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Year 2020

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Rani, Goyal, Kaur, Bhardwaj, and Marwah: Adenomyomatous polyp – A culprit for infertility: rare case report


Introduction

Adenomyomatous polyp is a rare subtype of endometrial polyp in which smooth muscle is the prominent stromal component.1 About 1.3% of endometrial polys are adenomyomatous polyps.2 This lesion affects the females of fourth decade and later. Grossly it is very difficult to distinguish adenomyomatous polyp from ordinary endometrial polyp. 3, 4, 5 This polyp is comprised of smooth muscles, endometrial glands and endometrial stroma.1

There was no history of hormonal therapy. We report a case of 38-year female with history of secondary infertility.

Case Report

A 38 years female presented with a complaint of secondary infertility to the OPD at Adesh institute of medical sciences and research, Bathinda. There was no history of hormonal therapy. Hysteroscopy guided polypectomy under general anaesthesia was performed and the specimen was sent to the department of Pathology. On gross examination, a polypoidal grey white to tan tissue measuring 0.6x0.6x0.2cm was received. Hematoxylin stained slides examined show a polypoidal tissue lined by columnar to flattened lining epithelium. Subepithelium show small to elongated endometrial glands embedded in an edematous stroma. Intermixed are seen intersecting fascicles of smooth muscle fibres along with scattered blood vessels and chronic inflammatory infiltrate comprising of Lymphocytes, plasma cells and eosinophils. On histopathology Adenomyomatous polyp was the diagnosis (Figure 1, Figure 2).

Figure 1

H&E(10x)- shows endometrial glands embedded in an edematous stroma. Intermixed are seen intersecting fascicles of smooth muscle fibres.

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Figure 2

H&E(40x)- Endometrial gland and stroma along with smooth muscle fibres.

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Discussion

Endometrial polyps of adenomyomatous type are rare. The origin is focal hyperplasia of basalis leading to the localized overgrowth of endometrial tissue containing variable amount of endometrial glands, stroma, smooth muscles and blood vessels. These polyps are sessile or pedunculated masses, single to multiple and vary in sizes from 0.5cm to 3 cm in diameter or may be larger.6

Table 1

Review of cases ofadenomyomatous polyp in literature and comparison with present case

Authors Patient age Hormonal therapy(tamoxifen) Symptoms Year of publication
Nasu et al 1 63 Yes None 1997
Fitzhugh et al 3 32 No Menometrorrhagia 2008
Takeuchi et al 9 64 Yes None 2005
Nasu et al 8 37-57 No Menorrhagia 1995
Sato et al 4 33 No None 2007
Silverberg SG 5 44 No Menorrhagia 1975
Huang et al 10 66 No Postmenopausal bleeding 2017
Babu et al 6 23 No None 2012
Bhagyalakshmi et al 7 25 No Menorrhagia 2018
Present case 38 No Secondary infertility

hows thatAdenomyomatous polyp usually seen in fourth decade and later in females which is in concordance to our case.

There is no history of any hormonal therapy in the present case that is similar to the studies of Fitzhugh et al,3 Nasu et al, 8 Sato et al 4, Silverberg SG,5 Huang et al,9 Babu et al6 and Bhagyalakshmi et al.10 Only two authors Nasu et al,1 and Takeuchi et al7 have history of tamoxifen therapy.

The most common presenting symptom is the bleeding per vaginum either menorrhagia or post- menopausal bleeding (Fitzhugh et al 3, Nasu et al,8 Silverberg SG 5, Huang et al 9 and Bhagyalakshmi et al. 10) In the studies of Nasu et al,1 Sato et al4 and Babu et al6 the patients were asymptomatic. Our case is unique in the way of presention as secondary infertility. To the best of our knowledge, no case of adenomyomatous polyp has ever been presented with the complaint of inability to conceive, in the literature.

About 1.3% of endometrial polys are adenomyomatous polyps.2 Incidence of endometrial polyps is higher in women treated with tamoxifen (8 to 36 %) than in untreated women (0-10 %)7

Treatment modalities depends on the size of the polyp and symptoms. Polypectomy suffices in small, asymptomatic lesions while hysterectomy is mandatory for the larger one causing frustrating symptoms.

Conclusion

Adenomyomatous polyp of endometrium is a rare entity which could be a possible culprit for the infertility.

Source of Funding

None.

Conflict of Interest

None.

References

1 

K. Nasu K. Arima J. Yoshimatsu I. Miyakawa Adenomyomatous Polyp of the Uterus in a Patient Receiving TamoxifenJpn J Clin Oncol19972753502

2 

W F Peterson E R Novak Endometrial PolypsObstet Gynecol19568409

3 

V A Fitzhugh G Murphy D S Heller Adenomyomatous polyp of the endometrium: a case reportJ Reprod Med2008532314

4 

Hirokazu Sato Hiroshi Nanjo Hidenori Tanaka Toshinobu Tanaka Arias-Stella reaction in an adenomyomatous polyp of the uterusActa Obstet Gynecol Scand20078611068

5 

Steven G. Silverberg Adenomyomatosis of Endometrium and Endocervix—A Hamartoma?Am J Clin Pathol19756421929

6 

Y P Babu Adenomyomatous polyp of the uterus: Report of an autopsy case and review of the literatureJ Forensic legal med2012192368

7 

Bhagyalakshmi Diffuse multiple giant adenomyomatous endometrial polyps- a rare case reportJNTR Uni Health Sci201872168

8 

K. Nasu T. Sugano I. Miyakawa Adenomyomatous polyp of the uterusInt J Gynecol Obstet199548331921

9 

S M Ascher J C Johnson W A Barnes MR imaging of the uterus in postmenopausal women receiving tamoxifen therapy for breast cancer: histopathological correlationRadiol199620010510

10 

Ci Huang Mun-Kun Hong Dah-Ching Ding Endometrial adenomyoma polyp caused postmenopausal bleeding mimicking uterine malignancyGynecol Minim Invasive Ther2017612931



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