Adenomyosis

Adenomyosis is a condition that affects the muscle of the uterus and is defined as the presence of the tissue that usually lines the uterus (called the endometrium) within the muscular wall of the uterus.  The uterus has a muscular layer and the lining is the part that grows and sheds each month with menstruation.  For a variety of reasons – most of which remain unclear – the lining of the uterus may grow backwards, or simply occur there and lead to the finding of the glands of the endometrium and their supporting tissues being present in this layer.  Now, for those women who have endometriosis, they will see that this process is the same for that disease (see our endometriosis blog) and therefore adenomyosis may be considered endometriosis of the uterus itself.

Perhaps not surprisingly the symptoms of adenomyosis are similar to that of endometriosis, with period pain, non-period pain and abnormal bleeding all potentially occurring.  These symptoms are not specific to either endometriosis or adenomyosis and when present, one or both conditions may be present.  The finding of the glandular material in the uterine wall may cause the uterus to become enlarged (called hypertrophy) and sometimes doctors use the term ‘bulky uterus’.  This simply means that the uterus (usually about 8 x 5 x 4 cm in dimension) is larger than 12 cm in length and more than 6 cm thick.  There are no absolute measurements that define adenomyosis, but an increasing size of the uterus is often demonstrated.  About one in three women with adenomyosis will have no symptoms at all.  This condition is not precancerous and when there are no symptoms, no treatment needs to be undertaken.

How is it diagnosed?

The clinical features of pain and abnormal bleeding and perhaps an enlarged uterus on a pelvic examination may suggest that adenomyosis is present.  The performance of a high-quality ultrasound by an ultrasound practice with specialist skills in this area is certainly the investigation of choice in Australia for this condition.  Studies have shown that a good transvaginal ultrasound is almost as good as an MRI at correctly identifying adenomyosis, although is much cheaper.  In Australia MRI is not covered by Medicare for this indication and incurs considerable expense, for limited additional gain.

Ultrasound findings that your doctor may use to help make a likely diagnosis of adenomyosis include:

1. Thickening of the area between the lining and the muscle layers in the uterus;
2. A differential thickness of the walls of the uterus;
3. An area of irregularity in the uterus that is not a fibroid;
4. Changes in blood flow patterns in the wall of the uterus;
5. A ‘lightglobe’ shaped uterus;
6. Enlargement of the uterus with dimensions that are outlined above.

There are of course limitations to ultrasound and the diagnosis of any imaging study (ultrasound scan or MRI) is only a suggestion that adenomyosis is present, since the only way to absolutely diagnose the condition is by taking a biopsy and looking at it under a microscope.  This of course means an invasive test and some researchers have suggested that this process may not show adenomyosis at the time of the biopsy, but the very process of biopsy itself may cause the condition.

What are the causes?

Genetic factors certainly play a role in the causation of adenomyosis, and many factors that we do not understand.  Other causes that may contribute are procedures that disrupt the layer between the muscle and the lining including a curettage and a caesarean delivery.  There does appear to be an overlap with endometriosis and many researchers believe that they are two manifestations along the same disease profile.

How is it treated?

Once the diagnosis is suggested (but not always confirmed as we have discussed above), the options for treatment are as follows:

1. Where there are no symptoms, then no treatment is needed at all, and monitoring of symptoms is all that is required.  Repeated interval ultrasounds are not necessary.
2. Oral treatments including progestogens and the combined oral contraceptive pill play an important role in the management of the heavy or irregular bleeding and the pain that may be associated with adenomyosis and other causes of abnormal uterine bleeding (AUB).
3. When progestogens are used, they work to decrease the activity of the glandular tissue within the wall of the uterus and decrease pain symptoms (and abnormal bleeding symptoms) however 50% of patients experience recurrence by 6 months.
4. Levonorgestrel-releasing intrauterine devices (Mirena) are inexpensive, well tolerated and achieve symptom control for more than three years.  These are an excellent way of controlling symptoms – particularly in the woman who has not had any children or not completed her family and wishes to maintain this option.  Studies show that this is probably the best long-term medical treatment.
5. Hysterectomy is considered gold standard in the treatment of adenomyosis in women who do not desire any more children, but is a major surgical intervention.  It also means that the diagnosis can be confirmed – but once the uterus is out, there is no turning back!  It is also a permanent solution to the bleeding and reduction in pain is substantial-complete in many women.
6. Other surgical treatment options include focal removal of the adenomyosis  – this is called an adenomyomectomy and may provide about 85% reduction in period pain post-operatively with post-operative pregnancy rates of up to 60%.  A substantial risk of this type of surgery prior to a pregnancy is, unlike removal of a fibroid, part of the uterine tissue is removed and there is a greater risk of scar rupture during pregnancy or delivery.
7. Endometrial ablation (removal of the uterine lining) may also be an option for treatment, although where the disease invades more deeply into the muscle, the rate of failure from this treatment may be 25% or more.
8. Newer techniques use ultrasound guidance and focal heat therapy to destroy the adenomyotic areas, although these techniques are largely confined to clinical studies since their efficacy has not yet been clinically demonstrated.

Adenomyosis is a common condition in women and may be troublesome to treat.  One of the primary issues with this disease is that we have to rely on indirect evidence for diagnosis at times, since only uterine removal will confirm the diagnosis (and also treat the issue) but this is of no value to the women who wants to maintain her uterus and/or her fertility.  Management options are limited, but may be successful in the long term.  If you have any more concerns, you can ask one of the Alana doctors for more information or advice.

At Alana Healthcare for Women we are dedicated to caring for the health of women at any age.  Please read more about our Gynaecology services here.