Symptoms of Adenomyosis
Uterine adenomyosis (ad-en-oh-my-o-sis) is a condition that causes heavy, painful periods. In those who have adenomyosis, the uterus gets larger than normal. This happens because the kind of cells that normally line the inside of the uterus grows in the walls of the uterus. It is generally estimated that adenomyosis is present in 20 to 35 percent of women, although the prevalence is uncertain since hysterectomy is required to make a definitive diagnosis. It is commonly seen in women with endometriosis and the symptoms overlap considerably. It is known to affect all ages and not just those who have a history of pregnancy.
Although symptoms of both diseases often overlap, adenomyosis is not the same disease as endometriosis. Endometriosis lesions are different from the cells that line the uterus. Adenomyosis is characterised by invasion of the endometrium (uterine lining), the uterine lining is not involved in endometriosis.
The most common symptoms of adenomyosis are severe pain before and during menstruation (periods), heavy menstrual bleeding, "bearing down" feeling in the pelvis and lower back pain. The pain is more severe than “normal” period cramps and it not relieved with basic pain medication. The pain can last for days. It is important to realise that to experience extreme pain with your period is not “normal”. If you have missed a family or social event due to pain, have heavy bleeding, have a diagnosis of endometriosis then adenomyosis should be considered.
If you have endometriosis and pain persists post excision surgery, adenomyosis should be considered.
Adenomyosis is defined as the presence of endometrial tissue (womb lining) inside the uterine (womb) muscle wall. (Ferenczy A, Hum Reprod Update
. Jul-Aug 1998;4(4):312-22. doi: 10.1093/humupd/4.4.312)
Types of Adenomyosis
There are two forms of adenomyosis: diffuse and focal. Adenomyosis can only be definitively diagnosed by removing the uterus (hysterectomy) and sent to the laboratory for a histopathology examination.
Diffuse adenomyosis – the uterus with diffuse adenomyosis appears uniformly enlarged and boggy. The myometrial (uterine muscle) wall appears thickened and often contains small chocolate-colored areas representing areas of endometrial bleeding.
Focal adenomyosis (also called adenomyoma) – Focal adenomyosis can resemble a fibroid, it is usually a well defined area within the muscle wall.
Adenomyosis can exist with endometriosis and also fibroids.
The classical symptoms of adenomyosis are:
Women with suspected adenomyosis should be evaluated by their doctor using their menstrual and symptom history, pelvic examination, and imaging. Laboratory testing may be performed to evaluate for anaemia (from heavy periods). The uterus can feel "boggy" or enlarged on examination. Women can also display abdominal swelling. Imaging can help with identification, definitive diagnosis is made by examination of the uterus after it has been removed.
Transvaginal ultrasound is the first-line imaging choice for evaluation of an enlarged uterus, pelvic pain, and/or abnormal bleeding. The images should be reviewed by a radiologist experienced in evaluating adenomyosis.
Magnetic resonance imaging (MRI) can help distinguish diffuse and focal adenomyosis from fibroids. If the patient is planning conservative surgery for adenomyosis or fibroids, an MRI is often performed to assist in surgical planning.
Management of Adenomyosis
The only proven treatment for adenomyosis is surgery to remove the uterus, called a hysterectomy. Hysterectomy is the only way to remove diffuse adenomyosis. Even in women with adenomyomas, hysterectomy is generally preferred to the removal of the adenomyomas with uterine conservation except where future pregnancy is desired.
There are other treatment options that may reduce the heavy bleeding caused by adenomyosis, including:
- IUD – An intrauterine device (IUD) is a small device that fits inside the uterus and is normally used to prevent pregnancy. One type of IUD, which releases the hormone progestin, might help with the symptoms of adenomyosis. (Mirena)
- Endometrial ablation – This is surgery to cause scarring in the lining of the uterus, which makes periods less heavy. It is unlikely to reduce pain symptoms. This is not the same procedure as ablation of endometriosis.
- Uterine artery embolization – This is a treatment that blocks the blood supply to the uterus. For women who have completed childbearing, uterine artery embolization (UAE) may be effective for reducing symptoms related to adenomyosis.
UAE is also an option for women who decline, or have contraindications to, a hysterectomy or have failed hormonal treatment.
- Uterus sparing surgery. Uterus-sparing resection of adenomyosis is an investigational approach that can be considered in women with extensive adenomyosis who are actively pursuing pregnancy.
The disadvantage of this approach is that even when performed by expert surgeons, there is a risk of uterine rupture in a future pregnancy. This is a highly skilled surgery and should only be carried out by someone who has proven experience of this procedure.
Treatments that can ease the pain of adenomyosis include:
- Pain medicines, such as NSAIDs (Ibuprofen, Ponstan, Difene)
- Oral Contraceptive Pills
- GnRHa drugs (brand names: Decapeptyl, Zoladex, Synarel), which cause the ovaries to stop making the hormones estrogen and progesterone. There are side effects similar to menopause with this treatment.
Pregnancy and Adenomyosis
If you want to get pregnant, you should not have a hysterectomy, endometrial ablation, or uterine artery embolization. You will need to work with your doctor to find other treatment options until after you have your children.
Adenomyosis may contribute to infertility and pregnancy complications. Discuss this with your gynaecologist/obstetrician.
- Ferenczy A. Pathophysiology of adenomyosis. Hum Reprod Update. 1998 Jul-Aug;4(4):312-22. doi: 10.1093/humupd/4.4.312
- Maheshwari A, Gurunath S, Fatima F, Bhattacharya S. Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. Hum Reprod Update. 2012 Jul;18(4):374-92. doi: 10.1093/humupd/dms006. Epub 2012 Mar 22. PMID: 22442261.
- Wood C. Surgical and medical treatment of adenomyosis. Hum Reprod Update. 1998 Jul-Aug;4(4):323-36. doi: 10.1093/humupd/4.4.323
- Osada H. Uterine adenomyosis and adenomyoma: the surgical approach. Fertil Steril. 2018 Mar;109(3):406-417. doi: 10.1016/j.fertnstert.2018.01.032
- Zhou J, He L, Liu P, Duan H, Zhang H, Li W, Gong S, Su G, Chen C. Outcomes in Adenomyosis Treated with Uterine Artery Embolization Are Associated with Lesion Vascularity: A Long-Term Follow-Up Study of 252 Cases. PLoS One. 2016 Nov 2;11(11):e0165610. doi: 10.1371/journal.pone.0165610
- Kitamura Y, Allison SJ, Jha RC, Spies JB, Flick PA, Ascher SM. MRI of adenomyosis: changes with uterine artery embolization. AJR Am J Roentgenol. 2006 Mar;186(3):855-64. doi: 10.2214/AJR.04.1661
- de Bruijn AM, Smink M, Hehenkamp WJK, Nijenhuis RJ, Smeets AJ, Boekkooi F, Reuwer PJHM, Van Rooij WJ, Lohle PNM. Uterine Artery Embolization for Symptomatic Adenomyosis: 7-Year Clinical Follow-up Using UFS-Qol Questionnaire. Cardiovasc Intervent Radiol. 2017 Sep;40(9):1344-1350. doi: 10.1007/s00270-017-1686-1
- Pelage JP, Jacob D, Fazel A, Namur J, Laurent A, Rymer R, Le Dref O. Midterm results of uterine artery embolization for symptomatic adenomyosis: initial experience. Radiology. 2005 Mar;234(3):948-53. doi: 10.1148/radiol.2343031697
- Shaaban OM, Ali MK, Sabra AM, Abd El Aal DE. Levonorgestrel-releasing intrauterine system versus a low-dose combined oral contraceptive for treatment of adenomyotic uteri: a randomized clinical trial. Contraception. 2015 Oct;92(4):301-7. doi: 10.1016/j.contraception.2015.05.015
- Sheng J, Zhang WY, Zhang JP, Lu D. The LNG-IUS study on adenomyosis: a 3-year follow-up study on the efficacy and side effects of the use of levonorgestrel intrauterine system for the treatment of dysmenorrhea associated with adenomyosis. Contraception. 2009 Mar;79(3):189-93. doi: 10.1016/j.contraception.2008.11.004
- Fedele L, Bianchi S, Raffaelli R, Portuese A, Dorta M. Treatment of adenomyosis-associated menorrhagia with a levonorgestrel-releasing intrauterine device. Fertil Steril. 1997 Sep;68(3):426-9. doi: 10.1016/s0015-0282(97)00245-8
- Fong YF, Singh K. Medical treatment of a grossly enlarged adenomyotic uterus with the levonorgestrel-releasing intrauterine system. Contraception. 1999 Sep;60(3):173-5. doi: 10.1016/s0010-7824(99)00075-x.
- Levgur M. Diagnosis of adenomyosis: a review. J Reprod Med. 2007 Mar;52(3):177-93.
- Wang PH, Liu WM, Fuh JL, Cheng MH, Chao HT. Comparison of surgery alone and combined surgical-medical treatment in the management of symptomatic uterine adenomyoma. Fertil Steril. 2009 Sep;92(3):876-885. doi: 10.1016/j.fertnstert.2008.07.1744. Epub 2008 Sep 6. PMID: 18774566.
- Abbott JA. Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. Best Pract Res Clin Obstet Gynaecol. 2017 Apr;40:68-81. doi: 10.1016/j.bpobgyn.2016.09.006
- Barrier BF, Malinowski MJ, Dick EJ Jr, Hubbard GB, Bates GW. Adenomyosis in the baboon is associated with primary infertility. Fertil Steril. 2004 Oct;82 Suppl 3:1091-4. doi: 10.1016/j.fertnstert.2003.11.065
- Kim MD, Kim S, Kim NK, Lee MH, Ahn EH, Kim HJ, Cho JH, Cha SH. Long-term results of uterine artery embolization for symptomatic adenomyosis. AJR Am J Roentgenol. 2007 Jan;188(1):176-81. doi: 10.2214/AJR.05.1613