VAGINAL ADENOSIS

VAGINAL ADENOSIS - Michael P. Hopkins, MD, MEd; Jennifer Savitski, MD; Eric L. Jenison, MD
BASICS
DESCRIPTION
• Adenosis is a term used to describe nonepithelialized columnar glandular epithelium in the vagina. At ~15th week of embryological development, the Mullerian system, which forms the upper 2/3 of the vagina, fuses with the invaginating cloaca, which forms the lower vagina. Squamous metaplasia from the cloacal region then produces a squamous epithelium through the vagina. Adenosis occurs when this squamous epithelium fails to completely epithelialize the vagina.
• System(s) Affected: Reproductive
ALERT
Geriatric Considerations
• Adenosis is a disorder of the young female. By the time of menopause the vagina and cervix should be completely epithelialized.
• The presence of glandular epithelium in the postmenopausal patient is an indication for excision and close evaluation for the possibility of a well-differentiated adenocarcinoma.
Pregnancy Considerations
Pregnancy produces a wide eversion of the transformation zone of the cervix. This will occasionally become so widely everted that it will extend onto the vaginal fornices, leading to the impression of adenosis. This will resolve after the pregnancy is completed.
EPIDEMIOLOGY
• Predominant age
- Teenage years: Epithelialization occurs from puberty to 20 years of age.
- By age 30 years, it is extremely rare for adenosis to be present.
• Predominant sex: Female only
Prevalence
In the US: Adenosis is relatively common, affecting 10-20% of young females studied. As maturation progresses with puberty, epithelialization occurs. (3)
RISK FACTORS
Diethylstilbestrol (DES)-exposed females
Genetics
Unknown
ETIOLOGY
• In the vast majority of young females, the etiology is incomplete squamous metaplasia. This occurs as a natural phenomenon and resolves with age.
• In DES-exposed females, the incidence of adenosis is higher and the etiology presumably is from the effect of the DES on the developing embryologic system.
ASSOCIATED CONDITIONS
DES exposure
• Adenosis from DES exposure should lead to an evaluation of other DES-related abnormalities.
• The greatest risk to the patient is from Mullerian tract anomalies. These include cervical abnormalities with cervical hood, ridges, shortened cervix, and incompetent cervix, T-shaped uterine cavity.
• Patients with known DES exposure should have the reproductive tract evaluated prior to conception.
• The vast majority of patients with adenosis have not been DES exposed and do not require evaluation of the reproductive system.
• DES was last used to prevent spontaneous abortion in ~1970. This is a problem of decreasing importance.


DIAGNOSIS
SIGNS AND SYMPTOMS
A clear, watery vaginal discharge, which is the glandular epithelium producing a small amount of mucus
TESTS
Diagnostic Procedures/Surgery
• 4-quadrant Pap smear should be utilized liberally, to isolate quadrants of the vagina which may contain abnormalities. This can be followed by colposcopy and biopsy.
• Colposcopy should be used to outline areas of adenosis and ensure that no malignancy is present.
Pathological Findings
Biopsy will show benign glandular epithelium, which has not yet undergone squamous metaplasia. Biopsies in the areas of ongoing squamous metaplasia will be typical for this process.
DIFFERENTIAL DIAGNOSIS
A thorough evaluation for adenocarcinoma of the vagina arising in adenosis should be done. A biopsy may be necessary to ensure that the process represents only benign adenosis. Colposcopy of the upper vagina aids in choosing the areas for biopsy. On visual inspection, adenosis appears as a fine, raised, reddened, granular-type tissue.
TREATMENT
STABILIZATION
Outpatient
GENERAL MEASURES
• Unless malignancy is present, conservative treatment is indicated.
• In the vast majority of young females with this condition, it will resolve with expectant management.
Diet
No special diet
Activity
• No limitations
• It is not necessary to avoid intercourse or placing objects in the vagina.
SURGERY
Aggressive therapy such as laser or surgical excision is necessary only if premalignant or malignant changes arise. (1)[C]
FOLLOW-UP
Yearly after a negative initial evaluation
PROGNOSIS
• It is expected that the vast majority of patients will have squamous metaplasia with complete resolution of the adenosis.
• The rare patient, 1:1,000-1:10,000, may develop adenocarcinoma in the adenosis and will require definitive therapy as for vaginal cancer.
COMPLICATIONS
Infertility, miscarriage, dysplasia, cancer
PATIENT MONITORING
• Initial evaluation consists of four-quadrant vaginal Pap smear, cervical Pap smear, and colposcopy of the upper vagina and cervix.
• If the initial colposcopy is normal, a yearly 4-quadrant Pap smear of the vagina and Pap smear of the cervix are all that is necessary.
REFERENCES
1. Chattopadhyay I, Cruickshank DJ, Packer M. Non diethylstilbesterol induced vaginal adenosis-A case series and review of literature. Eur J Gynaecol Oncol. 2001;22(4):260-262.
2. Herbst A. Behavior of estrogen-associated female genital tract cancer and its relation to neoplasia following intrauterine exposure to diethylstilbesterol (DES). Gynecol Oncol. 2000;76:147-156.
3. Sandberg EC. The incidence and distribution of occult vaginal adenosis. Am J Obstet Gynecol. 1968;101:322-334.