Adenomyosis: a neglected disease

Adenomyosis is a heterogenous gynecologic condition. Patients with adenomyosis can have a range of clinical presentations. The most common presentation of adenomyosis is heavy menstrual bleeding and dysmenorrhea; however, patients can also be asymptomatic. Currently, there are no standard diagnostic imaging criteria, and choosing the optimal treatment for patients is challenging. Treatment including Medical and Surgical. The medications most commonly used to treat bleeding and pain in adenomyosis are hormonal treatments that induce an endometrial atrophy either by a local action (levonorgestrel intrauterine system) or by a systemic action both on the endometrium and on the hypothalamic-pituitaryovarian axis (progestogens, danazol, GnRH agonists). Adenomyosis is characterized by a decreased expression of progesterone receptors A and B in ectopic endometrial lesions, possibly related to epigenetic changes. This progesterone resistance in adenomyosis could potentially lead to an abnormal expression of progesterone receptor-related genes, to a reduced expression of implantation-related genes, and to a resistance to progestogens treatment.In symptomatic young women desiring to conceive, the concept of conservative, uterine-sparing surgery for adenomyosis is acquiring more and more consensus; nevertheless, conservative surgery has not become the standard treatment for adenomyosis yet. This is mainly because adenomyotic tissue invades the uterine muscle layer with unclear borders, determining the absence of a surgical cleavage plane, so complete excision of the affected area remains inaccurate and often causes heavy blood loss. Moreover, the excision of adenomyotic tissue is always accompanied by excision of myometrium, so it is partly destructive for the uterine wall. Therefore, the advantages of removing an affected area must be balanced against the disadvantages of leaving a possibly defective uterine wall.In 1952 the term ‘‘hysteroplasty’’ was used to describe uterine-sparing surgery in young women with extensive adenomyosis. The currently available uterine-preserving surgical options for adenomyosis could be classified as complete excision of adenomyosis (preferably used in case of localized adenomyosis), debulking surgery/ partial adenomyomectomy (preferably used in case of diffuse adenomyosis), and nonexcisional techniques, used when removal of adenomyotic tissue is not included (i.e., uterine artery ligation, electrocoagulation of myometrium, hysteroscopic and nonhysteroscopic endometrial resection/ablation). A recent review concluded that uterine-sparing surgery for adenomyosis appears to be feasible and satisfactory: After complete excision, the dysmenorrhea reduction, menorrhagia control, and pregnancy rates were found to be 82.0%, 68.8%, and 60.5%, respectively. After partial excision, the dysmenorrhea reduction, menorrhagia control, and pregnancy rates were 81.8%, 50.0%, and 46.9%, respectively.