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Table of Contents
Definition / general | Essential features | ICD coding | Epidemiology | Sites | Pathophysiology | Etiology | Clinical features | Case reports | Gross description | Microscopic (histologic) description | Microscopic (histologic) images | Cytology description | Cytology images | Videos | Differential diagnosis | Additional referencesCite this page: Maldonado L. Adenosis. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/cervixadenosis.html. Accessed January 21st, 2019.
Definition / general
- "Vaginal adenosis" refers to the persistence of Müllerian 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 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 Müllerian 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
- 6 year old girl with vaginal adenosis without exposure to DES (Gynecol Obstet Invest 2001;51:271)
- 21 year old woman with in utero DES exposure (Am J Clin Pathol 1979;71:715)
- 24 year old woman with vaginal adenosis (J Natl Med Assoc 2007;99:166)
- 25 year old woman with continuous urine flow (Open Journal of Obstetrics and Gynecology 2013;3:435)
- 40 year old woman with vaginal adenosis (Journal of South Asian Federation of Obstetrics & Gynecology 2013;5:80)
- 45 year old woman with primary vaginal adenocarcinoma (Int J Gynecol Pathol 2010;29:193)
- Vaginal adenosis in a patient on Tamoxifen therapy (Cytopathology 1999;10:127)
- Vaginal adenosis without exposure to DES (Asia Oceania J Obstet Gynaecol 1991;17:27)
Gross description
- The vaginal mucosa displays cysts or red granular spots or patches
Microscopic (histologic) 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
Microscopic (histologic) 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)
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