Adenomyosis

What is adenomyosis?

The term adenomyosis comes from the words:

• adeno – gland
• myo – muscle and
• osis – condition

Adenomyosis is a condition of the uterus (womb) where cells similar to the lining on the inside of the uterus are also present in the muscle wall of the uterus.

Although women with adenomyosis often have endometriosis, they are different conditions. With endometriosis, cells similar to those that line the uterus are found on other parts of the body such as the fallopian tubes, the ovaries or the tissue lining the pelvis (the peritoneum).

Where does adenomyosis occur?

Adenomyosis is most likely to occur in the muscle layer of the back wall of the uterus but can occur anywhere in the muscle layer.

If adenomyosis is concentrated in one area, it can lead to a non-cancerous growth called an adenomyoma.

What are the signs and symptoms?

The most common symptoms, experienced by up to two-thirds of women with adenomyosis, are:

• painful periods, often after years without pain
• heavy periods
• anaemia or iron deficiency (due to heavy periods), and you may feel:
  • tired
  • dizzy
• painful sex (dyspareunia)
• chronic (ongoing) pelvic pain

In addition, during an examination, the uterus may feel tender, and the doctor may notice that it is enlarged (bulky).

What causes adenomyosis and who is at risk?

The cause of adenomyosis is unknown; however, there are a few theories, such as:

• The lining cells grow into the muscle layer due to surgery
• Lining tissue was set down into the uterine muscle early in foetal life, before birth
• Inflammation of the uterine lining after childbirth causes cells to pass into the weakened muscle layer

Oestrogen is needed for adenomyosis to occur, so it is only seen in women in their reproductive years, particularly in women aged between 30-50 years.

What happens when you get a period?

The lining cells within the muscle wall behave the same as the lining cells of the uterus. This means when you have your period, these cells also bleed but because they are trapped in the muscle layer, they form little pockets of blood within the uterine muscle wall.

How is adenomyosis diagnosed?

Sometimes the uterus is tender or enlarged on vaginal examination. Unfortunately, adenomyosis may be difficult to diagnose, because there is no single set of agreed tests for confirming diagnosis.

The first test recommended is a transvaginal ultrasound (where an ultrasound probe is gently placed in the vagina). If available, the test is ideally performed by a gynaecologist who specialises in ultrasound.

MRI (magnetic resonance imaging) may sometimes be needed to confirm the diagnosis and exclude other conditions such as fibroids.

Adenomyosis is often only diagnosed by pathology tests after the uterus has been removed (hysterectomy). This is because a small biopsy (tissue sample) may miss an area of adenomyosis. There are no blood tests to diagnose adenomyosis.

Management of adenomyosis

Treatment for adenomyosis depends on a woman’s symptoms, her stage of life and whether she plans to have children.

What are the non-medical options?

Non-medical options such as exercise, meditation or acupuncture may reduce symptoms.

What are the medical options?

Non-hormonal options

• Anti-inflammatory painkillers, such as mefenamic acid (Ponstan®) or ibuprofen (Nurofen®):
  Reduces period pain. May also be prescribed to reduce heavy bleeding
• Antifibrinolytic medication (tranexamic acid - Cyclokapron®):
  Reduces heavy bleeding by slowing blood clot breakdown in the womb lining

Hormonal options

• Mirena® IUD:
  This T-shaped device is inserted into the uterus, and slowly releases a hormone called a progesterone. It reduces bleeding, pain and shrinks the uterus and the adenomyosis by thinning the endometrial cells. Can be removed if you are planning pregnancy. You can find more information about the Mirena® IUD here
• Combined contraceptive pill (also known as 'The Pill'):
  May reduce bleeding and pain but the data is not as strong as for the Mirena® IUD in adenomyosis. Can be stopped if you are planning pregnancy

What are the surgical options?

Surgical options depend on whether you wish to keep your uterus, and whether you are planning a future pregnancy.

Planning a future pregnancy

Surgery to remove adenomyosis can be technically difficult, and it is not clear whether it reduces pain and bleeding. Additionally, surgery may result in scar tissue in the uterus that can affect future fertility.

Not planning a future pregnancy

• Endometrial ablation (operating to remove the lining inside the uterus) can reduce heavy bleeding but may not reduce pain. Further improvement can be achieved by combining endometrial ablation with a Mirena® IUD. Future pregnancy is currently not recommended after ablation as there is a greater risk of ectopic pregnancy or miscarriage.
• Hysterectomy removes the uterus so adenomyosis cannot come back. It is the gold standard treatment for women who have no desire for future fertility. You can read more about this procedure here.

What are the other options?

High-intensity ultrasound and uterine artery embolisation (which blocks blood supply to parts of the uterus) are non-surgical options for women with adenomyosis. These techniques may reduce pain and bleeding. Unfortunately, they are not suitable for everybody, can be expensive and can have complications. They are not currently recommended if you are planning a future pregnancy.

Impact on fertility

Women in their 30s and 40s with adenomyosis may have fewer spontaneous and successful assisted pregnancies. This is because normal sperm movement and embryo implantation into the uterine lining can be affected. The risk of miscarriage may also be higher if adenomyosis if is present.

Adenomyosis & pregnancy

Adenomyosis may affect how the placenta and baby grow during pregnancy. Studies have shown baby’s growth may be slower, and waters may break early causing premature birth.

When to seek help

Talk to your doctor when your symptoms are:

• impacting on your health
• impacting on your ability to live your life normally
• interfering in your sexual function and relationship.