Adenomyosis

Adenomyosis is a condition related to the uterus. In adenomyosis, the cell of the inner lining of the uterus (the endometrium) breaks through and enters the muscle wall of the uterus (the myometrium). This makes the muscle wall of the uterus to become thick and the whole uterus becomes bulky. Sometimes, the uterus can become double or triple in size. On average one in 10 women will have this condition. It can appear at various age groups of women who are still menstruating but commonly seen between 40-50 years. Adenomyosis usually disappears once menopause happens.

Adenomyosis is a benign (non-cancerous) condition. And can have a long-term health condition that can have a significant impact on your general physical health, emotional wellbeing, daily routine, and quality of life.

What are the causes?

  • We do not know the exact cause for adenomyosis, but it is associated with an increased level of a hormone called estrogen, hence seen in the reproductive age group.

  • Some risk factors:  commonly seen in those women who have had many children, undergone uterine surgeries such as cesarean section (LSCS) or surgery to remove fibroids (myomectomy)

What are the symptoms?

Some women with adenomyosis may not have any symptoms.

Symptoms can vary from person to person. The most common symptoms would be:

  • Heavy and prolonged menstrual bleeding (may also be passing big blood clots)

  • Spotting of blood from the vagina in between your periods

  • Pain during sexual intercourse (this is because the uterus has become bulky)

  • Severe cramps or sharp pain during periods

  • Lower tummy feels tender even on normal days

  • Sometimes adenomyosis may interfere with conception (can cause infertility)

  • Due to excessive bleeding, you can develop anemia (low hemoglobin) and this in turn will lead to tiredness and dizziness

  • Sometimes when the uterus becomes really bulky, you can have pressure symptoms such as heaviness in the lower tummy, increase in the frequency of passing urine, incomplete or pressure while passing stools

What test will be required for diagnosis?

  • Physical examination:

    • Your doctor will need to do a thorough physical examination, which includes feeling your tummy and an internal examination to check if your uterus is bulky. An internal examination will be required to ensure that there are no other conditions that could be leading to your symptoms (such as cancer of the womb, vagina, and cervix), hence a thorough physical examination is important. 

  • Ultrasound:

    • An ultrasound will help your doctor to make a proper diagnosis of the condition. An ultrasound will not only help to make a diagnosis of adenomyosis but also helps to rule out any possibility of a tumor in the uterus.

    • There are two ways of doing an ultrasound, one by placing the ultrasound probe on the tummy (called trans-abdominal) and others by placing an ultrasound probe in the vagina (called trans-vaginal).

  • MRI (Magnetic Resonance Imaging): Sometimes you may have to undergo MRI to know the exact cause for your symptoms and MRI is superior in diagnosing adenomyosis.

What are the treatment options?

It is important to remember that adenomyosis is difficult to treat with medications. Adenomyosis will disappear after you attain menopause, hence treatment will depend on your age and severity of symptoms.

Options available:

Medical Management:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs): NSAIDs, such as mefenamic acid or ibuprofen, help reduce menstrual blood loss. NSAIDs also have the added benefit of relieving painful menstrual cramps (dysmenorrhea).

  • Tranexamic acid: Tranexamic acid is an antifibrinolytics group of medications that help reduce menstrual blood loss and only needs to be taken at the time of the bleeding.

  • Oral contraceptive pills (OCP): apart from providing birth control, oral contraceptives can also help regulate menstrual cycles and reduce excessive or prolonged menstrual bleeding. This is generally taken for 21 days and repeated cyclically.

  • Hormonal Intrauterine Device (IUD): Mirena this IUD releases a type of progestin called levonorgestrel into the uterus and makes the uterine lining thin and thus decreases menstrual blood flow and cramping. This device also acts as a contraceptive method like Copper-T.

Non-Surgical Management:

HIFU: high intensity focused ultrasound:

This is a non-invasive local thermal ablation technique, which has been used in the treatment of adenomyosis. Advantages of HIFU in adenomyosis:

  • This is a non-invasive procedure. It is not like surgery where your tummy will be cut, but here the ultrasound waves are focused, and the temperature at this point increases and destroys the abnormal cells, which later the body absorbs.

  • It will not harm the surrounding normal uterine tissue.

  • Since it is not surgery, you will recover faster and return to your work the very next day since HIFU removes only the abnormal areas of adenomyosis, this will preserve your fertility and you may have a chance to conceive and have a normal pregnancy.

  • This procedure is not available in India.

Surgical Management

If medical management fails to control your symptoms and your quality of life is disturbed, then your doctor may advise surgery.

1.  Adenomyomectomy: to remove only adenomyosis and retain the uterus this is called adenomyomectomy. This surgery will be offered to those women who wish to retain their uterus for further childbearing.

2.  Hysterectomy: If you have failed medical management and have completed your family then your doctor may offer removal of the whole uterus and cervix. Removing ovaries is not required to control your adenomyosis. Ovaries need to be removed or not will be discussed with you depending on what stage of life you are in.

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