Phenotypic heterogeneity in adenomyosis: internal and external subtypes

To investigate and compare the clinical characteristics and risk factors between intrinsic and extrinsic adenomyosis (AM), as well as the differences in their perioperative management and findings in the two subtypes.

This observational study included women who were diagnosed with either intrinsic or extrinsic AM based on magnetic resonance imaging (MRI) and who underwent a hysterectomy with a subsequent pathological examination. Demographic characteristics, clinical features, treatment outcomes and associated factors were evaluated.

77 patients were classified in the intrinsic group and 54 in the extrinsic group. The results show that gravidity (P < 0.001), parity (P < 0.001), abortion (P < 0.001) and endometrial curettage (P = 0.017) were significantly higher in the intrinsic group, while the education level was lower in the intrinsic group (P = 0.012). Women in the extrinsic group had an earlier age of menarche (P = 0.026) and more commonly associated ovarian endometrioma (OMA) (P < 0.001) and deep infiltrating endometriosis (DIE) (P < 0.001). Dysmenorrhea was more severe in the extrinsic group (P = 0.009), whereas women in the intrinsic group had heavier menstrual blood loss (P < 0.001). Surgery time (P < 0.001), operative blood loss (P < 0.001), hospitalization cost (P < 0.001), and the intensity of postoperative medical treatment (P < 0.001) were significantly higher in the extrinsic group. Multivariate analysis showed that lower education level, higher gravidity and more endometrial curettage were significantly associated with intrinsic AM. OMA and DIE were more commonly associated to extrinsic AM.

These results suggest that intrinsic and extrinsic AM exhibit specific clinical profiles, perioperative characteristics and associated risk factors.