Abstract
Cystic degeneration is a rare complication of uterine leiomyoma. We came across such a case and reporting the same for the benefit of medical fraternity.

Introduction
Adenomyosis is defined as heterotropi endometrial glands and stroma located deep within the myometrium. Diffuse adenomyosis can be relatively localised but is never encapsulated. Localised encapsulated disease of the uterine wall is termed as adenomyoma. Reported incidence of adenomyosis varies from 8% to 62%. Cystic degeneration is not an uncommon complication of uterine leiomyoma.¹ Cystic degeneration of an adenomyoma have been reported only once till now in medical literature.²

Case Report
Mrs. RJ, a 39 yr old housewife came with complaints of pain in lower abdomen since 6 months and severe dysmenorrhoea. She was an old case of bilateral renal calculus and had undergone bilateral DJ stenting for bilateral hydronephrosis. Except severe dysmenorrhoea she didn’t have any other menstrual complaints. She had 2 caesareans in the past. On clinical examination her vitals were normal, On per abdomen examination 1 vertical and 1 pfannestiel scar were present. On per vaginal examination, a mass of 6 x 8 cms was felt in anterior fornix going towards right side and uterus was not felt separately. Pelvic Ultrasound showed uterus normal size, Right ovary around 9.8 x 9.1 x 8.6 cms with thick walls and internal septation, Lt ovary was bulky 4.3 x 3.4 x 1.8 cms.Patient was posted for exploration for bilateral pyeloplasty in view of DJ stents not draining well. In situ findings: Uterus bulky around 14 wks globular very soft, Left ovary appeared cystic 3 cms size and Right ovary was normal in size. Impression was degenerated fibroid uterus. Case was discussed with the patient’s husband and decision of hysterectomy was made. Uterine specimen section in the anterior wall showed 50 ml clear fluid and the walls of the mass were thick (Fig. 1). Histopathology of the specimen came as Adenomyosis as stroma and endometrial glands were seen in the anterior myometrium (Fig. 2) as well as atrophic changes were seen occurring in endometrial glands (Fig. 3). Patient’s recovery was fine and was discharged on 8th day of surgery.

Fig. 1 : Cut section of anterior wall of uterine specimen showing approx.50 ml of clear fluid and thick walls.	Fig. 2 : Histopathology slide which shows presence of endometrial glands and stroma in myometrium.

Fig. 3 : Histopathology slide shows endometrial glands undergoing atrophic changes.

Discussion
Leiomyoma undergoes degeneration as a result of ischaemia but such is not known within adenomyoma, because it is not a tumour of myometrium that can grow and compress its vessels in periphery, or outgrow the ability of its vessels to feed it.2 Ultrasound can fail to differentiate adenomyoma with cystic degeneration, leiomyoma and adnexal mass.3 MRI is better modality to differentiate between adenomyoma, adnexal mass and leiomyoma.4,5 This is second case of its type in the world literature.

References

1. John D Thompson, John A Rock. Te Linde’s Operative Gynaecology. 8th edition, Philadelphia, Toronto : JB Lippincott Company; 1997; pg731-65.
2. Parulekar SV. Cystic degeneration in an adenomyoma (case report) JPGM, 1990; 36 (1) : 46-7.
3. La Fianza A, Abbati D, Casai S, et al. Subserous Uterine adenomyosis mimicking an adnexal mass on sonography. J Clin Utrasound 2004; 32 (2) : 95-7.
4. Ascher SM, Jha RC, Reinhold C. Benign myometrial conditions: Leiomyomas and Adenomyosis. Top Magn Reson Imaging 2003; 14 (4) : 281-304.
5. Dueholm M, Lundrof E, Hansens ES, et al. Magnetic resonance imaging and transvaginal ultrasonography for the diagnosis of adenomyosis. Fertil Steril 2001; 76 (3) : 588-94.