Adenomyosis
Description, Symptoms
Adenomyosis occurs when the endometrial lining of the cavity of the uterus – the endometrium - grows into the muscle of the uterus. When adenomyosis occurs, patients will have severe pain and heavy bleeding. This occurs because the endometrial lining bleeds and then sloughs within the muscle. Patients with adenomyosis actually have periods in the muscle, which causes severe and often incapacitating pain with bleeding. Note that patients with fibroids in the muscle or in the cavity may have similar symptoms. Adenomyosis is underdiagnosed by most OBGYN and primary care physicians – they do not consider this condition when diagnosing and treating patients with bleeding and pain. It is more common in patients in their mid 30’s and older. CGS experience shows that up to 60% of patients diagnosed with fibroids have adenomyosis within the uterus. Many of these patients were misdiagnosed as having fibroids.
Adenomyosis is a progressively worsening condition. This is because with every menstrual cycle, there will be continuous penetration of the uterine muscle, with expansion of the adenomyosis into the uterus. Many patients will develop collections of adenomyosis, called adenomyomas, that are sometimes diagnosed by ultrasound as fibroids.
In addition to pain and bleeding, adenomyosis will cause infertility as well. The muscle becomes fibrotic due to the bleeding within, and cannot support implantation of the embryo into the muscle for formation of the placenta. What this means is that if the embryo – the sperm and the egg combined – falls to an area of the uterine cavity involved with adenomyosis, the baby cannot develop.
Diagnosis
MRI is the best method for diagnosing adenomyosis, although it is always not accurate. Ultrasound, or sonogram, is less reliable. Since the treatment of adenomyosis is very different than for fibroids, and since fibroids can cause similar symptoms, an MRI should be performed to rule out adenomyosis. Patients undergoing fertility evaluation, or those considering pregnancy in which there is a question of adenomyosis should undergo MRI as well.
Treatment
Treatment is difficult. Medical therapy has limited use. Estrogen causes growth and progression of adenomyosis. Lupron blocks estrogen production and will decrease the symptoms and growth of adenomyosis. Lupron will not remove the disease, and can only be used for 6 month periods of time. Longer use results in osteoporosis. Once Lupron is stopped, the adenomyosis will continue to grow and cause symptoms. Note that Lupron will stop all estrogen production and will result in menopausal symptoms such as hot flashes, night sweats, mood swings, anxiety, depression, vaginal dryness, etc.
Surgical therapy for removal of adenomyosis from the uterus is not a treatment option. Since adenomyosis grows into the muscle, removal of adenomyosis will result in resection of large portions of the uterine muscle causing extensive bleeding and injury to the uterus. Definitive treatment is limited to hysterectomy. Hysterectomy can be accomplished with a DualportGYN procedure using two ¼ inch incisions resulting in minimal pain and the fastest recovery possible. For many patients, hysterectomy is a welcome relief from this difficult disease. Removal of the uterus stops pain, bleeding, reverses anemia thereby increasing energy levels and activity, and restores a normal lifestyle to patients. Note that hysterectomy for adenomyosis does NOT require removal of the ovaries. Hormone function is normal after removal of the uterus, and menopausal symptoms do not occur. Infertility patients diagnosed with adenomyosis should see a fertility specialist, or reproductive endocrinologist, for consultation and management.