ADENOMYOSIS: A CLINICO-PATHOLOGICAL STUDY
                     ADENOMYOSIS: A CLINICO-PA'l'HOLOGICAL STUDY 
By 
ASHWINI R. BHALERAO, MALAVIKA A. VIDWANS, S. S. KHANDEPARKA~ 
A. A. PANDIT, I. M. VORA AND S. S. SHETH 
SUMMARY 
..,. The diagnosis of adenomyosis is underestimated clinically as 
well as histopathologically. To find out the true incidence of 
adenomyosis and clinicopathological profile of women having adeno-
myosis, a prospective study was undertaken. One, hundred succes-
sive women undergoing hysterectomy for various indications were 
studied. The incidence of adenomyosis was 15% by routine 
sections which increased to 25% by taking extra sections. This 
signifies that to rule out adenomyosis, extra sections should be 
taken in all cases of suspected DUB, adenomyosis and fibroid 
uterus. Maximum incidence of adenomyosis was seen in 4th and 
5th decade of life and in multiparous women having 3 or more 
deliveries, 72% women had history of last delivery 10 years 
earlier. Most of the endometria showed proliferative phase or 
cystic hyperplasia. Leiomyoma was the commonest associated 
lesion. All these factors indicate prolonged action of estrogens 
uninhibited by progesterone leading to development of adeno-
myosis. 
Introduction Mat erial and Methods 
The diagnosis of adenomyosis i.e. in- To eliminate all these factors and find 
ternal endometriosis is usually under- out the true incidence of adenomyosis 
estimated clinically because of obvious and clinicopathological profile of women 
difficulties in the diagnosis. The cases having adenomyosis, we undertook a 
,. labelled as 'DUB' preoperatively may prospective study in collaboration with 
turn out to be those of adenomyosis the "Pathology Department". 100 succes-
histopathologically. But even histopatho- sive women undergoing hysterectomy 
logical diagnosis may be missed due to for various indications were studied. 
lack of taking adequate number of sec- Their history and preoperative clinical 
tions. findings were noted. After hysterectomy, 
every specimen of the uterus was weigh-
From : Department of Obstetrics and Gynaeco· 
ed without tubes and ovaries. 
logy and Pathology, K.E.M. Hospital, Parel, Bom· 
ba-j 400 012. Routinely only 1 random section is 
Accepted for publication on 24-5·89 . taken from the uterus which may not be 
716 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA 
of full thickness. In our study, alongwith TABLE I 
roui ine section&, 6 extra sections were Adenomyosis-Correlation with Parity 
taken from various predetermined sites 
No. of Children No. of % 
viz. right, miC: and left anterior walls cases 
and right mid and left posterior walls 
0 - 2 5 20.t'O 
including the whole thickness of myo-
3 - 4 14 56.00 
meLrlum. Adenomyosis was diagnosed if More than 4 6 24.00 
endometrial gJa11ds and stroma were seen 
Total 25 100.00 
one or more high power fields away from 
the junction d Endometrium and myo-
mei.rium. Correlation between adenomyosis and 
number of years after last delivery is 
Results and Discussion shown in Table U. Only 8% had thei~ 
According to Bird et al, by takin~ last delivery less than 5 years back. In 
extra sections, the incidence of adeno- this study 72% women had their last 
myosis almost doubles. In our study, by delivery more than 10 years earlier 
taking routine sections the incidence which indicates that prolonged action of 
was found to be only 15%. With extra estrogens uninterrupted by progesterone 
sections the incidence increased to 25% . may be responsible for the development 
In a study carried out by Vora et al in of adenomyosis. 
1979, with routine sections the incidence 
TABLE II 
was 22% and with extra sections it in-
Adenomyosis-Correlation with Last Delivery 
creased to 60%. Thus it is evident that 
extra sections should be taken in sus- No. of years after No. of % 
pecteJ cases of DUB, adenomyosis and last delivery .-ases ... 
fibroid uterus. By doing so, diagnosis of Less than 5 yrs 2 8.00 -
adenomyosis will not be missed histo- 5 - 10 yrs 5 20.00 
pathologically. Out of 25 women having 10 - 20 yrs 15 60.00 
adenomyosis, 48% were in their 4th More than 20 yrs 3 12.00 
decade of life and 48% were in their 5th Total 25 100 
decade. 
Majority means 80% had 3 or more Among 25 women shown to have ade-
deliveries in the past indicating that nomyosis, 40% complained of menor-
adenomyosis is common in multiparous rhagia, 16% had dysmenorrhoea, 20% 
women (Table I). This is explained by complained of irregular bleeding per 
Israel et al. According to them, every vaginum and 20% had prolapse of uterus 
pregnancy increases the chances of en- (Table III). 
dometrial penetration into myometrium. 
This could be explained on anatomical Weight was taken of alllOO uteri with-
basis that because of lack of submuco~a out tubes and ovaries. According to 
in the uterus, endometrial glands pene- Mathur et al, normal uteri weigh be-
trate into the myometrium easily and tween 70-80 gms. Hypertrophic uteri 
get caught as infoldings into the hyper- weigh above 80 gms. In our study, out of 
trophied myometrium when it contracts 25 positive uteri, 24 uteri were hyper-
after delivery. trophic. 16% weighed between 80-100 
~· 
ADENOMYOSIS: A CLINICO-PATHOLOGICAL STUDY 717 
TABLE Til responsive only to the estrogenic stimu-
Adenomyosis-Presenting Symptoms lus, but not to progesterone. In our 
Symptoms No. of study, in 84% uteri surface as well as ---
Cases % ectopic endometrium showed prolifera-
Menorrhagia 10 40 .00 tive phase and remaining showed secre-
Dysmenorrhoea 4 16.00 tary phase. 
Irregular bleeding PV 5 20.00 
Prolapse 5 20.00 Applying Molitor's criteria adenomyo-
Lump in Abdomen 1 4.00 sis was graded histologically according 
Leucorrhoea 4.00 to the depth of penetration of ectopic 
glands into myometrium. Grade I means 
gm i.e. mild hypertrophy. 76% weighed penetration into inner third, Grade II 
~ between 100-150 gm i.e. moderate hyper- means penetration till middle third and 
trophy and 4% were severely hyper- grade III showing penetration reaching 
trophied weighing more than 150 gm. to outer third of myometrium. Following 
Clinically 28% were normal in size and Bird et al, the degree of involvement 
64% were bulky to 12 wks in size (Table was judged according to number of ecto-
lV). pic glands per low power field. Mild 
TABLE IV 
Adenomyotic Uteri-Analysis of Weigh t and Clinical Size 
Weight in grams Small Normal Bulky Upto Total % 
12 wks 
Less than 80 gms 1 4.00 
- 80-100 2 2 4 16.00 
(Mild hypertrophy) 
100-150 6 11 2 19 76.00 
(Moderate hypertrophy) 
More than 150 1. 1 4 .00 
(Severe hypertrophy) 
Total 2 7 14 2 25 100 .00 
On gross examination, the most fre- means 1 to 3 glands, moderate showing 4 
• quent finding was a trabeculated appear- to 9 and severe means 10 or more ecto-
ance of the myometrium with a few pic glands per low power field. In our 
cystic spaces, most marked in enlarged study, majority of uteri had grade II 
uterus. Anterior as well as posterior penetration and moderate degree of 
walls of uteri were equally involved. involvement. The higher was the degree 
Novak and De'lima believe that occa- and grade of involvement, the greater 
sionally ectopic endometrium exhibits were the menstrual disturbances and 
cyclic functional response, but more larger was the uterus. 
often it is of an immature unripe and The triad of menorrhagia, dysmenor-
.anovulatory type of endometrium. It is rhoea and bulky uterus leads to clinical 
718 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA 
diagnosis of adenomyosis. However, out References 
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which unfortunately turned out to be 
583, 1972. 
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