Adenomyosis is where endometrial tissue, the tissue that normally lines the womb, grows inside the wall of the womb. It is not the same as endometriosis, a condition where parts of endometrial tissue escape the womb and implant on organs outside it. However, many women with endometriosis also have adenomyosis, the cause of adenomyosis is unknown.
Usually adenomyosis affects the posterior wall of the uterus. Most commonly a woman with this condition experience the symptoms like heavy, prolonged or excessive bleeding during menstruation and periods with severe pain. Depending on the severity of disease and its levels of penetration into the uterine walls, the amount of cramps and bleeding varies.
Symptoms: Much of the time, a woman has few or no symptoms. However, as the condition worsens, many women begin to be troubled with heavy menstrual bleeding and increasing cramps. On physical examination, a soft, boggy enlargement of the uterus may be detected. During examination, an unusual type of tenderness will be noted when the uterine muscle is compressed. Some adenomyomas are exquisitely tender to touch on pelvic examination or during intercourse.
Reasons for cramps and heavy menstrual bleeding: The function of the uterine muscle during normal menstruation is to provide a coordinated involuntary contraction. This contraction reduces the volume of the endometrial cavity and pinches off the capillary blood vessels passing through the junction of uterine muscle and endometrial junction. With adenomyosis, the presence of many tiny islands of functioning endometrial glands scattered in between the normally tightly laced muscle bundles creates numerous little pressure points that can be extremely tender. This creates pain that is worsened when the muscle is contracting. In addition, the efficiency of the contraction is reduced. Because the uterine muscle contractions aren’t as effective as they should be, the resulting menstrual flow is heavier. The ‘endometrial slough’ is determined by the size of the uterus and the hormonally induced endometrial thickness. The uterus has large blood vessels that come through the myometrium to feed and supply the endometrium. Really heavy bleeding occurs when the uterine muscle cannot do its job of contracting around these vessels. This is important because after the endometrium is passed out; the basalis layer may be very thin, which could expose the raw muscle surface. This means that the large vessels can pump blood directly into the uterine cavity of the muscle cannot contract well.
Investigative tools : Pelvic ultrasound scan and MRI scans are the main modalities to confirm the diagnosis. Pelvic US scan has a specificity of 85%, while MRI has 91%.
Conservative treatments can be tried. Treatment options include GnRH agonists and Mirena intrauterine system insertion. Adenomyotic foci have been shown to contain progesterone and oestrogen receptors and may undergo decidualisation when exposed to progesterone; symptoms may then become more apparent. Progestogenic agents alone or in combination with oestrogen may therefore not be effective.
National Institute of Clinical Excellence (NICE) states that Uterine artery embolisation can be offered to symptomatic patients who have completed their family. Current evidence shows that the procedure is efficacious for symptom relief.
Surgery is still the main method of diagnosing and managing adenomyosis.
Hysterectomy is the gold standard for relief of symptoms. However, there may be a role for hysteroscopic endometrial resection if the adenomyosis has been confirmed to involve mostly the superficial 3 mm of the myometrium.
Unfortunately, most of the time the disease is scattered invisibly throughout the uterine muscle. Attempts to control the symptoms of deep adenomyosis with endometrial ablation have not been uniformly successful. Most of the time the decision to perform a hysterectomy is made by the patient who comes to the point that conservative avenues of treatment have been tried and found unsatisfactory and quality of life has declined to unacceptable levels.