Health Information

Summary/Definition

Adenomyosis is a pathological process in which endometrial cells grow into the muscular layer of the uterus. As the size of the lesions increases and the infiltrate germinates during the menstrual cycle, regular menstrual pains may occur, as well as the outflow of blood accumulated in the muscle layer, which leads to a delay in menstruation. In many cases, pain appears throughout the uterus or in the anterior or posterior wall, creating a feeling of enlargement of the uterus. However, sometimes, as with uterine fibroids, an overgrowth called adenomyosis can form in a certain area of the uterus. Although adenomyosis can also occur in young women of childbearing age, it is more common in women aged 40 or older and is often accompanied by uterine fibroids and endometriosis. The causes of adenomyosis are still unknown, but the frequency of its occurrence increases due to childbirth, miscarriages and cesarean section.

Symptoms

Typical symptoms include heavy menstruation, prolonged menstrual bleeding, dyspareunia, dysmenorrhea, and chronic pelvic pain. As the uterus itself grows, the contractions of the uterus become stronger, the thickness of the endometrium increases, causing menorrhagia and severe menstrual pain. Adenomyosis can be asymptomatic in 50% of cases, but symptoms such as copious menstruation, dyspareunia and intestinal problems usually appear in late reproductive age (over 35 years). Usually, the pain begins a week before menstruation and continues until it ends.

Diagnostics

According to the clinical manifestations, the presence of adenomyosis can be assumed, but a diagnosis based on a thorough medical examination is necessary to confirm the diagnosis. Since it can be difficult to distinguish it from uterine fibroids, several studies are necessary to make an accurate diagnosis. Clinically, the diagnosis is suspected when the patient complains of abnormal uterine bleeding and severe menstrual pain, and during internal examination the uterus is enlarged, feels hard and painful, and ultrasound or magnetic resonance imaging shows the presence or absence of adenomyosis. Histological examination is performed after the removal procedure.

Treatment and course of the disease

Treatment options may vary depending on the patient’s age and desire to get pregnant. For patients with severe symptoms and who do not want to have children anymore, hysterectomy is the most reliable method of treatment. For patients who need to give birth in the future, various auxiliary methods of treatment are used to preserve the uterus.

Non-surgical treatments include nonsteroidal anti-inflammatory drugs, oral contraceptives, progestins, gonadotropin-releasing hormone agonists and aromatase inhibitors. Progestin treatment aims to suppress the menstrual cycle to relieve symptoms and includes oral, injectable medications and progestin-releasing intrauterine devices (LNG-IUDs).

With localized adenomyosis, wedge-shaped resection of the uterine wall can be considered as a treatment method that allows preserving the uterus, but its use is limited. With severe uterine bleeding, the possibility of hysteroscopic endometrial ablation may be considered. There is also some evidence that treatment with HIFU (high-intensity focused ultrasound) is effective for reducing menstrual irregularities.

There are four non-surgical methods of treatment: intrauterine device with progestogen, gonadotropin-releasing hormone agonists, uterine artery embolization and focused ultrasound therapy under the control of MRI.

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