What is adenomyosis?

Adenomyosis is a medical condition characterized by the presence of ectopic endometrial tissue (the inner lining of the uterus) within the myometrium (the thick, muscular layer of the uterus). It is sometimes called "internal endometriosis". When the gland tissue grows during the menstrual cycle and then at menses tries to slough, the old tissue and blood cannot escape the uterine muscle and flow out of the cervix as part of normal menses.

Adenomyosis - Thickened Uterine Muscle and Histology

Adenomyosis - Thickened Uterine Wall with Endometrial Glandular Tissue

What symptoms are associated with adenomyosis?

This trapping of the blood and tissue causes uterine pain in the form of monthly menstrual cramps - dysmenorrhoea.

It also produces abnormal uterine bleeding when some of the blood finally escapes the muscle resulting in prolonged spotting. It more often occurs in the posterior wall of the uterus.

In studies of chronic pelvic pain in which women had hysterectomies, the incidence of adenomyosis is about 15% to 25%8801,9504.

The condition is typically found in women between the ages of 35 and 50. Patients with adenomyosis can have painful and/or profuse menses (dysmenorrhea and menorrhagia, respectively). Cyclic, cramping uterine pain beginning later in reproductive life (generally after age 35) and often associated with prolonged and heavy menses is the classic presentation. On pelvic examination there may be uterine enlargement from about 6-10 weeks pregnancysize.

adenomyosis may involve the uterus focally, creating an adenomyoma, or diffusely. With diffuse involvement, the uterus becomes bulky and heavier. Patterns of adenomyosis as recognized by MRI seem to either be diffusely spread throughout the uterus (about 66%) or focal lesions (33%) that only occur in one or two places9401.

The cause is basically unknown although there seems to be an increased incidence associated with any child birth8001, pregnancy terminations2003, Cesarean sections and and even tubal ligations9403. Some say that the reason adenomyosis is common in women between the ages of 35 and 50 is because it is between these ages that women have an excess of estrogen. Near the age of 35, women typically cease to create as much natural progesterone, which counters the effects of estrogen. After the age of 50, due to menopause, women do not create as much estrogen.

The diagnosis of adenomyosis.

The uterus may be imaged using ultrasound (US) or magnetic resonance imaging (MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus.

On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize uterine fibroids.

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small uterine fibroids. The uterus will have a thickened junctional zone with diminished signal on both T1 and T2 weighted se quences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the junctional zone greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MRI can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

There is no increased risk for cancer development. As the condition is estrogen-dependent, menopause presents a natural cure.

Treatment options for adenomyosis.

Treatment options range from use of NSAIDS and hormonal suppression for symptomatic relief to hysterectomy for a permanent cure.

Like endometriosis and uterine myomas, adenomyosis presents the typical characteristics of oestrogen-dependent diseases. Although the two diseases have distinct epidemiological features, they have the same 'target tissue' for hormonal therapy, namely ectopic endometrium. Recognized approaches are systemic hormonal treatments, which are generally used for endometriosis and are capable of suppressing the oestrogenic induction of the disease, and local hormonal treatment that targets the ectopic endometrium directly.

Gonadotropin-releasing hormone agonists, danazol and intrauterine levonorgestrel- or danazol-releasing devices have been used in the treatment of adenomyosis.0803 Despite the solid rational basis for its hormonal treatment, few studies have been performed on medical therapy for adenomyosis.

The Mirena IUS has been shown to provide benefit.0802

Women's Health

 


This is the personal website of David A Viniker MD FRCOG, retired Consultant Obstetrician and Gynaecologist - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.
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Answers to FAQs on women's health, patient information and medical advice by David A Viniker MD FRCOG, Consultant Obstetrician and Gynaecologist (Gynecologist - OBGYN), Department of Obstetrics and Gynaecology,

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