Adenomyosis is a prevalent gynecological disease in which endometrial (uterine lining) cells invade into the uterine muscle layer (myometrium). This ectopically located endometrial tissue is functional, proliferating and “menstruating” during every menstrual cycle. The ensuing inflammation will permeate into the uterine muscle, causing it to undergo hyperplastic changes leading to a bulkier, heavier, and occasionally tender uterus. The prevalence of adenomyosis may be as high as 35% of reproductive-age women and typically presents with painful and heavy menses.
Adenomyosis can vary widely in the type and severity of symptoms that it causes, ranging from being entirely asymptomatic 33% of the time to being a severely debilitating condition in some cases. Women with adenomyosis typically first report symptoms between age 40 and 50, but symptoms can occur much earlier. The cause of adenomyosis is unknown, although it is associated with trauma, usually surgical, that may break the barrier between the endometrium and myometrium, such as a caesarean section or endometrial curettage.
Adenomyosis is typically diagnosed with either transvaginal sonography or pelvic MRI. Overall, it is estimated that transvaginal ultrasonography has a sensitivity of 79% and specificity of 85% for the detection of adenomyosis. MRI provides slightly better diagnostic capability compared to sonography due to an increased ability to differentiate between different types of soft tissue. MRI also has a better capacity to distinguish adenomyosis from small uterine myomas.
Hysterectomy is the definitive curative procedure for adenomyosis but is not applicable for women in their reproductive years trying to conceive. Therefore, several medications and fertility-sparing surgical techniques have emerged that can be considered in these cases.
- Nonsteroidal anti-inflammatory drugs, such as ibuprofen and naproxen, are commonly used with other therapies for pain relief. NSAIDs lower prostaglandin levels, the source of pain, by blocking the enzyme cyclooxygenase.
- Levonorgestrel-releasing IUDs (Mirena) are effective against adenomyosis. The use of hormonal IUDs in patients with adenomyosis has been proven to reduce menstrual bleeding, improve anemia, reduce pain, and even help normalize the size of the uterus.
- Oral contraceptives reduce the menstrual pain and bleeding associated with adenomyosis, especially when taken continuously. Oral contraceptives may even lead to short-term regression of adenomyosis.
- Gonadotropin-releasing hormone (GnRH) agonists, such as leuprolide, lower estradiol levels, prevent ovulation, and lead to a hypoestrogenic environment that helps shrink the adenomyosis implants, ameliorating symptoms. In IVF settings, long down-regulation before IVF might have a positive effect on pregnancy rates. Unless estrogen is added-back into the daily routine however, long-time use of GnRH-analogues can cause loss of bone density and increased risk of cardiovascular events.
Uterine artery embolization (UAE): In this minimally invasive procedure, doctors inject agents to block the uterine arteries to reduce the blood supply to the uterus, essentially starving the adenomyosis. Most women will report long-term improvement in their symptoms. However, there is a recurrence rate of ~ 35% with a 5% risk of major complications including infection, significant bleeding, and in some cases, reduced ovarian function. Therefore, this procedure should best be avoided in those seeking future pregnancies, especially those women with already low egg reserve.
Myometrium or adenomyoma resection: To be successfully resected, the adenomyosis should ideally be somewhat circumscribed with minimal diffuse spread. Unfortunately, this is uncommon and therefore this procedure is successful only 50% of the time. The procedure is performed with either a laparoscope or hysteroscope. Additionally, this surgery can be technically difficult because diffuse adenomyosis can weaken the myometrium, making it hard to suture. When successful, the procedure significantly improves menstrual pain and bleeding. Additionally, it can result in improved fertility in women trying to conceive with a 78% pregnancy rate and live birth in as many as 69% of those pregnancies.
Adenomyosis can lower fertility and should ideally be mitigated in women struggling to conceive. IVF patients with adenomyosis are less likely to become pregnant and more likely to miscarry. The discontinuation of an adenomyosis treatment should ideally coincide with the start of fertility treatments. Given this, women should ideally be screened for adenomyosis before starting fertility treatments. Women suspecting they may have adenomyosis should get evaluated by their OBGYN or fertility specialist so the best treatment options can be provided early on, thereby limiting the symptoms, spread, and sequela of this often debilitating disease.