AdenomyosisSymptoms, Causes and Treatment
What is adenomyosis?
Adenomyosis is a condition where tissue — like the tissue that lines the inside of the uterus — occurs within the muscle wall of the uterus.
The lining of the uterus undergoes a series of changes throughout the menstrual cycle:
- Oestrogen stimulates the growth of the lining
- Progesterone arrests the growth
- Hormone withdrawal at the end of a cycle results in prostaglandin release
- The uterus cramps, the lining dies and is shed, and the underlying blood vessels bleed
These same changes will occur to any tissue found within the muscle wall. However, being within the wall, this causes pain as the growth stretches the wall of the uterus.
Depending on how much adenomyosis there is, the uterus will be larger. The larger the uterus, the larger the surface area of the lining. This results in a greater loss of blood during the period.
Adenomyosis and endometriosis
Adenomyosis is similar to endometriosis in that both are ectopic endometrium. That means that the lining of the uterus is in the wrong place. The difference between them is the location of the tissue, and the reason it occurs.
A woman may have both conditions, but they are separate. Endometriosis is more common in women before they have had children, while adenomyosis is more common after children.
Adenomyosis is usually associated with heavier and more painful periods. As it occurs more commonly after having children, it most often presents in women in their late 30s and early 40s.
It can cause chronic pelvic pain that is not just limited to the menstrual cycle.
Diagnosis is often only made during a hysterectomy, when the pathologist examines the specimen. With continuing improvements in ultrasound, it may soon be possible to diagnose the condition through adenomyosis ultrasound.
The cause of uterine adenomyosis is not known, but there may be a correlation between adenomyosis and pregnancy. The condition is more common after childbearing, so perhaps it is related to the changes that occur in the uterus in pregnancy.
It is a relatively common condition, occurring in 20-35% of women, the estimate varying between studies.
During a caesarian section, surgical implantation of the lining tissue into the c-section scar is possible — but this is a minor component of the spectrum of women with this condition.
The treatment of adenomyosis is primarily directed at the symptoms that it causes, which are predominantly heavy or painful periods.
Laparoscopic surgery — why I do not recommend it
There have been attempts to surgically remove the tissue deposits while still retaining the uterus. The only reason people consider this conservative surgical management is to maintain fertility. The surgery is difficult, can cause potential short and long term damage to the uterus, and there is no clear evidence that it improves outcomes for women.
I have never, and will never, treat adenomyosis laparoscopically.
Adenomyosis usually involves many, possibly hundreds, of small deposits in the muscle of the uterus, usually close to the lining. The deposits range from small to microscopic. Occasionally, there may be bigger deposits.
Ultrasound looks through the uterus but, when we do a laparoscopy, we look at the surface of the uterus. Here, adenomyosis is very indistinct.
Operating on an area of adenomyosis involves cutting potentially deep into the wall of the uterus in the hope that you can find and remove all of these deposits. Constant bleeding makes this challenging surgical task even more difficult. One or two deposits may be removed — only a tiny fraction of the total. The deep wound to the uterus needs to be closed, and it will heal with scar tissue, which is weaker than the unscarred uterus.
In this context, it is hard to believe that there is any benefit for the patient from attempting to remove those deposits.
However, there is published data claiming that there is a benefit, written by those who undertake this surgery. These are surgeons who are, essentially, prepared to experiment on their patients. These experiments are usually outside of the structure of a formal study, and almost certainly outside of a formal randomised trial.
I have said elsewhere that fibroids, a more common condition with a vastly larger surgical experience, defy good science. This condition is even more challenging. I do not think it will ever be possible to prove benefit from a laparoscopic approach to the resection of adenomyosis. However, someone whose entire practice is based on performing laparoscopic surgery will have a strong bias to perform such surgery. I do not recommend this approach.
I am happy to discuss this and other adenomyosis treatment options with you.