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PäiviHärkki

Adenomyosis

Essentials

  • The risk of adenomyosis is increased by childbirth, miscarriage, uterine curettage and menorrhagia.
  • The symptoms resemble those of endometriosis.
  • An underdiagnosed disease
  • In fertile age treated like endometriosis
  • Hysterectomy is the best and final treatment for older women with severe symptoms.

General remarks

  • Adenomyosis is characterised by the presence of intramyometrial foci of endometrial glandular and stromal cells (in endometriosis, endometriotic tissue is found outside the uterus).
  • The foci of adenomyosis react to oestrogen in a manner similar to that of endometrium.
  • The foci have either diffuse (usually in the posterior uterine wall) or local (adenomyoma) distribution where a large number of foci become localised in one area.
  • The aetiology remains unclear.
  • The risk of adenomyosis is increased by childbirth, miscarriage, uterine curettage and menorrhagia.
  • Currently adenomyosis is suspected to be associated also with infertility and hence to be more common than previously thought; in 5-70% of women.
  • Most common at the age of 35-50 years
  • Changes are found in 15-20% of hysterectomy patients.
  • About 40% of patients with endometriosis also have adenomyosis.

Symptoms

  • An enlarged and tender uterus
  • Feeling of heaviness in the lower abdomen
  • Chronic lower abdominal pain
  • Infertility; impaired attachment of the embryo to the uterine wall
  • 40-50% have menorrhagia
  • 10-30% have dysmenorrhoea
  • 30-40% are symptom free
  • The symptoms are similar to those of endometriosis Endometriosis and differential diagnosis may prove to be difficult.

Diagnosis

  • Gynaecological examination will reveal uterine tenderness.
  • The ultrasound appearance is that of thickened posterior uterine wall and hypoechoic and blind areas of 1-5 mm in the myometrium.
  • An MRI scan will show thickening of the junctional zone (the interface between the endometrium and myometrium) or a lesion with poorly defined borders (adenomyoma).
  • Diagnosis is challenging and can only be confirmed with a histopathological examination carried out after hysterectomy.
  • Diagnosis may also be obtained by a biopsy taken through hysteroscopy or laparoscopy.

Treatment

  • Prostaglandin inhibitors (anti-inflammatory drugs) reduce menorrhagia and pain in one third of patients.
  • Tranexamic acid halves menorrhagia.
  • Combined oral contraceptive pills as well as progestin pills are effective in reducing both menorrhagia and pain.
  • Levonorgestrel-releasing intrauterine device (IUD) reduces menorrhagia and pain in up to 90% of patients.
  • A gonadotropin-releasing hormone agonist (GnRH agonist) will cause a hypo-oestrogenic state and amenorrhoea leading to both cessation of menorrhagia and pain as well as reduction in the size of the foci (adverse effects include menopausal symptoms if oestrogen/progestogen is not used as add-back therapy).
  • Uterine artery embolization reduces menorrhagia related to adenomyosis and the number of bleeding days.
  • Surgical excision of a localised adenomyoma is possible.
  • The new MRI- or ultrasound-guided focused ultrasound (HIFU, high-intensity focused ultrasound) seems to alleviate the symptoms of adenomyosis.
  • The aforementioned treatments alleviate symptoms but there is no scientific evidence on them in improving fertility.
  • Hysterectomy is the best and final treatment for older women with severe symptoms in whom the above treatment forms have proved ineffective.

    References

    • Maheshwari A, Gurunath S, Fatima F et al. Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. Hum Reprod Update 2012;18(4):374-92. [PubMed]
    • Zhai J, Vannuccini S, Petraglia F et al. Adenomyosis: Mechanisms and Pathogenesis. Semin Reprod Med 2020;38(2-03):129-143. [PubMed]
    • Struble J, Reid S, Bedaiwy MA. Adenomyosis: A Clinical Review of a Challenging Gynecologic Condition. J Minim Invasive Gynecol 2016;23(2):164-85. [PubMed]
    • Pontis A, D'Alterio MN, Pirarba S et al. Adenomyosis: a systematic review of medical treatment. Gynecol Endocrinol 2016;32(9):696-700. [PubMed]
    • Dueholm M. Minimally invasive treatment of adenomyosis. Best Pract Res Clin Obstet Gynaecol 2018;51:119-137. [PubMed]