FOCAL ADENOMYIOSIS (INTRAMURAL ENDOMETRIOTIC CYST) IN A VERY YOUNG PATIENT

DIFFERENTIAL DIAGNOSIS WITH UTERINE FIBROMATOSIS

INTRODUCTION
Adenomyosis is a widespread disease affecting the reproductive period of women's life and having a great impact on their fertility. The most common form is diffuse adenomyosis, while focal adenomyosis, cystic variant, is
very rare, particularly in patients younger than 30 years old. It is characterised by the presence of ectopic endometrial tissue within the uterine myometrium, with adjacent smooth muscle hypertrophy. The diagnostic criteria
for juvenile cystic adenomyosis proposed by Hiroyuki et al include severe dysmenorrhea, age <30 years and a cystic lesion ≥ 1 cm in diameter independent of uterine lumen and covered by hypertrophic myometrium on diag-
nostic images .

CASE REPORT DISCUSSIONS

We report a case of a 20 years-old Caucasian woman that was Gynecological adenomyosis is a clinical challenge, due sometimes diffi-
admitted in our service complaining of chronic pelvic pain exacerbated cult diagnosis that occurs mainly in multiparous women in perimeno-
during menstrual period and menorrhagia. The patient is nulliparous pause. Pregnancy seems to favor the development adenomyosis in the my-
with no significant personal or family history, menarche at age 12 with ometrium due to invasive nature of the trophoblast extension through my-
a BMI of 19.She had regular menstrual cycle with severe dysmenorrhea ometrial fibers.In addition adenomiotic tissue seems to have an increased
for years, worsened in the last 3 months, treated with NSAIDs. On ad- sensitivity to estrogen, so increased levels of estrogen in pregnancy would
mition laboratory values disclosed no abnormalities. promote the development of this condition. Uterine curettage abortions and
Phisical examination revealed an increased uterine volume such as a births by caesarean section also represent risk factors.
10 weeks old pregnancy,extremely painful during palpation,easily mo- The causal link between a history of uterine surgery and adenomyosis, alt-
bilised,with no other abdominal masses. hough it has not been demonstrated, it should be taken into account. Smok-
Transvaginal ultrasound : uterus in AVF with long diameter of 6,48cn , ing appears to be a protective factor for adenomyosis, which is explained by
antero-posterior diameter of 2.6 cm, linearly endometrium with thick- lower estrogen serum levels between heavy smokers, knowing that adeno-
ness of 4mm.Within the anterior wall, intramural, towards the uterine myosis, endometriosis and uterine fibroids are estrogen-dependent diseases.
fundus, round oval sized tumor formation 3.97/4cm with thin echogenic Adenomyosis development favors the appearance of intramural ectopic
content, well defined, with no distortion or protrusion in the uterine pregnancies and increases the risk of uterine rupture during pregnancy.
cavity. No ovarian abnormalities were noted. Depression and antidepressant therapy that interferes with the prolactin me-
Preoperatively we suspected necrobiosis of a uterine fibroid and we tabolism,promotes progression of endometriosis and adenomyosis, acting as
decided to practice a classic myomectomy with extemporaneous histo- a miotogen at myometrial and endometrial level. As estrogen dependent dis-
pathological exam. ease, uterine fibroids can coexist in 15-57% of cases of adenomyosis, as
demonstrated by histopathological examination in our case. Although uter-
ine fibroids and adenomyiosis have mutual symptoms like pelvic pain, dys-
Figure 1
menorrhea, uterine bleeding and dyspareunia, studies have shown that they
are more pronounced in women with adenomyosis than in those with fibro-
RESULTS matosis. Uterine volume in adenomyosis is generally samaller than in
uterine fibroids.
Intraoperative we found an increased uterine volume due to a 5 In this case the patient was nonsmoker, infertile, nuligesta, nulliparous,
cm nodule within the anterior wall without any visceral adhesions. Dur- with a normal BMI so none of the risk factors for the development of ade-
ing excision the nodule presented as a remitting cyst with white pearly nomyosis was present. Although adenomyosis and endometriosis have dif-
walls and well defined cleavage planes.When opening the cyst we no- ferent etiopathogenesis they have similar pathological substrate, namely, ec-
ticed chocolate-like content highly suggestive for endometriosis which topic endometrial tissue. In this case, even if the ectopic endometrial tissue
was confirmed on the extemporaneous histopathological exam. The in- location was that of adenomyosis, the risk factors and the evolution have
tervention continued with dual-layer myometrium suture with favorable approached the case pathophysiological and clinical more to endometriosis.
postoperative evolution. Histopathological examination revealed adeno- The main differential diagnosis was made after clinical examination with
myosis associated with fibroleiomyoma with hyaline dystrophy and uterine fibroids, a pathology more common in young pacients, because of
multiple foci of endometriosis in the wall of cystic formation.

Figure 2

CONCLUSIONS
Although a rare lesion in young patients, cystic adenoma should be
considered when chronic pelvic pain exacerbated during menstruation
is associated with a uterine cyst.

Figure 3 Figure 4

Cristian D
References