Adenomiosis

Historically, the diagnosis of adenomyosis has been made by histologic findings after a hysterectomy. At hysterectomy, often the uterus is enlarged globally with areas of focal hemorrhage. On microscopic examination, adenomyosis is identified when endometrial tissue is found inside the myometrium. 
A histologic diagnosis of adenomyosis could also be obtained from hysteroscopic or laparoscopic myometrial biopsies. Moreover adenomyosis does not have pathognomonic signs at hysteroscopy and those types of biopsies are very uncommon in clinical practice.
Commonly, the diagnosis of adenomyosis is made histologically; however, the use of imaging can help to guide the differential diagnosis. The two most common modalities are transvaginal ultrasound (TVUS) either two-dimensional (2D) or three-dimensional (3D) and magnetic resonance imaging (MRI), even if there are no standard diagnostic imaging criteria for adenomyosis.

Treatment options for adenomyosis include both medical and surgical management. Combined oral contraceptives continuously or high-dose progestin may help improve symptoms by inducing amenorrhea and for a short period of time may also induce regression of adenomyosis. The levonorgestrel intrauterine device(LNG-IUD) is currently one of the most effective treatment for adenomyosis. It acts by releasing 20 μg levonorgestrel per day for up to 5 years, resulting in symptoms improvement. Gonadotropin-releasing hormone agonists(GnRHa)  can also be effective in treatment of adenomyosis. Moreover, those therapies must be limited in time, since they cause a suppression of pituitary gonadotropins and thus induce a medical menopausal, hypoestrogenic state. 
Historically, the standard treatment for adenomyosis has been hysterectomy. It is the only approach that provides definitive treatment for patients with adenomyosis. This procedure can be completed laparoscopically, vaginally, or abdominally. Commonly, it is the treatment of choice for patients with significant symptoms who have completed childbearing.  However, this is not always an option for patients, especially those women who wish to spare fertility options or who are not good surgical candidates because of other comorbidities. As a matter of fact, determining the optimal treatment for patients must be discussed by a specialized team of gynecologists.