Adenomyosis is now found in young women and linked to pregnancy risks
A 2019 narrative review from Florence says adenomyosis is no longer found only after hysterectomy in older women. Imaging now finds it in young women. Researchers still lack a shared definition and classification for adenomyosis. The review reports associations between adenomyosis and infertility, miscarriage and pregnancy problems.
Key Findings
Among infertile women, adenomyosis prevalence was 24.4% at age 40 or older and 22% under 40, rising to 38.2% with recurrent pregnancy loss and 34.7% after previous ART failure.
A meta-analysis reported miscarriage rates of 31% in women with adenomyosis and 14.1% in unaffected women (relative risk 2.12, 95% CI 1.20–3.75).
Two-dimensional transvaginal ultrasound had pooled sensitivity of 83.8% and specificity of 63.9%. MRI had pooled sensitivity of 0.77 and specificity of 0.89.
Adenomyosis was associated with preterm birth (aOR 1.84, 95% CI 1.32–4.31) in one study and with pre-eclampsia (OR 21.0, 95% CI 4.8–124.5) in a retrospective case-control study.
Sonographic signs of adenomyosis appeared in 20.9% of the general population in ultrasound-unit data. Histology reports after hysterectomy gave figures from 10% to 35%.
Interpretation
The paper is a narrative review of published studies. The figures describe women who had imaging or a hysterectomy. The authors state that studies define and image the disease in different ways, which makes them hard to compare. They also state that no international guidelines exist for treatment. The review found no studies of natural conception in adenomyosis, and the fertility evidence comes from women in IVF and from surgical series.
RRM Context
Adenomyosis often occurs with endometriosis. The review cites it on ultrasound in 47.8% of patients operated on for deep infiltrating endometriosis. RRM looks for the root cause of pain, heavy bleeding and infertility, and checks every condition involved.
Our editorial summary of this paper, not the article's abstract.
Abstract
Adenomyosis is a benign uterine disorder in which endometrial glands and stroma are pathologically demonstrated in the uterine myometrium and it is considered a specific entity in the PALM-COEIN FIGO (polyp; adenomyosis; leiomyoma; malignancy and hyperplasia; coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet classified - International Federation of Gynecology and Obstetrics) classification of causes of abnormal uterine bleeding (AUB). Although it has always been considered the classic condition of multiparous women over 40 years old who have pain and heavy menstrual bleeding, diagnosed at hysterectomy, the epidemiological scenario has completely changed. Adenomyosis is increasingly identified in young women with pain, AUB, infertility, or no symptoms by using imaging techniques such as transvaginal ultrasound and magnetic resonance. However, there is no agreement on the definition and classification of adenomyotic lesions from both the histopathology and the imaging point of view, and the diagnosis remains difficult and unclear. A uniform and shared reporting system needs to be implemented in order to improve our understanding on imaging features, their relationship with pathogenic theories, and their importance in terms of clinical symptoms and response to treatment. In fact, adenomyosis pathogenesis remains elusive and not a single theory can explain all of the different phenotypes of the disease. Furthermore, adenomyosis often coexists with other gynecological conditions, such as endometriosis and uterine fibroids, increasing the heterogeneity of available data. Treatment requires a lifelong management plan as the disease has a negative impact on quality of life in terms of menstrual symptoms, fertility, and pregnancy outcome and has a high risk of miscarriage and obstetric complications.
