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Adenomyosis


 

Adenomyosis: Just the Facts

What it is: 

  • The normal glandular lining of the uterus (the “endometrium”)—normally designed to be a layer which is sloughed away with a period—instead, grows into the muscular portion of the uterus with glandular cells.

 

What it does: 

  • Causes symmetrical, boggy enlargement of the uterus.
  • Causes pain and tenderness, including painful periods, lower abdominal pain, and painful sex.
  • Causes heavy/prolonged menstrual bleeding.

The invasion of the glandular endometrium into the muscle layer “myometrium” elements interferes with this muscular layer’s closing the typical bleeding sinuses of the lining; hence, bleeding with periods is heavier—the normal checks and balances to curtail bleeding with a period defeated.

Hence, more muscular contraction is needed to extrude the extra blood hence, more cramping à hence more painful periods.

It can become a cause for needing a hysterectomy, especially if anemia develops or if the pain becomes debilitating.

  • Causes symptoms due to increased size of the uterus and the accompanying heaviness:
  • Pain and pelvic pressure.
  • Painful sex due to the mechanical action of intercourse agitating the overly-sensitive uterus.
  • Impacts fertility, specifically the ability to maintain early pregnancy. Adenomyosis makes implantation of a fertilized egg unreliable.

 

Who is at risk for adenomyosis?

Actually, no one can say exactly. However, it seems to be more prevalent in middle-aged women and those who have two or more pregnancies. 

Adenomyosis is diagnosed via:

  • Surgical removal of the uterus and studying the tissue under the microscope (demonstrating glandular elements in the muscle layer).

This is the only “official” way to diagnosed it—the only way to identify it with certainty. Of course, such a method is after removal of the entire uterus, which prevents any confirmation in those who want to preserve their childbearing potential, i.e., preserve their uterus. Aside from this, a diagnosis of adenomyosis can only be suspected, and this is done via

  • History and physical: history of symptoms (painful, heavy periods) and your physician feeling a larger-than-normal, boggy, tender uterus on exam.
  • Ultrasound: accurate in the majority of the cases, short of confirmation.
  • MRI: more accurate than ultrasound, but MRI is very expensive, so it is seldom used.

Importantly, imaging is useful in ruling out pregnancy, another cause for an enlarged, boggy uterus. (By exam, adenomyosis may be impossible to distinguish from a pregnancy in the first trimester.)

Confirmation is very important to rule out pregnancy, since the treatment for adenomyosis is hysterectomy [SEE BELOW], which is not compatible with pregnancy.

How adenomyosis is treated: 

  • Doing nothing. It is a benign condition, and if the symptoms don’t justify intervention (if a patient can “live” with it), watchful waiting is reasonable.
  • Hormonal suppression: birth control pills, hormonal IUD, medications used in endometriosis to suppress the cycle, are generally NOT successful in adenomyosis. In fact, some doctors have used a “birth control pill challenge” to see if the heavy periods improve or not: if so, there could be fibroids involved; if not, it’s probably adenomyosis.
  • NSAIDs (ibuprofen, etc.), for the pain only. These analgesics do nothing for the condition itself.
  • Surgery:
    • Hysterectomy in those finished childbearing is not only definitive therapy, but affords a definitive diagnosis.
    • Conservative (uterus-sparing) methods such as hysteroscopy or ablation (destruction of the inner lining with heat, “cryo,” or radio frequency procedures are usually ineffective and only serve to delay the inevitable).

 

A note from Dr. Bozdogan about adenomyosis:

Dr. Bozdogan:

It is fortunate that the condition of adenomyosis typically begins in middle-aged women and in those who have had pregnancies already, because its ‘cure,’ hysterectomy, would be a tragedy for any woman still desiring future pregnancy. Having finished one’s family, however, makes the decision easier for a woman. With the pregnancy issue aside, then a woman with adenomyosis need only ask, "Is the pain, inconvenience, and bleeding bad enough that I am willing to undergo hysterectomy to remedy it?’

He further states,

Certainly, conservative approaches make sense, especially in those who need to maintain their reproductive potential. However, in women whose childbearing is considered “complete,” I have found the more conservative measures are neither entirely harmless nor overwhelmingly successful. In spite of that, here at Advanced Endometriosis center I support the conservative approach, but I also will give my patients a realistic and personalized assessment of their condition and which approach would make the most sense. If appropriate, I will also explain the advantages of robotic hysterectomy–that is, why robotic surgery is superior to minimize scarring and pain and shorten your recovery compared to other surgical approaches and why it is more definitive compared to even what are considered the ‘conservative’ approaches.’”  

 

Summary:

Adenomyosis is a benign condition that can severely affect your quality life with heavy, painful periods and abdominal pain. If you have minimal symptoms that are bearable or easily tolerated, you don’t have to do anything; although if conditions become unbearable (and only if you’ve finished your family), hysterectomy is the treatment of choice. As “final” as that sounds, today’s state-of-the-art techniques using robotic surgery makes this procedure—once a major ordeal—a much easier process in discomfort, scarring, and recovery. Today, at Advanced Endometriosis Center, Dr. Bozdogan can begin your evaluation for an informed decision by your simply making an appointment.

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