What is Adenomyosis?
Adenomyosis is a women’s health issue that happens when a type of tissue, normally found lining the uterus, grows in the muscular wall of the uterus. This condition was first identified by Carl von Rokitansky, a German scientist, in 1860. It can cause a variety of symptoms, but the most common ones are painful periods and heavy bleeding during menstruation.
In the past, a diagnosis of adenomyosis required a tissue sample often obtained through biopsy or more commonly, surgery to remove the uterus. Nowadays, however, it can be diagnosed non-invasively using ultrasound technology or magnetic resonance imaging (MRI).
If a woman no longer wants to have children, removing the uterus (a procedure known as a hysterectomy) is the most effective treatment. But for those who wish to keep their fertility or avoid major surgery, there are other medical treatments and minimally invasive procedures available.
What Causes Adenomyosis?
The exact cause of adenomyosis, a condition where the inner lining of the uterus breaks through the muscle wall, is not clearly known yet. Scientists are considering several theories. The most accepted one is that adenomyosis arises because the boundary line between the innermost part of the uterus lining (the endometrium basalis) and the muscle layer beneath it (the myometrium) becomes disrupted. This results in the improper growth of the endometrium into the myometrium that further leads to the formation of new small blood vessels and the enlargement of nearby muscle cells. The fact that adenomyosis is more common in women who have had a procedure to remove uterine tissue or a Cesarean section supports this theory.
Another theory suggests that an issue arises during the developmental stage where pluripotent Muellerian stem cells – cells that can develop into various types of cells – change improperly and lead to the creation of abnormal endometrial tissue. This theory is backed by data showing alterations in specific genetics markers and case reports of finding endometrial tissue in women with Rokitansky-Kuster-Hauser syndrome — an ailment where the female reproductive organs do not develop properly.
Additional theories, although they’re not as widely accepted, involve changes in the ways the body drains lymph fluid and the displacement of bone marrow stem cells to explain the occurrence of misplaced endometrial tissue.
Risk Factors and Frequency for Adenomyosis
Adenomyosis is a disease whose exact numbers and reach are uncertain due to underreporting and misdiagnosis. The estimated prevalence varies widely, anywhere from 5% to 70%, but more recent research indicates it’s likely to affect 20% to 35% of the population.
This illness traditionally manifests in women who are pre-menopausal, have had multiple children, and are in their thirties to forties. But please note: this reflects a bias since these are the women more likely to undergo a procedure known as a hysterectomy. Our ability to detect this disease has considerably improved, thanks to advancements in ultrasound and MRI technology.
There is a rare variant of this disease, called juvenile cystic adenomyosis, which is characterised by extensive bleeding within myometrial cysts and is typically seen in women under 30. Unfortunately, these symptoms are often resistant to medical therapies and may require surgical intervention, such as myomectomy or hysterectomy.
- Risk factors for adenomyosis include conditions that expose the body to higher levels of estrogen, such as having multiple children, early puberty, short menstrual cycle durations, a higher body mass index, oral contraceptive pill use, or tamoxifen use.
- Previous surgeries on the uterus, such as dilation and curettage, cesarean sections, and myomectomies, can also increase the risk of adenomyosis.
Signs and Symptoms of Adenomyosis
Adenomyosis can be hard to diagnose, as it shares symptoms with many other common gynecological conditions. The most frequently seen symptoms are heavy or painful periods, but the condition can be challenging to confirm based solely on these. Some people may also experience other symptoms like chronic pelvic pain and pain during sex, although these are less common. Interestingly, a third of women with adenomyosis may not show any symptoms at all. While some believe that adenomyosis could be linked to infertility, the evidence is unclear with only 11% to 12% association reported in some studies.
On physical examination, the uterus might appear abnormally large and feel “squishy” to the touch. This enlargement is caused by an increase in blood vessels from displaced endometrial tissue and the growth of smooth muscle cells. It is worth noting that a tender uterus is a more common finding, particularly in comparison to a uterus enlarged due to leiomyomatous.
Testing for Adenomyosis
Laboratory tests can be used to help identify other possible diseases and potential complications, such as anemia from heavy periods, when looking into an adenomyosis diagnosis. However, no known biomarkers can definitively confirm adenomyosis.
Imaging technologies are critical in making an adenomyosis diagnosis. Priorly, MRI was often the go-to option but recent data shows that a transvaginal ultrasound has similar sensitivity and is often more accessible and cost-effective. Thus, ultrasounds are now commonly used first, and MRI is reserved for trickier cases where ultrasound results weren’t clear.
In diagnosing adenomyosis, a transvaginal ultrasound is the preferred method. The specific ultrasound findings can be grouped into three categories:
1. Endometrial infiltration: this is shown by distinct striations and nodules, myometrial cysts, and “lollipop” diverticula.
2. Smooth muscle proliferation: this is seen as a thickening of the myometrium with unclear borders, often in the posterior fundus. This can lead to a “venetian blind” appearance of thin linear shadows.
3. Vascularity: Doppler color ultrasound can show an increased number of winding vessels throughout the myometrium, differentiating it from leiomyomas.
However, other conditions or circumstances like tamoxifen use, prior endometrial ablation, endometriosis, uterine contractions, vascular malformations, leiomyomas, and cancer can also exhibit similar ultrasound findings. Special techniques can be used to differentiate between these, such as low-frequency, coronal reconstructions, 3-D ultrasound, cine-clips, color Doppler, and saline infusion sonohysterography (SIS).
When it comes to MRI, many of the findings are similar to ultrasound observations. On T2-weighted imaging, a thicker junctional zone may indicate smooth muscle hyperplasia. Similarly, myometrial cysts with a high signal on T2 imaging can point to ectopic endometrial tissue. However, contrast enhancement isn’t as reliable in assessing vascularity compared to color Doppler ultrasound.
Interpretations can be complicated by varied factors, from other gynecological conditions to physiological variations. Different imaging methods and strategies like susceptibility-weighted imaging, diffusion-weighted imaging, MR spectroscopy, cine MR imaging, and increased 3T field strength can help in these cases. It’s also recommended to get the MRI between day 7 and day 28 of the menstrual cycle to avoid potential confusion due to the decreased signal of normal myometrium during the early proliferative phase (days 1 to 6).
Treatment Options for Adenomyosis
The first step in deciding on the treatment for a patient is understanding their desire to get pregnant in the future, which will largely determine the treatment options. The removal of the uterus, known as a hysterectomy, is the certain cure. Other choices focus on reducing the typical symptoms of painful and heavy menstrual bleeding, while still keeping the uterus intact.
Medications
Non-steroidal anti-inflammatory drugs, often known as NSAIDs, are one of the main treatment methods. These medications help to alleviate the severe cramping experienced during menstruation.
There also exists various hormone treatments, including birth control pills, an intrauterine device that releases the hormone levonorgestrel, and aromatase inhibitors. These treatments work by reducing the growth of the lining of the uterus. However, it’s unclear which one is the best as we don’t have enough well-designed studies. In general, the levonorgestrel IUD is often considered the first-line therapy because it has fewer side effects and is generally quite effective.
Minimally Invasive or Surgical Treatments
Several procedures exist for patients in whom medication doesn’t work and who still want to get pregnant in the future. These procedures include MRI-guided and ultrasound-guided high-intensity ultrasound thermal ablation, which target specific areas. Another procedure called uterine artery embolization reduces the blood flow to the uterus which leads to a reduction in the size of the uterus. While these treatments show promise, more research is needed to compare their effectiveness and long-term outcomes. Even though these treatments aim to preserve fertility, there is a risk of infertility.
Endometrial ablation may be an option for patients who don’t want to have children in the future but prefer a less invasive alternative to hysterectomy.
Myomectomy and partial hysterectomy are more invasive options that aim to preserve fertility. These options allow for targeting of deeper areas; however, subsequent scarring may lead to the return of the disease. Additional considerations include the potential for future pregnancy complications due to altered uterine anatomy with an increased risk of uterine rupture, premature rupture of membranes, premature labor, and spontaneous abortion.
A hysterectomy remains the surest cure for adenomyosis.
What else can Adenomyosis be?
Adenomyosis, a condition that affects the uterus, can be difficult to diagnose. This is because its signs and symptoms, like abnormal bleeding, painful periods, or infertility, are similar to those of other diseases. To standardize the diagnosis process of abnormal uterine bleeding, The Federal International Board of Gynecology uses a handy tool known as the PALM-COEIN system. This breaks down the causes into structural and non-structural:
- Polyps
- Adenomyosis
- Leiomyoma (a type of benign tumor in the uterus)
- Malignancy/hyperplasia (unusual growth)
- Coagulopathy (a disease that affects the blood’s ability to clot)
- Ovulatory dysfunction
- Endometrial issues
- Iatrogenic causes (health problems caused by medical treatments)
- Conditions not yet classified
Adenomyosis often occurs alongside other conditions that can cause similar symptoms. These typically include leiomyoma (common in 50% of cases), endometriosis (11%), and endometrial polyps (7%).
What to expect with Adenomyosis
Adenomyosis can be challenging to manage as it involves many health factors. These can include a person’s ability to have children, certainty in the diagnosis, side effects of medication, and the risks posed by certain medical procedures. Recent data shows that adenomyosis is becoming more common in younger people and those without symptoms, indicating that we don’t yet have a full understanding of this disease. It appears that the symptoms are linked with the number and the depth of adenomyosis spots.
The general approach to treating adenomyosis is to start with medication like anti-inflammatory and hormone treatments. Depending on how the disease progresses, this could move towards less invasive procedures like endometrial ablation (a treatment that thins or removes the lining of the uterus), myomectomy (a surgery to remove fibroids), or uterine artery embolization (a procedure to block the blood vessels that supply the uterus). If all else fails, the final treatment option is a hysterectomy, which is the surgical removal of the uterus.
Possible Complications When Diagnosed with Adenomyosis
The link between adenomyosis, a condition in which the inner lining of the uterus breaks through the muscle wall of the uterus, and infertility is not very clear. Some researchers suggest an association of 11% to 12%, but there’s conflicting information as well. This is due to several factors and the different criteria used to diagnose adenomyosis, so a firm connection hasn’t yet been identified.
Given the recent advances in ultrasound diagnostic criteria, we can expect future studies to provide us more reliable data about the relationship between adenomyosis and infertility.
Preventing Adenomyosis
It’s important to know that diagnosing and treating adenomyosis—a condition affecting the uterus—can be tricky. The severity of the condition and the patient’s future fertility plans largely determine the treatment options. Additionally, adenomyosis often occurs alongside other gynecological issues, which can make treatment plans more complex.
While some minor therapies exist, and the data shows promising outcomes, these procedures—such as ultra-high frequency ultrasound or cutting off the blood supply to the uterus—haven’t been thoroughly validated by comprehensive research studies with unknown long-term results. Therefore, it’s essential for the patients to understand all the complexities involved before deciding on a treatment plan.