Understanding Adenomyosis - A Comprehensive Guide
Adenomyosis is a condition that affects many women, yet it remains relatively unfamiliar to a significant portion of the population. The incidence of adenomyosis is relatively higher in certain populations, such as 20% of those seeking treatment for various gynecological diseases. Among people with infertility, the incidence of adenomyosis in women over 40 years old is relatively higher, about 30%. Adenomyosis, the 'evil sister' of endometriosis, seems to have , less recognition, less understanding, and is even more likely to be a 'missed' diagnosis for many years.
In this article, we aim to shed light on what adenomyosis is, its symptoms, causes, impact on fertility, diagnostic methods, and available treatment options.
What is Adenomyosis?
Adenomyosis is a medical condition where the tissue that normally lines the uterus (endometrium) starts to grow into the muscular walls of the uterus. This results in an enlarged uterus and often painful uterus.
Figure: On the left is a normal uterus, with normal endometrium lining the cavity. Adenomyosis is on the right, with invagination, trapping of endometrial tissue and reactive muscle thickening.
Types of Adenomyosis
Adenomyosis is classified into different types based on the location, symptoms and certain characteristics. This classification helps to decide on the treatment especially when it comes to conservative surgery without removing uterus.
1. Focal Adenomyosis:
In this type, adenomyosis is limited to a specific area or region within the uterus. It may not affect the entire organ and could be confined to one part of the uterus.
2. Diffuse Adenomyosis:
This type involves a more widespread and uniform distribution of adenomyotic tissue throughout the entire uterus. The myometrium is infiltrated by endometrial tissue, leading to a diffusely enlarged uterus.
3. Adenomyoma:
An adenomyoma is a localized mass or tumor-like growth within the uterine muscle. It is essentially a form of focal adenomyosis but is often identified as a distinct lump or nodule.
4. Adenomyosis with Cystic Changes:
In some cases, adenomyosis may lead to the formation of cysts within the uterine tissue. These cystic changes can contribute to the symptoms and complications associated with adenomyosis.
Why Does Adenomyosis Happen?
The exact cause of adenomyosis is not fully understood. However, it's believed that the invasive growth of endometrial tissue into the uterine walls. Several factors may contribute to its development. Here are few potential reasons why adenomyosis happens:
* Hormonal Influence:
Fluctuations in hormonal levels, particularly estrogen, may play a role in the development of adenomyosis. Estrogen is known to stimulate the growth of the uterine lining, and an imbalance in hormonal levels could lead to the abnormal invasion of endometrial tissue into the muscular walls of the uterus.
* Inflammation:
Chronic inflammation within the uterus may contribute to the development of adenomyosis. Inflammatory processes could weaken the normal boundaries between the endometrium and the uterine muscle, allowing the endometrial tissue to penetrate into the muscle layer.
* Genetic Predisposition:
There might be a genetic component to adenomyosis, as it often runs in families. Certain genetic factors may influence an individual's susceptibility to the condition. Research is ongoing to identify specific genes or genetic variations associated with adenomyosis.
* Uterine Trauma or Surgery:
Previous uterine surgeries, such as cesarean sections or fibroid removal procedures, may create pathways for the abnormal growth of endometrial tissue into the uterine walls. Trauma to the uterine lining during childbirth or surgical interventions might contribute to the development of adenomyosis.
* Childbirth and Aging:
Adenomyosis is more commonly diagnosed in women who have had children. The theory is that the stretching and contracting of the uterus during childbirth may facilitate the invasion of endometrial tissue into the uterine walls. Additionally, adenomyosis is more prevalent in women in their late 30s and 40s, suggesting a potential association with aging and hormonal changes.
What Are the Symptoms?
1. Menstrual Pain (Dysmenorrhea):
Intense and prolonged menstrual cramps are a hallmark symptom of adenomyosis. The pain can be more severe than typical menstrual cramps and may not be adequately relieved by over-the-counter pain medications.
2. Heavy Menstrual Bleeding:
Adenomyosis is often associated with increased menstrual flow, leading to heavier and longer periods. Excessive bleeding can result in anemia over time.
3. Pelvic Pain and Pressure:
Chronic pelvic pain may occur outside of the menstrual period. Some women describe a constant dull ache or pressure in the pelvic region.
4. Painful Intercourse:
Adenomyosis can cause discomfort or pain during sexual intercourse, particularly if the condition has led to an enlarged and tender uterus and associated with endometriosis.
5. Back Pain:
Some women with adenomyosis may experience lower back pain, which can be associated with the uterine contractions and inflammation.
6. Bloating and Enlarged Abdomen:
The uterus may become enlarged due to adenomyosis, leading to a feeling of bloating and an increase in abdominal size.
7. Blood Clots during periods:
Women with adenomyosis may pass blood clots during their periods due to the increased menstrual flow.
8. Irregular Menstrual Cycles:
Adenomyosis can cause irregular menstrual cycles, usually longer cycles than usual.
It's important to note that the severity of symptoms can vary among individuals, and some women with adenomyosis may not experience noticeable discomfort or symptoms. Additionally, the symptoms of adenomyosis can overlap with other gynecological conditions, such as endometriosis or fibroids.
How is it Diagnosed?
Diagnosing adenomyosis involves a combination of medical history, physical examinations, and imaging studies.
* Ultrasound: Transvaginal Ultrasound is a good imaging modality in diagnosing adenomyosis especially in experienced hands.
* MRI (Magnetic Resonance Imaging): MRI is considered more accurate in detecting adenomyosis, offering detailed images that help in confirming the diagnosis.
Medical therapy for Adenomyosis
Medical therapy for adenomyosis refers to medications or pills aimed at easing symptoms. These treatments, however, are not addressing the underlying disease itself. They consist of treatments for period pain and heavy bleeding. Like all medications, there are potential short- and long-term side effects. When symptoms are severe, these medical therapies are usually used as a short-term fix while a long-term solution is being organised.
* Pain Management: Non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to be effective in reducing period pain. Examples include ibuprofen (Nurofen), mefenamic acid (Ponstan), naproxen (Naprogesic), and diclofenac (Voltaren). These drugs work by blocking prostaglandin production and can reduce uterine cramps. They also have a mild effect on reducing the heaviness of menstrual bleeding. However, none of these drugs have been tested specifically for effectiveness in the setting of adenomyosis.
* Hormonal Therapy: Birth control pills, hormonal IUDs, or other hormonal medications can regulate menstrual cycles and alleviate symptoms.
Surgical Treatment Options
Surgical treatment for adenomyosis is decided based on the age of the patient, symptoms, fertility desire and type of adenomyosis. Below are the different surgeries offered for pateints suffering with adenomyosis.
Adenomyomectomy:
This surgery involves removing or excising the adenomyotic tissue while preserving the healthy parts of the uterus. It's a conservative approach for those who want to retain their uterus.
Uterine Artery Embolization (UAE):
In UAE, tiny particles are injected into the uterine arteries to block blood flow to the adenomyosis-affected areas. This procedure aims to shrink the adenomyotic tissue and alleviate symptoms.
Endometrial Ablation:
Endometrial ablation is a minimally invasive procedure where the lining of the uterus (endometrium) is destroyed or removed. While it can provide relief from heavy bleeding, it may not be suitable for all adenomyosis cases especially those with severe dysmenorrhea and pelvic pain.
Hysterectomy:
Hysterectomy involves the removal of the uterus and is considered a definitive solution for adenomyosis. Total hysterectomy removes the entire uterus, while subtotal or partial hysterectomy removes the uterus but leaves the cervix intact.
The choice of surgical intervention depends on factors such as the severity of symptoms, the desire for future fertility, and the extent of adenomyotic involvement. Adenomyomectomy and uterine artery embolization are options for those who wish to preserve fertility, while endometrial ablation and hysterectomy are more suitable for those seeking a more definitive resolution.
Understanding adenomyosis is the first step toward effective management. If you suspect you may have adenomyosis or are experiencing symptoms, consult with a gynecologist, expert in managing endometriosis and adenomyosis,for a thorough evaluation and personalized treatment plan. Remember, early detection and intervention can significantly improve the quality of life for those affected by this condition.
Dr Alphy S Puthiyidom
Appointments 800-1999
www.mediclinic.ae