Adenomyosis

Overview

Adenomyosis is a medical condition characterized by the presence of ectopic endometrial tissue (the inner lining of the uterus) within the myometrium (the thick, muscular layer of the uterus). The condition is typically found in women between the ages of 35 and 50. Patients with adenomyosis can have painful and/or profuse menses (dysmenorrhea & menorrhagia, respectively). Adenomyosis may involve the uterus focally, creating an adenomyoma, or diffusely. With diffuse involvement, the uterus becomes bulky and heavier.

Symptoms

Sometimes, adenomyosis is silent — causing no signs or symptoms — or only mildly uncomfortable. In other cases, adenomyosis may cause:

  • Heavy or prolonged menstrual bleeding
  • Severe cramping or sharp, knifelike pelvic pain during menstruation (dysmenorrhea)
  • Menstrual cramps that last throughout your period and worsen as you get older
  • Pain during intercourse
  • Blood clots that pass during your period

Your uterus may get bigger. Although you might not know if your uterus is enlarged, you may notice that your lower abdomen seems bigger or feels tender.

Some women with adenomyosis do not experience any symptoms, while others may have severe, debilitating symptoms. The endometrial implants that grow into the wall of the uterus bleed during menstruation (the same as endometrial tissue bleeds) and are discharged vaginally as menstrual bleeding. The vaginal pressure can be severe enough to feel like the uterus is trying to push out through the vagina, like the first stage of labor when the baby's head pushes into the cervix. Other symptoms include;

  • Intense debilitating pain all the time and/or
  • Acute & increasing pain at menstruation and ovulation
  • Strong 'contraction' feel of uterus
  • Abdominal cramps
  • A 'bearing' down feeling
  • Pressure on bladder
  • Dragging sensation down thighs and legs
  • Heavy bleeding and flooding
  • Large blood clots
  • Prolonged bleeding i.e.; up to 8–14 days

Causes

The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as a caesarean section, tubal ligation, pregnancy termination, and any pregnancy. Some say that the reason adenomyosis is common in women between the ages of 35 and 50 is because it is between these ages that women have an excess of estrogen. Near the age of 35, women typically cease to create as much natural progesterone, which counters the effects of estrogen. After the age of 50, due to menopause, women do not create as much estrogen.

Diagnosis

The uterus may be imaged using ultrasound (US) or magnetic resonance imaging (MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize uterine fibroids. MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small uterine fibroids. The uterus will have a thickened junctional zone with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the junctional zone greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (

Prognosis

There is no increased risk for cancer development. As the condition is estrogen-dependent, menopause presents a natural cure. Patients with adenomyosis often also have leiomyomata and/or endometriosis.

Treatment

Treatment options range from use of NSAIDS & hormonal suppression for symptomatic relief, with hysterectomy the only permanent cure option. Women with Adenomyosis fail endometrial ablation because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain. The result of failed ablation due to Adenomyosis is hysterectomy. Those that believe an excess of estrogen is the cause or adenomyosis, or that it aggravates the symptoms, recommend avoiding products with xenoestrogens and/or recommend taking natural progesterone supplements.