An Accessory Uterine Cavity as a Cause of Pelvic Pain

Uterine Cystic Adenomyosis: A Disease of Younger Women

PURPOSE OF REVIEW

We adopted a life-cycle approach to further our understanding of the natural history of the cystic forms of uterine adenomyosis first described by Cullen in 1908.

SEARCH STRATEGY

Scopus and PubMed were searched for all terms referring to cystic variant of adenomyosis or adenomyoma. References found in major publications were also included in the review.

MAIN FINDINGS

With the introduction of non-invasive imaging techniques, a number of cases of cystic variants of adenomyosis have been reported. Progressive, severe, medication-resistant dysmenorrhea is the main clinical feature but delay in diagnosis remains problematic. The life-cycle approach demonstrates that cystic adenomyosis is more relevant to adolescent and young adulthood. Congenital müllerian and wolffian cysts and the uterus-like masses are more frequent in women >30 years of age. The latter is frequently located outside the uterus and may represent a form of endometriosis rather than adenomyosis. Differential diagnosis includes ovarian cysts and congenital uterine anomalies. Menstruation suppression with continuous oral contraceptive pill with ultrasonographic monitoring of cyst regression may prove successful in the young woman, but surgical excision using minimally invasive endoscopy is highly effective. The various terms used in literature to describe these lesions cause considerable confusion. Here we propose a classification into 3 subtypes and standardized reporting criteria to enable comparison.

CONCLUSIONS

Endometrial lined myometrial cysts are almost specific to adolescent and young women. We propose a new classification system.

Hysteroscopic diagnosis and excision of myometrial cystic adenomyosis

In 1908, Cullen described the first cases of cystic adenomyosis in his textbook on adenomyomata. Although not very common, with the introduction of noninvasive imaging techniques such as magnetic resonance imaging (MRI) and 3-D transvaginal ultrasound, an increasing number of cases have been reported. Patients primarily complain of severe dysmenorrhea, chronic pelvic pain, and dysfunctional uterine bleeding. Currently, it is unclear whether adenomyosis and, more specifically, cystic adenomyosis can be an underlying reason for impaired fertility and reproductive outcome. With the postponement of childbearing, the number of patients with adenomyosis and cystic adenomyosis seeking fertility treatment is increasing. Therefore, in these patients, uterine exploration should include not only the evaluation of the endometrial cavity but also the exploration of the sub-endometrial zone. Indirect imaging techniques, combined with office mini-hysteroscopy, offer the possibility of complete uterine exploration. Two patients with cystic adenomyosis are described in this paper: one had the chief complaint of menorrhagia and the other was referred for evaluation of infertility and severe dysmenorrhea. The aim of these case reports is to present hysteroscopic dissection and ablation of adenomyotic cysts as an alternative procedure for the surgical management of this condition.

Role of hysteroscopy in evaluating chronic pelvic pain

OBJECTIVE

To provide a survey of various gynecological conditions causing chronic pelvic pain (CPP) that might be diagnosed by hysteroscopy.

DESIGN

Review article.

SETTING

Departments of obstetrics and gynecology and pathophysiology of human reproduction at a university in Italy.

PATIENT(S)

Women affected by CPP.

INTERVENTION(S)

Hysteroscopy.

MAIN OUTCOME MEASURE(S)

Effectiveness in diagnosing intrauterine pathologies that cause CPP.

RESULT(S)

Hysteroscopy is highly effective in diagnosing various gynecological causes of CPP, including adenomyosis, chronic endometritis, Müllerian anomalies, retained fetal bones, endocervical ossification, and intrauterine abnormalities. Furthermore, hysteroscopy may play a primary role in the resolution of some of these conditions.

CONCLUSION(S)

Because it can be executed safely in an office setting without anesthesia, hysteroscopy may be indicated, together with the other noninvasive procedures such as transvaginal ultrasonography, as a first-level investigation in women who are affected by CPP.