Adenomyosis

Adenomyosis is a type of endometriosis. Endometriosis occurs when the endometrial lining somehow gets outside of the uterus and grows, thus Endometri (endometrial lining) -osis (outside). Adenomyosis is when the endometrial lining grows into the muscle of the uterus, thus Adeno (glands) myosis (muscle). Once inside the muscle, the endometrial glands grow with each cycle, causing severe pain and bleeding.

• As with endometriosis, Estrogen makes Adenomyosis grow.
• Adenomyosis is a very common but ignored condition.  At CIGC, Adenomyosis is found in up to 60% of those patients complaining of severe pain and bleeding in hysterectomy specimens.
• This can be a debilitating disease, causing what many women describe as “the worse pain of my life” and extremely heavy bleeding and clots.  These symptoms become worse with time.
• Since it is often not diagnosed by the OBGYN, DELAY IN CARE is common, and severe suffering results.

Adenomyosis can be difficult to diagnose and is often identified by clinical symptoms – not imaging such as Ultrasound – which cannot identify the disease.

The adenomyosis Hyper-Specialists at The Center for Innovative GYN Care are highly experienced in both diagnosing and treating adenomyosis and can often make the diagnosis by clinical symptoms alone.

Symptoms

The most common symptoms include severe pelvic pain, heavy bleeding, and severe back pain. Pain with intercourse can occur. Anemia and fatigue due to blood loss, leg pain, abdominal distension and bloating.

Diagnosis

Ultrasound cannot diagnose endometriosis unless it is more advanced.  A pelvic exam and CT scan are not helpful.

• A high clinical suspicion is needed to make the diagnosis. This means that a diagnosis can be made in many cases by listening to the patient and understanding her symptoms.
• Diagnosis of adenomyosis comes with experience and understanding that the disease exists when no other obvious causes are identified.
• MRI can detect the disease up to 80% of the time and may be helpful for treatment planning, especially for fertility patients.

Delay in Care/Complications

Delay in care is common. This is because ultrasounds are normal, and OBGYNs seeing patients with adenomyosis are not experienced in diagnosing and treating this disease. Delay in care results in:

• Advanced disease causing very severe bleeding and intolerable pain
• Severe back pain, which can be incapacitating
• Anemia and fatigue with required blood transfusions
• Infertility
• Severe emotional impact and depression are common with an unknown diagnosis and unrelenting symptoms.

For non-fertility patients, Hysterectomy is the best option. 

• Customized approaches to partial hysterectomy keep the ovaries to maintain hormone production and in some cases, the cervix to maintain normal sexual function and pelvic support. 
• Partial hysterectomy provides immediate and dramatic relief, with almost all patients very satisfied with their decision with immediate relief. 

For Fertility patients, medical therapy to suppress estrogen production is the best short-term option. 

• Suppression treats symptoms and suppresses the disease while fertility options are pursued. 
• Adenomyosis is NOT CURED or removed with birth control pills, Orlissa, MyFemBree or other options, but rather is suppressed. Once the medication is stopped, the Adenomyosis will recur and cause symptoms once again due to the production of estrogen. 

HyperSpecialists: The BEST option for diagnosis and treatment. Hyperspecialists are GYN Oncology trained, the highest level of surgical training possible.

• OBGYNs are NOT HyperSpecialists – they focus on Obstetrics, not Adenomyosis. 
• “Specialists” online are often OBGYNs that perform surgery. Obstetricians are more specialists in Obstetrics, not surgery. 

HyperSpecialists: Procedures for the Treatment of Adenomyosis

• DualPortGYN Hysterectomy is a proven better option than other hysterectomy approaches, such as robotic and laparoscopic, providing the fastest recovery, lowest complications, and lowest cost. 
• LARA – Laparoscopic Assisted Resection of Adenomyosis – is possible in some patients desirous of fertility, depending on the size and location of the disease. 

Insurance:

• Do not pay cash, use your insurance.
• CIGC surgeons are in network with your insurance and provide equal and often superior care than “cash-based adenomyosis specialists.”

The following section is a more detailed discussion of the summary above. For more information on CIGC Specialists, the Treatment of Adenomyosis, as well as information on Publications, Insurance and other issues, please go to the section on Conditions:  CIGC Treatment and choose Adenomyosis.

Adenomyosis Symptoms

Adenomyosis occurs when cells that are normally found in the lining of the uterus (endometrium) begin to grow into the muscle of the uterus (myometrium), thickening the uterine wall. Adenomyosis can vary greatly from case to case. It can be Focal (localized in one area of the uterus), Diffuse (involving large areas of the uterine muscle),  or develop into a collection of adenomyosis called an Adenomyoma. Adenomyosis can cause debilitating pain and severe menstrual bleeding for some women. However, some women with adenomyosis have no symptoms at all.

Adenomyosis symptoms may include:

• Heavy bleeding
• Severe or chronic pelvic pain
• Severe menstrual cramps
• Pain in the legs and back
• Pelvic pressure
• Swelling of the abdomen
• Abdominal bloating
• Pain with intercourse
• Clots in the legs and pelvis

Symptoms:  Adenomyosis vs. Endometriosis

Many patients ask about the difference between adenomyosis and endometriosis because the symptoms sometimes resemble each other or occur simultaneously. 

• Although both can cause pain, endometriosis does not typically cause heavy bleeding and does not have the same severe back pain usually seen with adenomyosis.  
• In general, Adenomyosis is a disease of older women, whereas Endometriosis is often seen in younger women.  
• Finally, many patients with Adenomyosis have had surgery to the uterus, such as Cesarean Section or Myomectomy.   That is usually not the case with endometriosis patients. 

The causes of adenomyosis are unknown. More common theories are as follows:

• Surgery and Movement of the Endometrial Lining into the Muscle. Surgery such as fibroid removal  (myomectomy) or C-Section may allow growth of the endometrial lining into the muscle, causing Adenomyosis. Patients after these procedures have a higher incidence of Adenomyosis.  
• Childbirth-related uterine inflammation – Multiple studies have shown higher rates of adenomyosis in women who have experienced childbirth.
• Developmental origins – It is possible for adenomyosis to develop at the same time the uterus is developing in a fetus.
• Stem cell origins – Bone marrow stem cells may invade the uterine muscle, causing adenomyosis to form.

Adenomyosis growth depends on the production of estrogen, so it’s possible for symptoms to resolve after menopause. 

The diagnosis of adenomyosis is generally made on a “clinical” basis through the patient’s history and symptoms. A specialist can typically identify adenomyosis as the cause of heavy bleeding and pain. 

Types of Adenomyosis 

Adenomyosis can be focal, diffuse, or form an adenomyoma.

• Focal adenomyosis means that the disease has involved only a small portion of the uterine muscle. MRI can measure the depth and width of adenomyosis and can identify where the focal area is in the uterus.

• Diffuse adenomyosis means that the disease is involving almost all of the uterus. Patients with this type of adenomyosis have severe symptoms of pain and bleeding, have a high rate of infertility, and often require surgical treatment.
• Adenomyoma is a large area of disease in the muscle that looks similar to a uterine fibroid. Adenomyomas are often mistaken by ultrasound as fibroids, and not uncommonly patients will undergo a myomectomy – removal of a fibroid – for what turns out to be an adenomyoma. 
  • Unlike fibroids, adenomyomas cannot be removed since they are invading into the muscle, and removal will remove the muscle of the uterus with the adenomyosis.

Diagnosis of Adenomyosis

MRI Scan

An MRI scan is the best imaging method for diagnosing adenomyosis and can detect the disease up to 80% of the time. MRI shows a  “thickened junctional zone” – this is where the endometrial lining is growing into the uterine muscle.  This confirms the diagnosis of adenomyosis.  

Note the thickening of the junctional zone, which is the uterine lining growing into the muscle.

Ultrasound 

An ultrasound can also be used to look for adenomyosis when it is in the advanced stages but is less sensitive than an MRI for early or even moderate-stage disease. 

• An enlarged “globular” uterus, thickened endometrial lining, and a heterogeneous uterine wall are sonographic features that can be indications of adenomyosis. 
• If your ultrasound comes back normal but you or your doctor still suspect adenomyosis, an MRI should be obtained.

Pelvic Exam

Pelvic exams are not helpful in the diagnosis of adenomyosis. 

Post-Hysterectomy Biopsy

The only way to definitively diagnose adenomyosis is by having a pathologist examine the uterus after a hysterectomy has been performed. Looking at the entire uterus under a microscope allows a pathologist to visually confirm the diagnosis.

Delay in Care/Complications

Missing the diagnosis of Adenomyosis will result in a Delay in Care in the diagnosis and treatment of this disease. Unfortunately, many OBGYNs will miss the diagnosis of adenomyosis more often than not. There are several reasons for this. 

• OBGYNs are mainly focused on pregnant patients and do far less gynecology than a specialist who sees the condition more often. 
• Pelvic exams will miss the condition completely since adenomyosis may not enlarge the uterus to any extent. 
• Finally, ultrasound, although a very good test for fibroids, pelvic masses and other pathology, completely misses the diagnosis of adenomyosis. 

Since patients access their OBGYN more commonly than a specialist and often have normal ultrasounds, the disease can be missed, and patients can suffer with progressive and debilitating pain and bleeding. In some cases, an MRI is obtained, which can identify adenomyosis in up to 80% of cases and can be helpful to make the diagnosis by imaging.

If left untreated, adenomyosis may lead to the following long-term complications:

• Chronic anemia and fatigue from more frequent and heavy bleeding during periods
• Severe incapacitating pelvic and back pain with progressive narcotic use and potential addiction
• Consults with other specialists such as Urology, GI physicians, Orthopedic Surgeons, and others delaying care, increasing frustration and costs. 
• Advanced disease leading to infertility
• Depression, Anxiety, and Mental Health Compromise
• Low quality of life from pain and fear of bleeding

For a full review of Adenomyosis Treatment and the role of CIGC Hyper-Specialists, please go to the section on Treatment Options and click on Adenomyosis.

Hysterectomy

The only cure for adenomyosis is a hysterectomy.

• Unlike fibroids, which are often surrounded by a capsule that separates each fibroid from normal tissue and allows it to be completely removed, there is no clear border between adenomyosis and normal uterine tissue.  
• Adenomyosis grows into the uterine muscle like a “spider” and cannot be removed without removing the muscle itself. If removal is attempted, portions of the uterine muscle will be removed with the adenomyosis. 

LARA – Laparoscopic Assisted Resection of Adenomyosis with Uterine Preservation

Any surgical procedure to remove adenomyosis is considered controversial since uterine muscle HAS to be removed if Adenomyosis is removed. Indications:

• Patients who desire fertility with extreme symptoms not responsive to medical therapy.
• Patients for fertility with FOCAL disease – isolated areas of adenomyosis in the uterine muscle. 
• Patients for fertility with FOCAL Posterior disease – these patients may benefit from resection, since up to 60% of implantations of the embryo are located to the posterior wall of the uterus. 

CIGC surgeons perform LARA in select patients.  A consultation is required for qualification and a discussion of risks.

In the above diagram, Focal adenomyosis, far left, can be attempted for removal by surgery since the disease is limited to one area in the uterus. Adenomyomas, a collection of adenomyosis in the muscle far right, can also be removed by surgery. Diffuse disease, second from the right, cannot be removed due to its almost complete involvement of the muscle. Attempts to remove diffuse disease would not remove all the disease or would remove the entire uterine muscle.

Non-Surgery: Hormonal Suppression

For women who are not yet finished with childbearing, the adenomyosis symptoms can be temporarily managed through medication that suppresses estrogen, the hormone responsible for adenomyosis growth. 

• Although not always very effective, hormonal suppression with continuous birth control pills, Depo-Provera or the Mirena IUD (intrauterine device) may help to keep symptoms manageable.
  • With all of these treatments, low levels of estrogen are continually present, and the adenomyosis will continue to grow. 
• For those patients with extensive disease that cannot undergo hysterectomy, medications such as Orlissa or MyFemBree can further suppress endometriosis by more effectively blocking estrogen production, and will help to treat the symptoms of pain and bleeding. 
  • Unfortunately, the treatment is not long term since side effects such as osteoporosis – bone loss – can occur. 
  • Even in the short term, many patients have difficulty with the loss of estrogen, having menopausal symptoms such as hot flashes, night sweats, vaginal dryness, anxiety, depression, mood swings, and other issues.

Pain Medication

Some patients may be able to effectively alleviate symptoms like cramping and pelvic pain with NSAIDs like ibuprofen or naproxen. Pain relief using medication is temporary and may only be effective for mild cases of adenomyosis.

Natural Treatments for Adenomyosis

Adenomyosis symptoms may also be managed through nonsurgical treatments, including pain management, acupuncture, pelvic floor physical therapy, nutritional counseling and more. These natural and at-home treatments should be advised by a GYN specialist and are not a replacement for essential surgical treatment.

Who does adenomyosis affect?

Although it is most commonly diagnosed in women over 35, it can occur even among teenagers. Current research suggests adenomyosis may be common in younger women as well

How common is adenomyosis?

Adenomyosis is an extremely common condition, but it is not always readily identified by many doctors. Initial imaging of the uterus is often conducted by an ultrasound, which is commonly used to detect fibroids, but has more difficulty detecting adenomyosis. An MRI scan is a better visual test to detect signs of adenomyosis.

What is the association between adenomyosis and infertility?

At this time, how adenomyosis affects fertility is unclear. Some studies show an association between adenomyosis and infertility and others show none. In general, it is thought that the severe inflammation caused by migration of the uterine lining into the uterine muscle may prevent implantation of an embryo into the uterine lining.

Will menopause occur after hysterectomy?

Many women fear that removing the uterus will immediately send them into menopause and all the symptoms that may accompany it. This is not the case. The ovaries, not the uterus, produce the hormones that dictate menopause. If the ovaries are left in place, a woman will go through menopause naturally.

The only obvious change will be the lack of a monthly menstrual cycle. In many cases, unless there is a genetic risk of ovarian cancer or signs of existing cancer, the ovaries can be retained. Speak to your GYN specialist about your long-term goals and how hormone therapy can play a role in managing symptoms, especially in the transition and early stages of menopause.

Is adenomyosis the same as endometriosis?

No. Although they can occur together, endometriosis is when endometrial cells (the lining of the uterus) are in a location outside of the uterus. Adenomyosis is when these cells are embedded into the uterine wall. Although both can cause pain, endometriosis does not typically cause heavy bleeding. 

The GYN Hyper-Specialists at The Center for Innovative GYN Care are GYN Oncology trained – the highest level of training possible. The CIGC state-of-the-art laparoscopic techniques make it possible to treat complex GYN condit/techniques/dualportgyn/”>DualportGYN hysterectomy and LARA procedures are options for patients with this condition and provide the fastest recovery, lowest complication rates, and lowest cost compared to any other surgical option.

If you think you have adenomyosis, our specialists are ready to evaluate your symptoms and conditions and recommend an appropriate solution.

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