REVIEW

Adenomyosis and endometrial ablation

Klaus J. Neis and Percy BrandnerDepartment of Obstetrics and Gynecology, Caritas Hospital St Theresia, SaarbruÈcken, Germany

ABSTRACT

Objective To present a synopsis concerning adenomyosis uteri interna withrespect to endometrial ablation. The definition of adenomyosis, differentdiagnostic methods and their effectiveness, as well as the influence ofadenomyosis on the outcome after endometrial ablation, are discussed.Design Review.Setting Obstetrics and gynaecology clinic of an academic teaching universityhospital.Results Depending on which definition is used, the incidence of adeno-myosis varies between 8 and 61%. The term `adenomyosis' should berestricted to those cases with a deeper ingrowth of glands, as only theseshow clinical symptoms. Adenomyosis can not be diagnosed or excludedwith certainty by either sonography, diagnostic hysteroscopy, or dilation andcurettage. Needle biopsies of the myometrium show low accuracy and aredifficult to obtain. Hysteroscopic resection of myometrium detects somecases of adenomyosis, but misses the majority. In patients undergoinghysterectomy after unsuccessful endometrial ablation, incidence rates of75±100% for adenomyosis were reported. Thus adenomyosis might be aprincipal reason for treatment failure. As there is no safe means ofexcluding adenomyotic foci, adenomyosis can be assumed in patientswith an enlarged uterus and marked dysmenorrhoea.Conclusion Patients with dysmenorrhoea and uteri .10 cm show a highincidence of adenomyosis. Because of an increased risk of failure, thesepatients should be excluded from endometrial ablation.

Keywords

adenomyosis, endometriosis,hysteroscopy.

Correspondence

K. J. Neis, Caritas Clinic St Theresia,Department of Obstetrics and Gynecology,Rheinstrasse 2, 66113 SaarbruÈcken,Germany.

Accepted for publication 8 September1999

INTRODUCTION

Increasingly, adenomyosis is cited as a cause of failedendometrial ablation. For this reason, several authorshave attempted to diagnose or exclude adenomyosispreoperatively. It has been suggested in various papersthat it is possible to make a preoperative diagnosis ofadenomyosis uteri interna by diagnostic hysteroscopy,1

endometrial or myometrial biopsies,2±4 ultrasound,5±7

computed tomography (CT)8 or magnetic resonanceimaging (MRI).9±13

A critical reading of these papers reveals, however,that the clinical picture of adenomyosis is not definedconsistently and that there are also differing opinions

about approaches to its diagnosis, and therefore alsoabout its correct treatment. Such a view has also beensuggested by other authors.14,15

This paper examines the following six questions inconnection with adenomyosis:

1 What exactly is adenomyosis?2 Is it possible to detect or exclude adenomyosis by

diagnostic hysteroscopy?3 Is it possible to diagnose adenomyosis using

myometrial biopsy?4 Does adenomyosis, in fact, play a significant role

in determining the outcome following endome-trial ablation?

5 Is it possible to identify patients with adenomyosis?

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6 Is there a simple way to exclude patients withadenomyosis from endometrial ablation?

1. WHAT EXACTLY IS ADENOMYOSIS?

Definition of adenomyosis

Adenomyosis occurs when the basal layer of theendometrium grows into the myometrium, with bothendometrial glands and endometrial stroma beingpresent. Since definitions vary, adenomyosis may bewidely over-diagnosed.16 For some authors, the termadenomyosis includes all cases in which the endome-trium can be detected in the myometrium at a depth ofmore than 2.5 mm,17 while for others it includes onlythose cases with glands at a depth of more than 5 mm18

Based on these varying definitions, the incidence ofadenomyosis may vary enormously, between 8 and27%. One source even quoted a rate of 61%. The meanincidence lies at 20%.18

Clinical symptoms occur only when there is a deeperingrowth of glands into the myometrium. Thus, theterm adenomyosis should be restricted to such cases.Adenomyosis is not only a disease of the endometrium.Histological findings indicate that the myometriumadjoining an area of adenomyosis is characterized byhypertrophy of the smooth musculature (Fig. 1). Thismay occasionally simulate small foci of myomas, andthereby lead to the macroscopic impression of distinctmyomas (Fig. 2). Adenomyosis is therefore notonly a disease of the endometrium, but also of themyometrium, and thus the uterus as a whole.

Clinical symptoms

The primary complaints of patients with adenomyosisare menorrhagia and dysmenorrhoea. The reasons forthis become clear if the underlying pathomorphologyis understood: The adenomyosis foci prevent acoordinated contraction, which may explain thedysfunctional menstrual bleeding. As the bleeding ofthe adenomyosis occurs in the deep musculature, thiscan create distension, pressure and the typical painexperienced during menstruation.

Adenomyosis has been found to coexist with externalendometriosis in around 10±15% of cases.

2. IS IT POSSIBLE TO DETECT OR

EXCLUDE ADENOMYOSIS BY DIAGNOSTIC

HYSTEROSCOPY?

Hysteroscopy is limited to observation of the surface ofthe endometrium, but adenomyosis is found only inthe depths of the myometrium. It is therefore notpossible to either diagnose or exclude adenomyosis byhysteroscopy. The same is true for the contactcolpomicrohysteroscopy that was widely used in thepast.

It should be noted that we are using a hysteroscope,not a microscope, and that we are looking at thesurface of an organ, not at a histological section.

3. IS IT POSSIBLE TO DIAGNOSE

ADENOMYOSIS USING MYOMETRIAL

BIOPSY?

This discussion first requires a definition of the term`endometrial biopsy'. Adenomyosis cannot be diag-nosed in the material of a fractionated curettage sinceonly the most superficial portions of the myometrium,if any at all, are collected during this procedure.

Attempts have therefore been made to obtainbiopsies from deeper segments of the uterine bodyby using transcutaneous and transcervical needlebiopsies. Such tests are complicated to perform, andthe subsequent accuracy is low.3,4,14

Under the best diagnostic conditions, the patholo-gist would have a specimen containing the fullthickness of the endometrium plus a significant layerof underlying myometrium. Such a specimen can beobtained with a resectoscopic chip from the uterinecavity. Nevertheless, the histological interpretation ofeven this type of specimen may be difficult. During the

Figure 1 Adenomyosis within the myometrium.

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histological preparation of the material, a cut must bemade at an angle of exactly 908 to the surface. Thisenables the visualization of the endometrium, includ-ing the basal layer, across the entire specimen. This isthe only method which allows an accurate calculationof the depth of ingrowth of the endometrium into themyometrium (Fig. 3). If the specimen is cut at anoblique angle, an adenomyosis uteri interna can besimulated by superficial branches of an irregular basallayer (Fig. 4).

In the majority of cases, there is only a punctiformingrowth of the adenomyosis deeply into the themyometrium at several pointsÐin contrast to carcino-mas which grow invasively over a broad frontÐso thatit is often a matter of chance whether such points arefound during the histological preparation. Pagedaset al. report that in 73% of patients who had ahysterectomy for apparent adenomyosis, this diagnosishad not been established correctly from the resecto-scopic specimens of the prior endometrial ablation.20

It is therefore possible to say that, given an adequatechip preparation, adenomyosis may be detected insome cases, but in the majority it will not be diagnosed.False-positive diagnoses are possible if the specimen iscut incorrectly during the histological preparation.

4. DOES ADENOMYOSIS, IN FACT, PLAY A

SIGNIFICANT ROLE IN DETERMINING

THE OUTCOME FOLLOWING

ENDOMETRIAL ABLATION?

According to data collected by Loffer,21 the failure ratefor endometrial ablation lies between 8 and 10%.Different results from different authors can beattributed to differences in preparation methods, in

the pharmaceutical methods of preparing the uterus,in patient age, size of the uterus, clinical symptoms,and follow-up period. In two studies the histologicalresults from patients requiring hysterectomies afterunsuccessful endometrial ablation (Table 1) wereexamined, and an incidence of adenomyosis ofbetween 75 and 100% was reported.20,22 In bothstudies, the indications for a hysterectomy followingendometrial ablation were persisting pain and/ordysfunctional bleeding.

5. IS IT POSSIBLE TO IDENTIFY PATIENTS

WITH ADENOMYOSIS?

Patients with adenomyosis uteri interna complain ofabdominal pain, primarily dysmenorrhoea. The symp-tom requiring endometrial ablation is dysfunctionaluterine bleeding which is also a symptom of adenomyo-sis. In most cases, adenomyosis results in an enlargementof the uterus. This enlargement can be either diffuseor focal, as in the case of an adenomyoma. Trueleiofibromyomas may occur concomitantly.

Imaging techniques provide the best opportunityfor preoperative diagnosis. Possible diagnostic toolsinclude ultrasound, CT, and MRI. Although theliterature increasingly includes reports about the useof MRI in adenomyosis, transvaginal ultrasound still isby far the most frequently used method for diagnosingdiseases of the female pelvis. The expensive MRIdiagnosis should be reserved for individual cases,such as when adenomyosis is suspected in a patientwho desires to become pregnant. In cases of adeno-myosis, the ultrasound typically shows an enlargeduterus. The myometrium is heterogeneous and fre-quently exhibits hypoechoic areas.

Figure 2 Macropathology of adenomyoma, according toCullen.19

Figure 3 Exact cutting of section with exposure of the entire,partly irregular basal layer.

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The main disadvantage of ultrasound diagnosis is theabsence of specific pathognomonic signs. The sono-graphic accuracy in the diagnosis of adenomyosisincreases along with the clinical and morphologicalseverity.23

6. IS THERE A SIMPLE WAY TO EXCLUDE

PATIENTS WITH ADENOMYOSIS FROM

ENDOMETRIAL ABLATION?

Since endometrial ablation represents a minimallyinvasive procedure, selection of patients who do notrequire complicated, expensive preoperative diagnos-tics is desirable. Provided the morphology and patho-physiology of adenomyosis are understood correctly,this is indeed possible.

The anamnesis of a typical patient with adenomyosisincludes complaints about dysfunctional uterine bleedingand abdominal discomfort, especially dysmenorrhoea.

Hysteroscopic findings may be completely unremark-able. Ultrasound examination usually shows anenlarged uterus, yet a normally sized uterus may also

be possible. Depending on the severity of the adeno-myosis, the myometrium may show more or fewerhypoechoic foci.

For these reasons, we recommend that patients withcombined bleeding and dysmenorrhoea should beexcluded from endometrial ablation if the uterusmeasures more than 10 cm in length. In these cases,the patient's problems may be better solved with avaginal hysterectomy than with an endometrial abla-tion. When coexistent endometriosis extragenitalis ispossible, both anamnestically and clinically, the proce-dure should be performed as a laparoscopically assistedvaginal hysterectomy so as to allow complete removalof all disease sites.24

If this principle is followed, it is expected that thefailure rate for endometrial ablation could be substan-tially reduced, possibly by more than 50%.

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Table 1 Failure rate after endometrial ablation, and frequencyof adenomyosis in hysterectomy specimens after failedendometrial ablation

Pagedas et al.20 RoÈmer22

Number of ablations 305 112Failure rate 7.8% 10.7%Adenomyosis inhysterectomy specimen

18/24 (75%) 8/8 (100%)

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