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%
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%
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