What is Adenomyosis (That Causes Women's Uterine Bleeding)

Adenomyosis is a common, but poorly understood condition that affects women of all age groups.

It is a common cause of dysmenorrhea, menorrhagia, and chronic pelvic pain but is often underdiagnosed.

Typically, because adenomyosis is confined to the uterus, diagnosis and management can be managed by an OB/GYN.

Signs & symptoms

Adenomyosis is defined as the presence of ectopic nests of endometrial glands and stroma within the myometrium, surrounded by reactive smooth muscle hyperplasia.

Patients with adenomyosis commonly report the following symptoms:

• Menorrhagia
• Dysmenorrhea
• Metrorrhagia
• Chronic pelvic pain
• Dyspareunia

On physical examination, a diffusely enlarged, tender, “boggy” uterus is suggestive of adenomyosis.

Diagnosis

A diffusely enlarged, tender, “boggy” uterus is suggestive of adenomyosis.

Alternatively, severe endometriosis often presents as a fixed, tender uterus, with palpable nodules within the posterior cul-de-sac and/or lining the uterosacral ligaments and rectovaginal septum.

Ultrasound is the most common imaging modality used to evaluate gynecologic symptoms. It may show:

• Presence of myometrial cysts

• A diffusely enlarged, globular, asymmetric uterus

• Distorted, heterogeneous myometrium with increased or decreased areas of echogenicity

Ultrasound of an adenomyoma dissecting through the anterior uterine wall separate from the endometrial cavity. (Pic source: Medscape)

Currently, adenomyosis remains a largely clinical diagnosis. Definitive diagnosis requires histologic examination of uterine tissue.

Causes

Some studies have suggested that elevated levels of estrogen are necessary for the development and maintenance of adenomyosis, just as they are required for ectopic endometrial proliferation and proliferation of endometriotic implants.

Some studies have noted elevated estradiol levels in the menstrual blood of women with endometriosis and adenomyosis, and other studies have noted elevated levels of aromatase enzymes in the endometrium of adenomyotic tissue, suggesting elevated estradiol levels are necessary to maintain active adenomyosis.

Prognosis

Some studies suggest that adenomyosis has a negative impact on fertility outcomes; however, limited data exist.

A meta-analysis by Cozzolino et al showed that infertile women with adenomyosis who underwent in vitro fertilization (IVF) had a lower live birth rate, clinical pregnancy rate, and ongoing pregnancy rate than did women without adenomyosis. Additionally, the rate of miscarriage was higher in women who had adenomyosis.

Management

Medical Treatment

• The medications most commonly used to treat symptoms of adenomyosis are anti-inflammatory medications and hormonal therapies.
• Nonsteroidal anti-inflammatory drugs are the most common class of anti-inflammatory medications used to treat menorrhagia. These inhibit the formation of prostaglandins, which are considered the primary mechanism of action in uterine pain.
• Hormonal therapies cause ovarian suppression, mainly through negative feedback on the hypothalamic-pituitary-ovarian axis. By suppressing ovarian function, hormonal stimulation of adenomyotic tissue is suppressed.
• No diet has been found to cause or prevent the development of adenomyosis. However, obesity has been identified as an independent risk factor associated with the presence of adenomyosis and endometriosis, possibly due to exposure to elevated estrogen levels.
• No known physical activities may cause or prevent the development of adenomyosis. However, as mentioned previously, obesity has been identified as an independent risk factor associated with adenomyosis and may be prevented with appropriate diet and physical activity.

Surgical Treatment

• High-intensity focused ultrasound (HIFU) is a conservative surgical method that allows patients to preserve their uterus. MRI or ultrasound imaging is used to visualize the uterus and direct high-intensity ultrasound beams at a targeted area within the myometrial tissue. These targeted ultrasound beams cause thermal ablation and necrosis. HIFU can be used on both focal and diffuse adenomyosis
• Uterine artery embolization (UAE) has long been used as a conservative treatment for women with symptomatic uterine fibroids. More recently, it has been considered as a treatment for symptomatic adenomyosis for women who are not candidates for surgical management. 
• Adenomyomectomy is a surgical option for adenomyomas and is performed in the same manner as a myomectomy. After the adenomyoma's location has been identified and possible using imaging techniques, the adenomyoma can be removed via laparotomy or laparoscopy.
• The only definitive treatment for symptoms associated with adenomyosis is hysterectomy; however, this is not an option for patients who desire future fertility and may not be an option for patients who are poor surgical candidates.

Article source: Medscape