Prolapsed Endometrioid Adenomyoma Associated with Post-Coital Bleeding

Uterine leiomyoma, more commonly known as fibroids, and adenomyosis are two common but distinct gynaecological conditions that may significantly impact women's health (1-3), often presenting with pain, abnormal vaginal bleeding and, more rarely, polyps (4,5).  These conditions share overlapping symptoms and clinical features but are inherently different in their pathophysiology, disease progression and clinical management (6, 7, 8, 9)

Uterine leiomyomas are benign smooth muscle tumours that typically originate from the myometrium of the uterine wall.  They are the most common benign pelvic tumours in women, affecting approximately 20-50% of women of reproductive age and occurring in up to 70% of women by age 50 (10).  Leiomyomas can range from tiny and virtually undetectable to large masses that distort and enlarge the uterus.  Symptoms vary widely, with many women being asymptomatic.  However, symptoms typically include heavy and prolonged menstrual periods, abnormal bleeding between periods, pelvic pain and pressure, urinary frequency and coital discomfort. (11)  Fibroids can affect reproductive health, causing infertility and abnormal pregnancy outcomes such as recurrent miscarriage and obstetric haemorrhage. (11) They may occasionally promote the growth of endometrial polyps or may present as a polypoidal or pedunculated intrauterine mass.  The aetiology of leiomyomas is not entirely understood but is believed to involve an interplay of genetic, environmental and hormonal factors, particularly estrogen and progesterone (11,12).

Adenomyosis, on the other hand, occurs when endometrial tissue, which typically lines the uterus, exists within and grows into the muscular wall of the uterus (myometrium) (13, 14, 15).  This condition is commonly found in middle-aged women and those with children.  Although it can be asymptomatic, adenomyosis often presents with heavy or prolonged menstrual bleeding, severe menstrual cramps, and chronic pelvic pain.  The exact cause of adenomyosis is unclear, but it is believed to be associated with various hormonal changes, including those induced by childbirth and menopause (5) While adenomyosis can lead to significant discomfort, it is typically not considered a risk factor for other health complications, although it may be coexistent with pelvic endometriosis (16, 17).  In rare cases, adenomyosis may contribute to the formation of polyps and lead to irregular bleeding (18).  Typically, they contain haemorrhagic cystic spaces, which are unusual in other polyps such as leiomyomas or malignancies (19). The characteristic sonographic features of polypoid adenomyomas include heterogeneous or homogeneous echogenicity relative to the myometrium, a smooth surface, a poorly defined margin with the underlying myometrium, haemorrhagic foci, and usually, associated adenomyosis in the myometrium (20).  When ultrasound evaluation demonstrates a soft tissue mass in the vagina prolapsed from the uterine cavity with a visible connecting stalk, it is termed the broccoli sign (21,22)

Uterine leiomyomas and adenomyosis can cause abnormal vaginal bleeding, typically heavier and longer than normal menstrual bleeding.  However, the bleeding associated with leiomyomas is usually due to the increased surface area of the uterine lining, while in adenomyosis, bleeding results from the disruption of the muscular wall of the uterus (23, 24).  In both cases, the bleeding may be severe enough to cause anaemia and disrupt a woman's perceived quality of life (25).

Regarding management, treatment for adenomyosis and leiomyomas can range from watchful waiting to medical therapy (e.g., hormonal treatments) and surgical interventions such as minimally invasive, local resection, or hysterectomy (8,11,14).  In both cases though more rarely for the latter, medical management using hormonal treatments to control or mitigate the menstrual cycle may effectively reduce provocateurs for growth, leading to regression or diminution of size and consequent reduction of symptomatic effect (8,11,14).