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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]