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Toronto Notes 2019 Adenomyosis
• medical
■ NSAIDs (e.g. naproxen sodium – Anaprox®) ■ 1st line
◆ cyclic/continuous estrogen-progestin (OCP)
◆ progestin (IM medroxyprogesterone (Depo-Provera®) or oral dienogest (Visanne®)) ◆ Mirena® IUS
■ 2nd line
◆ GnRH-a example: leuprolide (Lupron®): GnRH agonist (suppresses pituitary)
– side effects: hot flashes, vaginal dryness, reduced libido
– long-term use should include add-back progestin or estrogen to ameliorate vasomotor side-
effects and prevent decreased BMD ◆ danazol (Danocrine®): weak androgen
• surgical – side effects: weight gain, fluid retention, acne, hirsutism, voice change
■ conservative laparoscopy using laser, electrocautery ± laparotomy
◆ ablation/resection of implants, lysis of adhesions, ovarian cystectomy of endometriomas
■ definitive: bilateral salpingo-oophorectomy ± hysterectomy
■ best time to become pregnant is immediately after conservative surgery
■ if patient is not planning to become pregnant post-op, patient should be suppressed medically to
prevent recurrence
Adenomyosis
• synonym:“endometriosisinterna”(uterinewallmaybediffuselyinvolved)
Epidemiology
• 15%offemales>35yrold;foundin20-40%ofhysterectomyspecimens
• meanageatpresentation:40-50yrold(olderagegroupthanseeninendometriosis) • adenomyosisisacommonhistologicfindinginasymptomaticpatients
Clinical Features
• oftenasymptomatic
• heavymenstrualbleeding,secondarydysmenorrhea,pelvicdiscomfort • dyspareunia, dyschezia
• uterussymmetricallybulky,usually<14cm
• Halbansign:tender,softeneduterusonpremenstrualbimanualexam
Investigations
• clinicaldiagnosis
• U/SorMRIcanbehelpful
• endometrialsamplingtoruleoutotherpathology
Treatment
• ironsupplementsforanemia
• analgesics, NSAIDs
• OCP,medroxyprogesterone(Depo-Provera®)
• GnRHagonists(e.g.leuprolide)
• Mirena®IUS
• lowdosedanazol100-200mgPOOD(trialx4mo) • definitive: hysterectomy
Fibroids
Epidemiology
• diagnosedinapproximately40-50%ofpre-menopausalwomen>35yr
• morecommoninAfricanAmericans,wheretheyarealsolargerandoccuratearlierage • commonindicationformajorsurgeryinfemales
• minimalmalignantpotential(1:1,000)
• typicallyregressaftermenopause
Pathogenesis
• estrogenstimulatesmonoclonalsmoothmuscleproliferation
• progesteronestimulatesproductionofproteinsthatinhibitapoptosis • degenerativechanges(occurwhentumouroutgrowsbloodsupply)
■ fibroidscandegenerate,becomecalcified,developsarcomatouscomponent,orobtainparasiticblood supply
Gynecology GY13
Adenomyosis
Extension of areas of endometrial glands and stroma into the myometrium
Final diagnosis of adenomyosis is based on pathologic findings, but predictably identified on MRI