What is adenomyosis?

Adenomyosis (pronounced “add-en-o-my-OH-sis”) is a gynecologic condition where endometrial-like tissue that usually lines the inside of the uterus  grows inward into the uterine muscle wall (myometrium).  This displaced and now ‘trapped’ endometrial-like tissue still undergoes stimulation by the hormones of the menstrual cycle and continues its normal  behavior to thicken — with each menstrual cycle.  Thus despite this endometrial-like tissue being trapped, in response to hormones it can expand, grow and bleed, all of which create extreme pain.  This can result in:

• the uterus enlarging as much as two or three times its usual size.  
• menstrual cramps, lower abdominal pressure & bloating prior to menstrual periods.
• Distortion of vasculature (blood vessels) leading to painful menstruation with heavy or prolonged. bleeding including clotting and abdominal/pelvic pain.
• a condition located throughout the entire uterus or isolated in one spot.
• pain during sex & infertility.

What are the symptoms and signs of adenomyosis?

While the symptoms and signs of adenomyosis can disrupt daily life and range from menstruation changes to chronic pelvic pain, it can also be an asymptomatic disease and one-third of women with adenomyosis  experience no symptoms at all.  Adenomyosis is often referred to as the ‘Silent Disease’ because the symptoms are often misdiagnosed as other conditions, or left undiagnosed altogether and women can go years before Adenomyosis is discovered. Possible symptoms of adenomyosis include:

• bleeding between periods
• worsening uterine cramps
• an enlarged and tender uterus
• general pain in the pelvic area
• a feeling a sense of pressure on the recturm and  bladder  
• pain while having a bowel movement
• Enlarged uterus
• Feelings of abdominal bloating, fullness or heaviness
• Heavy bleeding during periods (menorrhagia)
• Pain during sex (dyspareunia)
• Severe cramps and or deep pain during periods (dysmenorrhea)

Women’s health magazines occasionally use the term adenomyosis belly in reference to how adenomyosis can produce a protruding abdomen to the extent that a woman may appear to be months into pregnancy.   Adenomyosis may also give rise to anemia in some women. If you feel chronically fatigued or cold, your body may not have sufficient iron-rich red blood cells due to heavy bleeding during menstruation.  If you are experiencing any of these symptoms, know that adenomyosis can be managed through medication, surgery, or hormone therapy.
Adenomyosis & infertility: For some women infertility is a symptom because adenomyosis can prevent implantation of an embryo on the uterus wall.  As endometrial-like tissue grows into the muscular wall of the uterus (myometrium), it can make it difficult for an embryo to implant, and also cause both miscarriages and premature births.  

What causes adenomyosis? 

Science isn’t exactly sure what causes adenomyosis, but theories include:

• Childbirth: Adenomyosis is common among women who have given birth, particularly to more than one child.  Some speculate endometrial-like tissue could invade the uterine muscle wall (myometrium) when an embryo attaches itself to the uterine wall.  Some also believe inflammation of the uterus that occurs after childbirth during the postpartum period — disrupts the normal boundaries of the cells lining the uterus.    

• Fetal development: Adenomyosis is a congenital disorder wherein endometrial-like stem cells may be deposited in the uterine muscle wall (myometrium) prior to birth when the uterus first forms in a fetus.   

• Previous surgeries: Research suggests uterine surgeries such as dilation and curettage (a procedure wherein tissue is removed from inside the uterus) or  cesarean sections due to incisions and the accompanying inflammation, might promote the direct invasion of the endometrial cells into the wall of the uterus. 

Regardless of what causes adenomyosis, its growth is reliant on the body’s circulating of hormones like estrogen. Most women coping with adenomyosis are 35-50 in age at the tail end of their childbearing years. Since the predominant symptoms of adenomyosis dramatically subside with menopause it is thought that the change in the levels of various hormones, such as estrogen, progesterone, and others accounts for the relief in symptoms experienced.

What’s the difference between adenomyosis and endometriosis?

Adenomyosis and Endometriosis are gynecological conditions involving the abnormal growth of endometrial-like tissue mostly afflicting women of reproductive age. They share similar symptoms such as painful periods and pelvic pain. Where they differ is the location of the endometriosis-like tissue lesions. With endometriosis the tissue collects outside the uterus.  With adenomyosis, the tissue implants inside the muscle wall of the uterus.  Nonetheless both are painful, can produce heavy bleeding and it is possible for a woman to have both adenomyosis and endometriosis at the same time.  Adenomyosis and Endometriosis also have their share of distinct characteristics that set them apart. Here is a profile listing the similarities and differences between the two diseases:

Similarities:

• Origin: Both diseases produce growth of endometrial-like  tissue away from its usual location.
• Symptoms: They can produce similar symptoms, including menstrual irregularities, painful intercourse and pelvic pain.
• Impact on fertility: Both diseases can make conceiving difficult and contribute to infertility.
• Hormonal influence: Hormones play a role in the growth and progression of both diseases. particularly estrogen – something hinted to by the fact that they both subside with menopause.
• Diagnosis: Both adenomyosis and endometriosis are commonly misdiagnosed for some other ailment, and diagnosis usually requires an ultrasound, MRI, or laparoscopy.

Differences:

• Location: With endometriosis the endometrial-like tissue collects outside the uterus, usually on the abdominal cavity or pelvic organs.  With adenomyosis the endometrial-like tissue is located within the uterus itself and into its muscular wall (myometrium).
• Tissue involvement: Endometriosis usually involves the formation of lesions or nodules, whereas adenomyosis gives rise to the infiltration of endometrial-like tissue into the uterine muscle (myometrium).
• Symptoms: Adenomyosis frequently results in heavier and more prolonged menstrual bleeding, coupled with expanded enlargement and tenderness of the uterus, whereas endometriosis typically centers on pain over the course of the menstrual cycle.
• Spread: Endometriosis can potentially exhibit a regional spread to multiple organs, while adenomyosis is restricted to the uterus.
• Treatment: Despite treatment options overlapping, management of care of adenomyosis and endometriosis can differ.  Pain management, hormonal therapies, and surgery are common approaches for endometriosis. Adenomyosis may involve more invasive procedures such as hysterectomy to alleviate symptoms.

How is adenomyosis diagnosed?

Diagnosis of adenomyosis usually begins with a thorough review of symptoms, medical history and If adenomyosis is suspected – the first step is a physical exam.  More specifically, a comprehensive pelvic exam may reveal a tender and enlarged uterus.  Based on all that can be discerned to this point, a few additional tests might be warranted.   These test involve imaging technology which can recognize adenomyosis without surgery and might include:

• Ultrasound: Typically a transvaginal ultrasound can identify thickening of the uterine muscular wall (myometrial), cystic glands within the myometrium, diverse myometrial texture, projections from endometriosis-like tissue into the myometrium, and an expanded size of the uterus.  Or simply put, while a transvaginal ultrasound cannot definitively diagnose adenomyosis, it can identify characteristics of the disease in the uterus and help to rule out other conditions with similar symptoms.

• A transabdominal ultrasound can identify changes to the muscular layer of the uterine wall or myometrium. If uterine fibroids (leiomyomas) are suspected, an MRI may be warranted to distinguish between the fibroids and adenomyosis.

• Laparoscopy:  Adenomyosis is frequently referred to as “the hidden disease,” because it is buried in the muscle and can be missed from being identified from imaging tests.   For this reason laparoscopy, an invasive procedure usually involving as many as 3 tiny keyhole incisions in the abdomen in which a small camera is inserted, may be warranted. This enables the visual inspection for any lesions or fibroids inside the uterus.

• Biopsy: A needle biopsy involves collecting a tissue sample inside the uterus from the myometrial layer or uterine muscular wall and sending it to a lab for testing.  There is research indicating biopsies be performed for definitive diagnosis of adenomyosis in circumstances where there is ultrasonographic or clinical suspicion and the patient does not  undergo a hysterectomy.

How is adenomyosis treated?

Treatment of adenomyosis is primarily focused on relieving symptoms, which may include pain and irregular menstruation. Since adenomyosis largely goes away post menopause, that’s something to consider if you’re at that stage of life. Treatment options include:

• Anti-inflammatory medications. Ibuprofen (Motrin IB, Advil, etc) and other non-steroidal anti-inflammatory medications NSAIDs is a standard initial response to cope with adenomyosis pain.  Many women have found taking anti-inflammatory medicine a few days prior to the start of their period and during menstruation has alleviated pain and cramping while also reducing blood flow.  Non-steroidal anti-inflammatory medications block a specific enzyme (cyclooxygenase) the body used to make prostaglandins, a hormone-like chemical.  Prostaglandins contribute to pain, inflammation, uterine contractions, and the dilating of blood vessels which increases tenderness and swelling.

• Hormone medications. A common first-line therapy for coping with the  adenomyosis symptoms hormonal contraceptives including progesterone-releasing intrauterine devices (IUDs) and birth control pills. Combined hormone-containing patches, vaginal rings, and estrogen-progestin birth control pills may reduce the pain and heavy bleeding accompanying adenomyosis.  

• Hysterectomy. If all else (treatment options) have proven ineffective and adenomyosis pain is severe and debilitating, surgery to remove the uterus may be the only option for symptom relief.  It’s important to stay mindful that removal of the uterus addresses the organ most affected by adenomyosis, but it doesn’t necessarily address the underlying cause of the condition – something medical science doesn’t exactly know.  Different from other uterine growths, adenomyosis isn’t always easy to remove, particularly if it’s spread over a sizable area.    There’s no research suggesting ovaries (important endocrine-hormone making organs) need to be removed in surgically treated adenomyosis.