What is Adenomyosis?
In April we raise our voices and shine the light on adenomyosis. Adenomyosis (ah-deh-no-my-oh-sis) is often confused with endometriosis. Adenomyosis is where endometrial tissue or cells similar to the lining inside of the uterus grow into and are present in the muscle wall of the uterus. Adenomyosis can occur alone, or you can have both adenomyosis and endometriosis. Some studies record presence of both adenomyosis and endometriosis in 80-90% of women, and presence of adenomyosis in premenopausal women at 20 – 34%.
Adenomyosis has many of the same symptoms of endometriosis which is why they be commonly confused or passed off as the same thing. Some main symptoms of adenomyosis include:
- Heavy periods
- Painful periods
- Pain during or after sex
- Chronic pelvic pain regardless of point in menstrual cycle
- Iron deficiency due to heavy periods
- Feeling of heaviness or ‘bulkiness’ of the uterus leading to a tender or enlarged uterus
What is the relationship between inflammation & adenomyosis?
Prostaglandin E2 or PGE2 is quite useful in the body at protecting us and being involved in that inflammatory response. Prostaglandins are any of a group of lipids, with varying hormone-like effects made at sites of tissue damage or infection that are involved in dealing with injury and illness. PGE2 is also released during various points in our menstrual cycles, and during labour. It assists with the shedding of the uterine lining during periods, aids ovulation and helps with contractions in labour. Things like our diet, or stress can lead to an over-production of PGE2. This over production can cause pain, either mid cycle or during periods. Read more about diet and adenomyosis here.
Diagnosis of Adenomyosis
It is unknown how adenomyosis occurs and who might be at risk of it developing. A common misconception is that adenomyosis occurs in women over 50. This is likely because much of the data around adenomyosis is based on hysterectomy data, and this fails to capture the experience of younger women with the condition. The common perception that adenomyosis affects older reproductive-age women based on hysterectomy data misses the experience of younger women with the condition. Adenomyosis, (like endometriosis) is an estrogen fuelled condition. It makes sense that this condition is most commonly seen in women in their reproductive years between 18 – 50 years of age.
The two main ways of diagnosis for adenomyosis is through transvaginal ultrasound sonography (TVUS) and magnetic resonance imaging (MRI). Both of these should be conducted by a specialist who is familiar with the appearance of adenomyosis on scans, and what to look for when conducting the imaging.
Generally, TVUS will be the first line of treatment, and expert sonographers will look at an asymmetrical thickening of uterine walls, general discomfort in areas of the uterus and the uterus may look globular in shape. It is important that this is conducted by a specialist who is experienced in this area. TVUS does not always accurately show adenomyosis, which is where MRI is used. The use of MRI and TVUS should be appropriate for adenomyosis diagnosis by a specialist gynaecologist.
There have been a few different classifications of adenomyosis proposed in the research, which can be seen in MRI. One study proposed four distinct types of adenomyosis, labelled diffuse, sclerotic, nodular and cystic. Other studies have labelled these according to where the lesion is found, these are labelled; subtype I—intrinsic (inner myometrium), subtype II—extrinsic (outer myometrium), subtype III—intramural (surrounded by normal outer myometrium), and subtype IV—indeterminate (not fit into any of the other types) (2,3). However, (at the time of writing) a shared classification system has not been developed yet as further research is needed in every area of adenomyosis. The only definitive diagnosis of adenomyosis is through pathology tests after the uterus has been removed, also known as hysterectomy. Biopsy of endometrial tissue is not carried out as it could miss an area of the uterus that has adenomyosis.
Treatment for Adenomyosis
Treatment options for adenomyosis can be split into surgical treatment, and hormonal treatment. Treatment for adenomyosis unfortunately only focuses predominantly on management of symptoms rather than getting to the source and managing the disease itself. The most common medical treatments include either hormonal or surgical options. Many treatment options are only appropriate for women who have no desire for children, or who have already reached the end of childbearing.
Hormonal treatment includes:
- The Contraceptive Pill
- Progesterone releasing IUD (Mirena)
- Gonadotropin releasing hormone (GnRH) agonists.
These aim to control estrogen levels, and therefore manage uterine bleeding, uterine size, and pain.
Surgical options include:
- Uterine artery embolisation
- Endometrial ablation
- The only known cure for adenomyosis, hysterectomy (removal of the uterus).
Below is a summary of each common treatment, and the way in which is assists with adenomyosis treatment and management.
| Treatment | How it helps |
| Contraceptive Pill | – Regulating hormones (especially excess estrogen) – Reduces the frequency of periods (theoretically reducing pain). – Reduces length of periods and heaviness of flow. – For some, the contraceptive pill can actually WORSEN symptoms *Bottom line – work with your gynae/GP* |
| Intrauterine device (IUD) such as Mirena | – Induces thinning of the endometrium – A reduction in the size of the uterus which would theoretically decrease pain experienced during menstruation and in between periods. – A reduction in the pain experienced with intercourse – Reduced bleeding overall which could help with other health issues (i.e. Iron deficiency and fatigue) |
| Gonadotropin releasing hormone (GnRH) agonists (artificial hormone to prevent ovulation) | – Induces thinning of the endometrium – Reduction in the size of the uterus (Theoretically decreasing pain) – Suppression of the period – A temporary chemical menopause In the presence of infertility and endometriosis these may be used temporarily. |
| Uterine Endometrial Ablation | – A surgical technique used to destroy the lining cells of the uterine lining. – May give some relief from the heavy menstrual bleeding – Can be used when adenomyosis has not penetrated the muscle wall – Still needs more research as results are mixed and inconclusive with some women reporting unbearable pain and bleeding 6 – 8 months post-surgery with some women needing hysterectomies. – Periods can return to being heavy, as adenomyosis in the muscle layer are not able to be fixed by the procedure. – Not recommended for women who haven’t had children due to the possibility of adverse effects. |
| Uterine Artery Embolisation | – Tiny particles are injected inside the uterine arteries to block the blood supply/flow to adenomyosis, and alleviating symptoms. – Could be considered as an alternative to hysterectomy to treat adenomyosis. – Not currently recommended if you are planning a future pregnancy. |
| Hysterectomy | – Removal of uterus which should remove the adenomyosis and symptoms associated. – The only known and proven cure for adenomyosis. |
Pain Management Strategies
The symptom that interferes with adenomyosis sufferers lives most would be severe chronic pelvic pain. There are a few medicinal pain management strategies that may be helpful, these include:
- Over the Counter pain relief medication
- Paracetamol
- NSAIDs short for non steroidal anti-inflammatory drugs (e.g. ibuprofen)
- Prescription Pain relief
- Ponstan (Can also be prescribed for heavy bleeding)
- Naproxen, which also reduces heavy bleeding
- Stronger pain relief such as panadeine, or tramadol
- Chronic Pain medications , that act as on nerve pain and acts as nerve / muscle relaxants
- Amitriptyline
- Pregabalin
For some, the overload of appointments, and medications can be overwhelming and some people with adenomyosis may like to use other management strategies. These are often called non-pharmacological strategies or interventions. These can include use of:
- Heat Packs
- Stretching, yoga or pilates to relieve pain
- TENS Machine e.g. Ovira
Lifestyle changes can also assist with adenomyosis management. Some of these include:
- Exercise
- Dietary change guided by a women’s health dietitian
To read more about non medical management of adenomyosis, head to our blog around Nutrition for Adenomyosis.
We hope this blog serves as a reminder to investigate ongoing pain, and heavy periods, and to continue to advocate for yourself, further investigations and answers. If you would like some more assistance around endometriosis, or adenomyosis management strategies, go to Jean Hailes, or book in for an appointment to explore your nutrition with me today!
Until next time,
Big Sis x
