Adenomyosis: new knowledge is generating new treatment strategies

Giuseppe Benagiano; Ivo Brosens; Sabina Carrara

Disclosures

Women's Health. 2009;5(3):297-311. 

In This Article

Adenomyosis and Endometriosis

The relationship between these two endometrial disorders seems to have gone in a full circle; at the beginning of the 20th Century only one pathological definition (adenomyoma) was utilized to describe the presence of heterotopic epithelial cells, stroma and glands. To use the words of Kelly and Cullen: "In cases of adenomyoma of the uterus, we usually find a diffuse myomatous thickening of the uterine muscle. This thickening may be confined to the inner layers of the anterior, posterior or lateral walls, but in other cases the myomatous tissue completely encircles the uterine cavity. This diffuse myomatous tissue contains large or small chinks, and into these the normal uterine mucosa flows. If the chinks are small, there is only room for isolated glands, but where the spaces are goodly in size, large masses of mucosa flow into and fill them. We accordingly have a diffuse myomatous growth with normal mucosa flowing in all directions through it. The mucosa lining the uterine cavity is perfectly normal".[30]

Then came Sampson,[7,8] and endometriosis was born. From there on, the two entities remained distinct, although a link persisted since, at times, one was termed endometriosis interna and the other endometriosis externa. Then, with the identification and characterization of the myometrium JZ, connections between them began to reappear. In 1995, a study by Salamanca and Beltran investigating inner myometrial contractility in women with endometriosis found a predominantly retrograde pattern of subendometrial contractions during menstruation.[31] After this, Kunz et al, using MRI, established a significant correlation between increased JZ thickness and peritoneal endometriosis.[13] As previously mentioned, they calculated a prevalence of diffuse and focal adenomyosis in 79% of all patients with endometriosis; this reached 90% in women younger than 36 years, a prevalence of 28% in their total control group (women without endometriosis) and only 9% in their healthy control group.

These data support the hypothesis that JZ hyperplasia precedes adenomyosis and endometriosis.[32] However, this did not explain why JZ hyperplasia may develop in some women at a young age. Recently, a new link seems to have been found in a common predisposing factor: an alteration of spiral arterioles' angiogenesis.

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