Cervix
Benign / non - neoplastic lesions
Adenosis

Author: Leonel Maldonado, M.D. (see Authors page)

Revised: 29 September 2016, last major update September 2016

Copyright: (c) 2002-2016, PathologyOutlines.com, Inc.

PubMed Search: Adenosis [title]

Cite this page: Adenosis. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/cervixadenosis.html. Accessed December 7th, 2016.
Definition / General
  • "Vaginal adenosis" refers to the persistence of Mullerian glandular epithelium in the vagina after birth
  • First described in 1877 by von Preuschen
  • Most well known for its association with diethylstilbestrol (DES) use during pregnancy (to prevent a threatened abortion) by mothers of affected young women during the mid 1940s and 1950s
    • Present in 35% to 90% after in utero exposure to DES (100% have adenosis if DES started before gestational week 8, 6% if started week 15 or later)
  • DES adenosis is similar histologically to non DES adenosis
  • Mouse model of DES exposure demonstrates vaginal adenosis and structural changes similar to actual changes observed in women (Hum Pathol 1982;13:190)
Essential Features
  • Strong association with DES exposure in utero (with incidence decreasing after discontinuation), although other causes have been reported
  • Most common type is mucinous, with endocervical-like glands present; tuboendometrial glands can also be present
  • Women are at risk of neoplasia, including clear cell adenocarcinoma, as well as squamous dysplasia
ICD-10 coding
  • N89.8 Other specified noninflammatory disorders of vagina
  • N89.9 Noninflammatory disorder of vagina, unspecified
Epidemiology
  • An estimated 5 to 10 million women in the United States received DES during pregnancy
  • Approximately one fifth of women who were exposed in utero to DES demonstrate gross structural changes in the cervix or vagina including vaginal adenosis
  • Vaginal adenosis has also been reported in 2 - 10% of nonexposed females
Sites
  • Involves the upper third of the vagina (34% of DES exposed cases), with the anterior wall more frequently involved than the posterior wall
  • Middle third (9% of cases) and lower third (2% of cases) may be involved
Pathophysiology
  • DES causes irregularities in p63 gene expression, which determines whether Mullerian duct epithelium becomes uterine or vaginal cells, leading to vaginal adenosis
Etiology
  • Diethylstilbestrol (DES), a synthetic, nonsteroidal estrogen, profoundly affects the development of the vagina, uterus and fallopian tubes
  • Today, in the post DES era, vaginal adenosis usually occurs in women exposed to other hormones, drugs, trauma, inflammation, laser, radiation or chemotherapy (5-Fluorouracil)
Clinical Features
  • Usually asymptomatic, although vaginal discharge or postcoital bleeding or dyspareunia have been reported
  • The vaginal mucosa displays red granular spots or patches and fails to stain with an iodine solution
  • Mosaicism and punctuation are common findings during colposcopy
Case Reports
Gross Description
  • The vaginal mucosa displays cysts or red granular spots or patches
Micro Description
  • Two adult (differentiated) forms of adenosis have been described:
    • Mucinous: most common type of adenosis (62% of biopsy specimens); characterized by mucinous columnar cells that resemble those of the normal endocervical mucosa
    • Tuboendometrial: found in 21% of specimens; glands are lined by light and dark cells, often ciliated and resemble fallopian tube and endometrial gland cells
    • Embryonic: glands composed of low columnar or cuboid cells
  • Glands may be simple, complex, cystic or papillary and usually found in the lamina propria, but also on the mucosal surface
  • Cysts lined by a single layer of columnar mucinous cells may resemble cervical nabothian cysts
  • Squamous metaplasia can be present and represents the process by which adenosis transforms and heals
  • Rarely, intestinal metaplasia may be seen
Micro Images

Images hosted on PathOut servers:

Vaginal wall lesion biopsy, courtesy of Leonel Maldonado, M.D.

Cytology Description
  • Vaginal specimens are characterized by endocervical-like glandular cells or metaplastic squamous cells
  • Endometrioid glandular cells can also occur
Cytology Images

Images hosted on PathOut servers:

Courtesy of Leonel Maldonado, M.D.

Differential Diagnosis
  • Clear cell adenocarcinoma (vagina): may be confused with the glands of adenosis that undergo microglandular hyperplasia (small, uniform, crowded glands without mucin, nuclear pleomorphism and prominent nucleoli)
  • Endometriosis: presence of endometrial stroma with glands that resemble much more closely those of normal endometrium than the glands seen in adenosis; a CD10 is useful to confirm the presence of endometrial stroma
  • Mesonephric (Wolffian) remnants: mesonephric tubules are lined by nonciliated, nonmucinous cuboid cells with dense, eosinophilic luminal secretions; these remnants are surrounded by a loose fibrovascular stroma that may contain smooth muscle fibers
  • Recurrent endometrial adenocarcinoma: glandular cells in vaginal cytology Papanicolaou tests in patients with hysterectomy for endometrial adenocarcinoma (Diagn Cytopathol 2012;40:138)