23 Histopathological diagnosis of adenomyosis The gold standard for adenomyosis diagnosis remains histopathology. Indeed, adenomyosis was first identified in hysterectomy specimens by von Rokitansky in the 1860’s as ‘cystosarcoma adenoids uterinum’ or ‘adenomyoma’, and eventually given its present name of ‘uterine adenomyosis’ by Frankl in 1925 (27). On histology, most often (and most accurately) after hysterectomy, adenomyosis is recognised as myometrial invasion of endometrial stroma, surrounded by myometrial hyperplasia. The minimum distance required for invasion into the myometrium to be considered as indicative of adenomyosis is debated (19). Some experts propose a range of 1-4mm, others at least one third of the total myometrial thickness. The common theme is that there must be recognisable endometrial tissue deeper than the endo-myometrial junction (7). An example of adenomyosis on histopathology is shown in Figure 1.3. The aforementioned criteria for adenomyosis are thus not uniformly classified, and different pathologists and hospital tend towards different definitions (19). The most commonly reported definitions for adenomyosis lesions are however, as follows: • At least one low power field from (an irregular) endo-myometrial junction, or • 1 to 2.5 mm below the basal layer of endometrium, or • Deeper than 25% of the overall myometrial thickness Another limitation of histological diagnosis is that accurate diagnosis is highly reliant on the method of tissue sampling and the number of slices taken at hysterectomy, and subsequently the size of the lesion. There is thus a potential for small adenomyosis lesions to be missed (19).
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