Adenomyosis – “Adeno-What?”
As a Reproductive Medicine and Women’s Health Specialist I often have women coming to see me for help with menstrual pain, heavy bleeding, irregular bleeding, IBS like symptoms, emotion disturbances, and pain with sex etc.
As someone who specialises in the diagnosis, treatment and management of endometriosis, many of the symptoms above are typically what someone with endometriosis would present with. But is it always endometriosis?
Could it be from another lesser-known condition, to the general population, called Adenomyosis?
Adenomyosis is a condition in which the inner lining of the uterus (the endometrium), glands and supporting structures of the endometrium breaks through the muscle wall of the uterus (the myometrium). Adenomyosis is very similar to endometriosis because it can cause menstrual pain, abnormal bleeding, heavy extended bleeding, menstrual cramps, lower abdominal pressure, bloating etc, before menstrual periods.
It can also overlap with symptoms of endometriosis and in fact, it can also exist at the same time, which can make it difficult to accurately assess which condition is causing the symptoms. Symptoms of Adenomyosis can also mimic a fibroid.
Both Adenomyosis and endometriosis have similar pathways and some medical professionals believe Adenomyosis is actually Endometriosis inside the uterine muscles. There is sound evidence to support this. The condition can be located throughout the entire uterus or localized in one spot. Like endometriosis, because it can be widespread, or just a small amount in one spot, it can often be hard to definitively diagnose.
Though Adenomyosis, like endometriosis, is considered a non-life threatening condition, the frequent pain, heavy bleeding associated and other associated symptoms can certainly have a negative impact on a woman’s quality of life. Some women do comment that they feel like they are dying each month when the symptoms present. Some women can be pushed to thoughts of suicide with both Adenomyosis and endometriosis and this is why emotional support is necessary for anyone with these disease states.
What Are the Symptoms of Adenomyosis?
We need to remember that just like women who have endometriosis often have no symptoms (are asymptomatic), some women diagnosed with adenomyosis have no symptoms as well and are only diagnosed when they are having issues trying to conceive.
The main symptoms of Adenomyosis are:
- Heavy, prolonged menstrual bleeding
- Severe pain and menstrual cramps
- Abdominal pressure and bloating
It can also cause other associated symptoms such as:
- Pain with bowel movement
- Irritable Bowel like symptoms or Urinary Tract Infection (UTI) like symptoms
- Mental and emotional disturbances (depression, premenstrual dysphoric disorder)
- Pain with intercourse
Who Gets Adenomyosis?
Adenomyosis is a common condition that can affect up to 35% of women, but just like endometriosis, this cannot be an accurate picture as these are only the people that have been diagnosed. It is most often diagnosed in middle-aged women and women who have had children. Sometimes the symptoms only show up after having children too.
Some studies also suggest that women who have had prior uterine surgery, such as a termination, caesarean section, or any other invasive surgery, may be at risk for adenomyosis.
Just like Endometriosis, the exact cause of adenomyosis isn’t known, but because it has the same, or similar pathways to endometriosis have suggested that various hormones such as estrogen may be a driving factor. We know that endometriosis is estrogen driven, so to Adenomyosis is thought to be the same. Research has shown that there may be a link with longer estrogen exposure at the time of a woman’s first period. There is also a link between short duration between the menses and obesity is also linked to the disease.
Until recently, the only definitive way to diagnose Adenomyosis was to perform a hysterectomy and remove the entire uterus and examine the entire organ and its tissue under a microscope.
A biopsy of the uterus can be taken to confirm the diagnosis but this also has potential flaws. If the biopsy isn’t taken in the right place, or multiple places, there is a potential to miss the disease, or misdiagnose the disease. There is some talk that any further invasive methods such as biopsy could actually cause the disease in the first place.
However, advancements in imaging technology has made it possible for doctors to recognize Adenomyosis without surgery. Using MRI or Transvaginal ultrasound, specialists can see characteristics of the disease in the uterus.
MRI (magnetic resonance imaging) can be used to confirm a diagnosis of Adenomyosis in women with abnormal uterine bleeding and pain.
If Adenomyosis is suspected, the first step is to see a specialist, not just a GP, and have a pelvic exam, which may reveal an enlarged and tender uterus. MRI and ultrasound can allow a doctor to see the uterus, its lining, and its muscular wall. Though ultrasound cannot definitively diagnose Adenomyosis, it can help to rule out other conditions with similar symptoms.
Sometimes saline solution is injected in the uterus at the same time as ultrasound is performed to give better imaging and to help evaluate the symptoms associated with Adenomyosis. This is called sono-hysterography.
While Transvaginal ultrasound can be used, it can also miss the disease, especially if the user doesn’t have an expert eye, or extra training, or specialises in the diagnosis of Adenomyosis. MRI is a much better option ultrasound may be inaccurate. Like endometriosis, blood tests definitely cannot diagnose this disease.
Adenomyosis is also often misdiagnosed as uterine fibroids, due to the symptoms being very similar, especially the heavy bleeding. However, it needs to be note that these two conditions are not the same at all. While fibroids are benign tumors growing in or on the uterine wall, adenomyosis is less of a defined mass of cells within the uterine wall. Accurate diagnosis is key in choosing the right treatment and what the ongoing management will be.
How Is Adenomyosis Treated?
The treatment for Adenomyosis will depend in part on your presenting symptoms, their severity, and whether you have completed childbearing.
The treatment options could be anything from:
- Surgical (hysterectomy, endometrial ablation, uterine artery embolisation),
- Medical treatments (drugs, hormones, contraceptives, pain medications,iron infusions)
- Complementary medicines (Acupuncture, Chinese herbal medicine, vitamins and nutrient support),
- Nutrition and diet
- Counselling & Psychology
- Meditation and Mindfulness
- Pain management clinics
- Exercise therapy (weight baring exercise, resistance training)
- Core strengthening (pilates, yoga)
- Pelvic floor management (Pilates, Yoni eggs, Kegels balls, Ba wen balls),
It could be a combination of all of these. Just like endometriosis requires a team for ongoing management, treatment and support, so too does Adenomyosis. In most causes treatment and management is the same as endometrosis. I always apply a multi-modality approach to all my patients who have endometriosis, or Adenomyosis.
Mild symptoms may be treated with over-the-counter pain medications, complementary medicines, vitamins and supplements and the use of heating pads to ease pain and cramps.
Anti-inflammatory medications. Your specialist may prescribe non-steroidal anti-inflammatory drugs (NSAID’s) to relieve mild pain associated with adenomyosis. NSAID’s are usually started one to two days before the beginning of your period and continued through the first few of days of your period.
Hormone therapy. Symptoms such as heavy or painful periods can be controlled with hormonal therapies such as a Mirena (levonorgestrel-releasing IUD), which is inserted into the uterus. Studies have shown that up to 70% of women get good control of symptoms with the Mirena. Drugs such as Zoladex, Danazol and Aromatase inhibitors are often used, but they can also have a high side effect profile
Uterine artery embolization. In this minimally invasive procedure, which is commonly used to help shrink fibroids, but it can be used to block the blood vessels that provide blood supply to adenomyosis. With blood supply cut off, sometimes the adenomyosis can be controlled.
Endometrial Ablation. This is another minimally invasive procedure but this procedure destroys the lining of the uterus. Endometrial ablation has been found to be effective in relieving symptoms in some patients when adenomyosis hasn’t penetrated deeply into the muscle wall of the uterus.
Please note: Embolization and ablation should only be considered if you have had children and do not wish to conceive in the future, as it can affect your future fertility. These two procedures may, or may not, help the symptoms of Adenomyosis and further surgical intervention such as hysterectomy may still be required.
Who Do I See For Surgery and Preserving Fertility?
A high level of skill is required for any of these surgical and radiological interventions, especially when it comes to preserving fertility. This is why one should consult with a fertility specialist, not just any gynaecologist. Surgery also requires an advanced trained laparoscopic surgeon, with extra training and specialisation in excision of endometriosis and Adenomyosis, not just any gynaecologist. The surgeon needs to be advanced trained and this is something that you need to ask before undertaking any surgical intervention. Not every gynaecologist, or fertility specialist is an advanced trained surgeon.
Does Adenomyosis Cause Infertility?
Because many women who have adenomyosis also have endometriosis it is difficult to tell precisely what role adenomyosis may play in fertility problems. However, just like endometriosis, some studies have shown that adenomyosis may contribute to infertility.
Once pregnant, women with Adenomyosis are more likely to have a premature delivery, or premature rupture of the membranes. They are also at risk of placental problems during the pregnancy too.
Can Adenomyosis Be Cured?
The only definitive cure for adenomyosis is a hysterectomy, or the removal of the uterus. This is often the treatment of choice for women with significant symptoms. But women need to be aware that if they do have endometriosis as well, that hysterectomy will not cure endometriosis and that the disease and symptoms may still be present after the hysterectomy is performed.
Potential complications of adenomyosis
Adenomyosis isn’t necessarily harmful, or life threating. However, the symptoms can negatively affect a woman’s lifestyle. Some women have excessive bleeding and pelvic pain that may prevent them from enjoying normal activities and having sexual intercourse.
Women with adenomyosis are at an increased risk of anemia. Anemia is a condition often caused by an iron deficiency. Without enough iron, the body can’t make enough red blood cells to carry oxygen to the body’s tissues. This can cause fatigue, dizziness, and moodiness. The blood loss associated with adenomyosis can reduce iron levels in the body and lead to anemia. Many women with anaemia from Adenomyosis, or endometriosis will also need an iron infusion. This is often overlooked and not taken as serious as it should be by many healthcare professionals.
The condition has also been linked with anxiety, depression, and irritability.
Long-term outlook for those with Adenomyosis
Adenomyosis is not a life-threatening condition, although if some symptoms, such as anaemia and emotional disturbances, aren’t managed properly, or early on, it could potential be life threatening. Many treatments, both medical and complementary are available to help alleviate your symptoms. A hysterectomy is the only treatment that can eliminate Adenomyosis altogether. However, the condition can go away on its own after menopause. If women with endometriosis as well, they often require ongoing treatment and management after hysterectomy, as hysterectomy does not cure endometriosis. It will however help Adenomyosis.
Dr Andrew Orr
Reproductive Medicine & Women’s Health Specialist
“The International Baby Maker and Women’s and Men’s Health Advocate”
“No Stone Left Unturned”