Adenomyosis

What is adenomyosis?

Adenomyosis is a condition in which tissue similar to the uterine lining - endometrial glands and stroma - is found within the muscular wall of the uterus, the myometrium. These lesions may respond to hormonal changes during the menstrual cycle and trigger local bleeding, an inflammatory reaction and remodelling of the uterine muscle. The result may be heavy and painful menstruation, chronic pelvic pain and gradual enlargement of the uterus.

Adenomyosis and endometriosis are two distinct conditions, but they can occur simultaneously. According to some studies, adenomyosis is present in a significant proportion of women with endometriosis - in some series, in approximately half of patients.

Focal and diffuse adenomyosis

Adenomyosis can occur in two forms that differ in the extent of uterine wall involvement:

• Focal adenomyosis - the lesion is confined to a specific area of the uterine wall, sometimes called an adenomyoma. Symptoms tend to be milder.
• Diffuse adenomyosis - tissue similar to endometrium is distributed throughout the thickness of the uterine wall. Causes more severe symptoms and has a significantly greater impact on fertility.

What is the difference between adenomyosis and endometriosis?

• Endometriosis - tissue similar to endometrium grows outside the uterus, on the ovaries, peritoneum or other organs
• Adenomyosis - tissue similar to endometrium grows within the uterine muscle

Both conditions cause pain and fertility problems, but differ in location, diagnosis and some treatment options.

Symptoms of adenomyosis

The symptoms of adenomyosis are similar to those of endometriosis, but have their own characteristics:

• Heavy and prolonged menstrual bleeding - the uterus cannot contract properly; bleeding may be significantly heavier than normal
• Severe menstrual pain - cramps that may worsen with age and with each period
• Chronic pelvic pain - dull pressure or pain in the lower abdomen even outside menstruation
• Enlarged uterus - the uterus may be two to three times larger than normal, sometimes causing a feeling of pressure or fullness in the lower abdomen
• Pain during sexual intercourse
• Fertility problems or recurrent miscarriage

Some women have no symptoms and adenomyosis is discovered incidentally on ultrasound.

Why does adenomyosis develop?

The exact cause of adenomyosis is not known. Factors that increase risk include:

• previous uterine surgery - caesarean section, curettage or myomectomy
• repeated uterine infections
• genetic predisposition
• hormonal imbalance - the condition is oestrogen-dependent, so symptoms subside after menopause

How does adenomyosis affect fertility?

Adenomyosis impairs fertility through a specific mechanism - it causes abnormal uterine contractions (hyperperistalsis and dysperistalsis) that impair egg transport through the fallopian tubes and embryo implantation in the uterus.

Research on women with endometriosis demonstrated how severely adenomyosis affects fertility:

• women without adenomyosis: tubal transport dysfunction in 33%
• women with focal adenomyosis: dysfunction in 58%
• women with diffuse adenomyosis: dysfunction in 91%

The study authors concluded that "the adenomyotic component explains much of the reduced fertility in women with endometriosis." If you are being treated for infertility or undergoing IVF, it is essential that your centre is aware of the presence and extent of adenomyosis.

How is adenomyosis diagnosed?

Transvaginal ultrasound

An experienced sonographer can identify characteristic changes in the structure of the uterine wall - uneven echogenicity, thickening of the myometrium or small cystic spaces. The quality of the ultrasound examination depends fundamentally on the doctor's experience with adenomyosis.

MRI

MRI provides a more precise picture of adenomyosis extent, distinguishes focal from diffuse forms and helps differentiate adenomyosis from fibroids (benign uterine tumours).

Histological confirmation

Definitive diagnosis can only be confirmed by microscopic examination of tissue - either from biopsy or after surgery. In practice, however, the clinical picture combined with ultrasound or MRI is usually sufficient for diagnosis.

How is adenomyosis treated?

Treatment depends on the severity of symptoms, the patient's age and pregnancy plans.

Hormonal treatment

Hormonal preparations suppress menstruation and thereby adenomyosis symptoms. These include hormonal contraception, the levonorgestrel intrauterine device, progestins or GnRH analogues. This treatment suppresses symptoms but does not cure adenomyosis - symptoms return after it is stopped.

Pain management

Non-steroidal anti-inflammatory drugs (NSAIDs) help relieve menstrual pain. Pelvic floor physiotherapy to release chronic muscle tension caused by long-term pain is also beneficial.

Surgical treatment

For women who no longer wish to conceive and symptoms are severe, hysterectomy - removal of the uterus - is an option. It is the only method that definitively cures adenomyosis. For women planning pregnancy, a conservative adenomyomectomy - aimed at removing the lesion while preserving the uterus - may sometimes be possible.

Radiofrequency ablation

A method suitable for focal adenomyosis or diffuse adenomyosis in women who no longer plan pregnancy. The procedure takes only a few minutes and can be performed as day surgery - the patient goes home on the same day.

Adenomyosis and adhesions

The chronic inflammation caused by endometriosis (and sometimes adenomyosis) leads to the formation of adhesions - bands of scar tissue that may connect organs to each other or to the pelvic wall. Adhesions can join the ovary to the pelvic wall or connect the bladder to the uterus. In severe cases, a so-called "frozen" or "fixed" pelvis develops, with firm adhesions between all pelvic organs.

Adhesion pain differs from endometriosis pain: adhesions typically cause sharp, stabbing, pulling pain, while endometriosis manifests more as burning, dull or heavy pain. This distinction helps doctors plan treatment.

When to seek help?

If you suffer from heavy periods, chronic pelvic pain or fertility problems, ask your gynaecologist for an examination focused on both adenomyosis and endometriosis. Both conditions are treatable and your quality of life can improve significantly.