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Vaginal Adenosis

BASICS

DESCRIPTION

The normal vaginal epithelium is squamous. Adenosis is defined by the presence of columnar or glandular epithelium within the vaginal wall.
- Occurs due to failure of complete squamous metaplasia during embryologic development.
- Types of adenosis epithelium:
- Endocervical
- Endometrial
- Tubal

Geriatric Considerations

By menopause, complete epithelialization should occur. Postmenopausal glandular epithelium warrants excision and evaluation.

Pregnancy Considerations

Cervical eversion may mimic adenosis; resolves postpartum.

EPIDEMIOLOGY

Incidence

  • Spontaneous adenosis seen in ~10% of adult women
  • Cloacal malformations: 1/20,000–25,000 live births

Prevalence by Age

  • \<1 month: 15%
  • 13–25 years: 13%
  • Rare after age 30

ETIOLOGY AND PATHOPHYSIOLOGY

  • Most cases due to incomplete squamous metaplasia
  • Congenital: from in utero DES exposure
  • DES: synthetic estrogen used 1938–1971
  • Disrupts TRP63 and BMP4/Activin A/RUNX1 pathway
  • Acquired: trauma, Stevens-Johnson syndrome, condyloma treatment

RISK FACTORS

  • DES daughters:
  • 90% may develop adenosis
  • 40-fold increased risk of clear cell adenocarcinoma

GENERAL PREVENTION

  • None needed now; DES no longer in use

COMMONLY ASSOCIATED CONDITIONS

  • DES-related anomalies:
  • Cervical hood/ridge
  • Short/incompetent cervix
  • T-shaped uterus

DIAGNOSIS

HISTORY

  • Maternal DES exposure
  • Mucoid discharge, postcoital bleeding, dyspareunia, pruritus

PHYSICAL EXAM

  • Variable appearance: patches, cysts, erosions, ulcers, warty lesions

DIFFERENTIAL DIAGNOSIS

  • Erosive lichen planus
  • Fixed drug eruption
  • Erythema multiforme
  • Adenocarcinoma

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests

  • Four-quadrant Pap smear
  • No imaging unless malignancy suspected

Follow-Up Tests

  • Colposcopy and biopsy as needed
  • Histology: benign glandular epithelium, possible squamous metaplasia

TREATMENT

GENERAL MEASURES

  • Expectant management unless symptomatic
  • Simple excision for focal lesions without DES history

ISSUES FOR REFERRAL

  • Refer to gynecologic oncology if malignancy present

SURGERY/OTHER

  • If malignant/premalignant:
  • Laser coagulation
  • Vaginal resection

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

  • Managed outpatient

ONGOING CARE

FOLLOW-UP

  • If colposcopy normal: annual Pap smear

PATIENT EDUCATION

  • No intercourse restrictions
  • Maintain routine screening

PROGNOSIS

  • Most resolve with age
  • Rare cases progress to clear cell carcinoma
  • Incidence: 1.5/1,000 in DES daughters

COMPLICATIONS

  • Infertility (DES-related)
  • Pregnancy complications
  • Adenocarcinoma, especially clear cell

REFERENCES

  1. Reich O, Fritsch H. J Low Genit Tract Dis. 2014;18(4):358–360.
  2. Kranl C, Zelger B, Ko...
  3. NTP Report on Carcinogens. 12th ed. 2011:159–161.
  4. Laronda MM et al. Dev Biol. 2013;381(1):5–16.
  5. Martin AA et al. J Am Acad Dermatol. 2013;69(2):e92–e93.

Additional Reading
- Bamigboye AA et al. Cochrane Database Syst Rev. 2003;(3):CD004353.

See Also: Vaginal Malignancy

ICD-10 CODES

  • Q52.4: Other congenital malformations of vagina
  • N89.8: Other specified disorders of vagina
  • T38.5X5A: Adverse effect of estrogens, initial encounter

CLINICAL PEARLS

  • Adenosis = presence of columnar/glandular tissue in vagina
  • Strongly linked to DES exposure
  • Must evaluate for malignancy when present, especially in older patients