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  • Title: Exacerbation of adenomyosis symptomatology by estrogen-progestin therapy: a case report and histopathological observations.
    Author: Falk RJ, Mullin BR.
    Journal: Int J Fertil; 1989; 34(6):386-9. PubMed ID: 2574708.
    Abstract:
    The present case report illustrates the hormonal sensitivity of adenomyosis. Administration of an estrogen-progestin combination for what was felt to be symptomatic endometriosis resulted in exacerbation of symptoms and growth of adenomyomas. Histopathologic examination of the hysterectomy specimen revealed a pattern of decidualization previously unreported, but consistent with current theories of experimental in vivo and in vitro decidua formation. A 32 year old woman underwent exploratory surgery because she had severe dysmenorrhea, the physicians found fibroids, and they excised pelvic endometriosis. 1 year later, she sought the assistance of the Center for Fertility and Reproductive Endocrinology at the Columbia Hospital for Women in Washington, D.C. because of continual dysmenorrhea and pain. A physician at the center treated her with Ovulen, a continuous estrogen/progestin therapy, yet her pain worsened. Upon a pelvic reexamination 16 months later, a physician noted a tender, enlarged, and irregularly shaped uterus (16 cm from fundus to cervix and 726g). Further, pelvic sonography detected multiple leiomyomas, 1 being 9x7 cm. The physician did a laparotomy to perform a myomectomy and therefore preserve fertility, but could not establish cleavage planes. Thus she needed to undergo a hysterectomy. Pseudodecidualized adenomyotic islands were found in the enlarged posterior myometrial wall. The results of this woman's use of Ovulen are similar to previous research on prostaglandins' role in which they act as intermediaries in decidual metaplasia. This case report affirms that progestins do not treat adenomyosis and cause significant exacerbation of its symptoms. Based on previous research and this case, the author believes that an undefined luminal component and progestin stimulation causes development of a decidual response in the uterus. Once the stimulus is defined, be it chemical, infectious, or mechanical, researchers could identify other approaches for the symptomatic relief of this debilitating and difficult to diagnose ailment.
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