțea

Rezumat: Adenomyosis continues to be a challenge for gynecologists, although the possibilities for diagnosis have greatly progressed. Modern imaging techniques (ultrasound, MRI) have led to precise diagnostic criteria and also the various therapeutic methods make total hysterectomy to be forgotten as the only solution for patients with adenomyosis. The anamnesis reveals dysmenorrhea (often primary), adding the progressive increase of the menstrual blood amount (up to menorrhagia). The patient may also report chronic pelvic pain, meaning dyspareunia in 10% of cases. The imaging examinations are the most valuable in helping to diagnose this pathology, because the image reflects the histopathological changes in the uterus. The most important feature of adenomyosis is the disturbance or deformation of the junctional zone (JZ), the functional layer between the endometrium and the myometrium. The ultrasound aspect depends on the variable proportion between the endometrial glandular structures, the endometrial stroma and the hypertrophic muscle elements inside the lesion. The ultrasound signs can be direct or indirect. It is considered that the presence of at least three signs outlines the imaging diagnosis of adenomyosis. We present the diagnostic ultrasound criteria as presented in the Consensus of the MUSA Group (Morphological Uterus Sonographic Assessment), 2015. For the imaging diagnosis of adenomyosis, it is considered that transvaginal ultrasound and MRI are complementary examinations. Regarding the obstetric implications of adenomyosis, the subfertility of patients with adenomyosis is discussed, with repeated failures of the assisted reproductive techniques, probably through exaggerated peristalsis at the level of JZ. During the pregnancy of patients with adenomyosis, we observe: abdominal pain, unrelated to increased contractile activity, premature contractile activity with abortion in the second trimester or even premature birth; imaging aspect of false abnormal insertion of the placenta(abnormally adherent), uterine rupture (several cases described in literature). We present some conclusions, from personal case studies – a retrospective clinical study combined with a prospective observational study.
Cuvinte cheie: adenomyosis, ultrasound, MRI, obstetric complications.