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:

• Painful menstrual periods
  

• Heavy menstrual periods
  

• Infertility
  

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.

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
  

• ·      Surgical
  

• ·      Uterine artery Embolization
  

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.

•  Painkillers can be used in women who want to become pregnant
  

·      Hormones:

•   The oral contraceptive pill has been found useful
  

•   Progesterone only pills
  

•  Mirena intrauterine system
  

                  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

• Osteoporosis
  

•  Hot flushes
  

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%