Adenomyosis

What is Adenomyosis?

Adenomyosis can be another cause of chronic pelvic pain. Adenomyosis is a condition where tissue like the lining of the uterus invades the muscle of the uterus. It can be either diffuse or focal, meaning it can spread out over the uterus or can be grouped together (Agostinho et al., 2017). According to Chapron et al. (2020), the symptoms of adenomyosis can include:

• heavy menstrual bleeding
• painful periods and menstrual cramps (medical term: dysmenorrhea)
• abnormal uterine bleeding
• bloating
• pain with sex (before, during, and/or after) (medical term: dyspareunia)
• pelvic pain
• infertility
• miscarriage

Many of these symptoms overlap with endometriosis. Endometriosis and adenomyosis share similar characteristics of sex steroid hormones abnormalities, inflammation, neurogenesis (growth of new nerves), and angiogenesis (growth of new blood vessels) (Gordts, Grimbizis, & Campo, 2018). However, there are differences between the two that leave researchers concluding that adenomyosis is its own separate disease process from endometriosis (Vannuccini et al., 2017).

Adenomyosis might be suspected and a transvaginal ultrasound (TVUS) or magnetic resonance imagining (MRI) performed. Some studies have suggested that MRI might be more accurate in detecting adenomyosis (Bazot & Daraï, 2018). A biopsy is the definitive way to diagnosis adenomyosis- its accuracy improved by the use of an ultrasound guided biopsy (Nam & Lyu, 2015). 

“The standard treatment of adenomyosis is hysterectomy, but there is no medical therapy to treat the symptoms of adenomyosis while still allowing patients to conceive. Medical therapies using suppressive hormonal treatments, such as continuous use of oral contraceptive pills, high-dose progestins, selective oestrogen receptor modulators, selective progesterone receptor modulators, the levonorgestrel-releasing intrauterine device, aromatase inhibitors, danazol, and gonadotrophin receptor hormone agonists can temporarily induce regression of adenomyosis and improve the symptoms.” (Pontis et al., 2016)

There are also surgical options which do not involve a hysterectomy, such as “(1) complete excision of adenomyosis, (2) cytoreductive surgery or incomplete removal of the lesion, or (3) nonexcisional techniques” (Grimbizis, Mikos, & Tarlatzis, 2014).

References

• Agostinho, L., Cruz, R., Osório, F., Alves, J., Setúbal, A., & Guerra, A. (2017). MRI for adenomyosis: a pictorial review. Insights into imaging, 8(6), 549-556. Retrieved from https://insightsimaging.springeropen.com/articles/10.1007/s13244-017-0576-z 
• Bazot, M., & Daraï, E. (2018). Role of transvaginal sonography and magnetic resonance imaging in the diagnosis of uterine adenomyosis. Fertility and sterility, 109(3), 389-397. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0015028218300244
• Chapron, C., Vannuccini, S., Santulli, P., Abrão, M. S., Carmona, F., Fraser, I. S., … & Pistofidis, G. (2020). Diagnosing adenomyosis: an integrated clinical and imaging approach. Human Reproduction Update, 26(3), 392-411. Retrieved from https://academic.oup.com/humupd/article-abstract/26/3/392/5756142  
• Gordts, S., Grimbizis, G., & Campo, R. (2018). Symptoms and classification of uterine adenomyosis, including the place of hysteroscopy in diagnosis. Fertility and sterility, 109(3), 380-388. Retrieved from https://link.springer.com/article/10.1007/s40271-017-0284-2
• Grimbizis, G. F., Mikos, T., & Tarlatzis, B. (2014). Uterus-sparing operative treatment for adenomyosis. Fertility and sterility, 101(2), 472-487. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0015028213031713 
• Nam, J. H., & Lyu, G. S. (2015). Abdominal ultrasound-guided transvaginal myometrial core needle biopsy for the definitive diagnosis of suspected adenomyosis in 1032 patients: a retrospective study. Journal of minimally invasive gynecology, 22(3), 395-402. Retrieved from https://www.sciencedirect.com/science/article/pii/S1553465014004129 
• Pontis, A., D’alterio, M. N., Pirarba, S., De Angelis, C., Tinelli, R., & Angioni, S. (2016). Adenomyosis: a systematic review of medical treatment. Gynecological Endocrinology, 32(9), 696-700. Retrieved from https://www.tandfonline.com/doi/abs/10.1080/09513590.2016.1197200 
• Vannuccini, S., Tosti, C., Carmona, F., Huang, S. J., Chapron, C., Guo, S. W., & Petraglia, F. (2017). Pathogenesis of adenomyosis: an update on molecular mechanisms. Reproductive biomedicine online, 35(5), 592-601. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S1472648317302961   

Links:

• Adenomyosis Support Group: https://www.facebook.com/groups/AdenomyosisSupport/ 
• “Adenomyosis – Sister To Endometriosis Or Distant Cousin?”
• “Adenomyosis”
• “Adenomyosis – A common cause of uterine symptoms after age 30”
• “Q&A on adenomyosis”
• “Adenomyosis: is it really endometriosis?”
• “Presacral Neurectomy”
• “What are the indications for hysterectomy?”
• Video “What is Adenomyosis?”

Studies:

• Jiang, C., & Cheng, Z. (2016). Update of recent studies of adenomyosis-associated dysmenorrhea. Gynecology and Minimally Invasive Therapy, 5(4), 137-140. Retrieved from https://www.sciencedirect.com/science/article/pii/S2213307016300387 
• Donnez, J., Dolmans, M. M., & Fellah, L. (2019). What if deep endometriotic nodules and uterine adenomyosis were actually two forms of the same disease?. Fertility and sterility, 111(3), 454-456. Retrieved from https://www.fertstert.org/article/S0015-0282(18)32307-0/abstract 
• Onchee, Y. U., Schulze-Rath, R., Grafton, M. J., Hansen, M. K., & Scholes, D. (2020). Adenomyosis incidence, prevalence and treatment: united states population-based study 2006-2015. American Journal of Obstetrics and Gynecology. Retrieved from https://www.ajog.org/article/S0002-9378(20)30023-5/fulltext?fbclid=IwAR0vRX3OQnfmq0v9f6jFw-jHbVOq8uuu0n8LKdS1eTOEofrhqmZWPle1PFw