Adenomyosis can be diffuse or focal. the ultimate management of adenomyosis is hysterectomy however many young women who have not completed their families also suffer from adenomyosis. After investigation it may be possible for this to be excised laparoscopically. It is important that the diagnosis be made early as the smaller the lesion the greater the likelihood of laparoscopic surgery being successful. for larger lesions open surgery may be an alternative however there is the associated risk with traditional open surgery
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Adenomyosis is a condition where the tissue that normally lines the cavity of the womb finds its way into the muscle of the womb. It is a relatively gynaecological condition and can be responsible for:
In a way it is similar to endometriosis, in that the lining of the womb is not where it is supposed to be. With endometriosis the same tissue that lines the cavity of the womb is found outside the uterus. With Adenomyosis even though it is in the uterus it is again in the wrong place i.e. in the muscle as well as the lining. How common it is in a normal population is unknown but figures quoted are between 20-30%. It is commonest in women between the ages of 40-50years but has been diagnosed in women as young as 17 years It is commoner in women who have had children but may also be a reason for infertility. It can co-exist with endometriosis in about 20% of women. In women with infertility and endometriosis it is seen in up to 28% of women. Historically it used to be only diagnosed in hysterectomy specimen. Now however it is possible to get a diagnosis with less invasive investigations. The correlation between clinical diagnosis and proof at investigation is still quite poor. And the management of this condition is hindered by the lack of reliable investigations. To make a diagnosis the first investigation would be an Ultrasound scan: The accuracy of this test varies and sometimes is operator dependent. There are however agreed specific findings that ultrasonographers use to make a diagnosis. MRI: This is probably more accurate than ultrasound but is more expensive. Hysteroscopy: with or without biopsy: there are certain features that suggest Adenomyosis at hysteroscopy Laparoscopy: There are also certain features that are identified at laparoscopy. It is however unusual that laparoscopy is carried out for the sole purpose of diagnosing Adenomyosis. It would be carried out for the investigation into a possible cause of pelvic pain. In the past certain investigators took biopsies of the uterus at laparoscopy to try and diagnose Adenomyosis but unfortunately the biopsies did not always prove the presence of Adenomyosis.
laparoscopic view of Adenomyosis being removed laparoscopically
Treatment of Adenomyosis The treatment of Adenomyosis depends on the age at presentation, the desire for future fertility, presenting symptoms, co-existing conditions and the severity of symptoms. For example some women may have endometriosis in addition to adenomyosis, others may have fibroids. In fact in some women during ultrasound scan there may be some confusion (what doctors call differential diagnosis) between adenomyosis and fibroids. Some women have well circumscribed “balls” of adenomyosis within the muscle of the uterus called Adenomyomas. And it is not until surgery is attempted that these abnormalities are recognized. The surgeon notices a difficulty in “shelling” out the fibroid. With difficulty in differentiating the mass and normal uterine tissue.
Medical management consists of · Painkillers: this is usually used in women who do not want to use hormones who suffer from painful periods. A common painkiller used is Mefenamic Acid that has the added benefit of reducing heaviness of the periods as well as pain.
· Hormones:
The Mirena system has been shown to decrease both pain and bleeding up to 3 years in up to 72% of women It is particularly efficient in women whose periods stop as a result of Mirena GnRH agonists These agents cannot be used long term because of the risk of
Surgery: Endometrial ablation or Transcervical resection of endometrium For women with heavy periods endometrial ablation or Transcervical resection of the endometrium (where the lining of the womb is removed) may be useful. It reduces pain in 30-50% of women and reduces the heaviness of the menstrual period in up to 70% of women. In a group of women who underwent endometrial ablation after diagnosis of adenomyosis they had a 1.5 times risk of failure of the procedure than women without adenomyosis. If the first procedure fails a repeat procedure tends to offer no additional benefit, and women tend not to respond to medical treatment either. So after the first treatment if it doesn’t work a hysterectomy is usually advised. Laparoscopic Adenomyomectomy: This is where an attempt is made to remove the adenomyosis, in an operation similar to removal of fibroids. It is usually reserved for young women who have intractable pain, but are too young to undergo a hysterectomy as they haven’t completed their families. Because of the difficulty in demarcating the adenomyoma some of it may be left behind and therefore lead to recurrence of symptoms. Doctors usually advice giving a few months of GnRH analogue after surgery to decrease or delay the risk of recurrence. Fertility after adenomyomectomy There is limited evidence to show that removal of adenomyosis improves fertility, however a small study of 71 women showed a pregnancy rate of 70% with improvement of symptoms of painful and heavy periods. Hysterectomy Hysterectomy remains the treatment of choice for women who have completed their families and suffer from heavy periods and dysmenorrhea thought to be due to adenomyosis. The guarantee that periods will stop is 100% though for women who have pain when not having a period the pain may not stop. But pain during periods will stop. The best route of hysterectomy is Laparoscopic as it allows the doctor to see into the pelvis and deal with any other possible abnormality. Uterine artery Embolisation. There is increasing evidence that this may be a useful tool to manage adenomyosis in women who do not want a hysterectomy, with an overall patient satisfaction in the region of 70% Adenomyosis is where the tissue from the lining of womb penetrates into the muscle. it can occur in the younger woman but is more common in women who have had children. Adenomyosis is often responsible for heavy, painful periods and for the younger patient can be responsible for infertility. it is sometimes difficult to diagnose adenomyosis as it can be confused with fibroids and or endometriosis. The final diagnosis is often made on histology after hysterectomy. As not all women are at a stage where they can have a hysterectomy or for women who do not want to have hysterectomy other therapies are available. Medical management may be with: hormonal therapy Mirena IUS or simple painkillers during the period time. Some women may consider surgery. Laparoscopic surgery is probably the best remove the adenomyosis. The surgery is performed in a similar way to laparoscopic myomectomy, but because the margins of adenomyosis within the uterus is not as well defined as fibroids usually are, some of the adenomyotic tissue may be left behind. For some women this will provide symptomatic relief of their symptoms till they have finished having children and may then go on to have a hysterectomy. |
Jimi's blogConsultant Gynaecologist and Obstetrician with a wide experience in Minimal access surgery. Enjoys teaching and training, photography and Travel Membership:Archives
May 2014
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