Adenomyosis

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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 (endometrium) grows in the walls of the uterus. It is generally estimated that adenomyosis is present in 20 to 88 percent of those born with a uterus, although the prevalence is uncertain since hysterectomy is required to make a definitive diagnosis. It is commonly seen in those with endometriosis; 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, which 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, 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.

Definition

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:

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    Heavy menstrual bleeding (defined as below)

    Soaking through one or more sanitary pads or tampons every hour for several consecutive hours
    Needing to use combined sanitary protection (pads, tampons, cup, period pants) to control your bleeding
    Needing to wake up to change pads/tampons/cups during the night
    Bleeding for longer than a week
    Passing blood clots
    Needing to restrict daily activities due to heavy menstrual flow
    Symptoms of anaemia, such as tiredness, fatigue, dizziness or shortness of breath

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    Dysmenorrhea or painful menstruation (pain in or around periods)
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    Leg pain, worse at the time of period
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    Bloating / Swelling in lower abdomen
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    Heavy "bowling ball" or "dragging" feeling in lower pelvis.
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    Dyspareunia or painful intercourse (painful sexual activity, pain after sex)
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    Infertility
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    Fatigue
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    Low back pain, worse at the time of period
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    Nonmenstrual pelvic pain or pain occurring when a woman is not menstruating. (pain at other times of the month)

Diagnosing Adenomyosis

Those 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.  Abdominal swelling can be a significant symptom. 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.
  • Tranexamic Acid (Cyclokapron) can be prescribed to help with the volume of bleeding

Pregnancy and Adenomyosis

If you want to get pregnant, hysterectomy, endometrial ablation, or uterine artery embolization are unsuitable treatments.  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.

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