What is adenomyosis?

Adenomyosis: Definition, Diagnosis, and Management

Adenomyosis is a benign uterine condition characterized by the invasion of endometrial glands and stroma into the myometrium, causing myometrial inflammation and hypertrophy, which can lead to abnormal uterine bleeding, pelvic pain, and infertility. 1

Pathophysiology and Clinical Presentation

Adenomyosis occurs when endometrial tissue infiltrates the myometrium, creating islands of ectopic endometrial tissue within the uterine muscle. This condition is distinct from endometriosis, though they can coexist.

Common Symptoms

• Heavy menstrual bleeding (menorrhagia)
• Painful menstruation (dysmenorrhea)
• Chronic pelvic pain
• Dyspareunia (painful intercourse)
• Infertility and spontaneous pregnancy loss 2

Risk Factors

• Multiparity
• Previous uterine surgery
• Middle age (typically 40-50 years)
• History of endometriosis

Diagnosis

The gold standard for diagnosis historically has been histopathological examination of hysterectomy specimens. However, modern imaging techniques now allow non-invasive diagnosis.

Imaging Modalities

1. Transvaginal Ultrasound (TVUS):

   • First-line imaging modality
   • Findings may include:
     • Heterogeneous myometrial echotexture
     • Asymmetric myometrial thickening
     • Poor definition of endometrial-myometrial junction
     • Myometrial cysts 3

2. Magnetic Resonance Imaging (MRI):

   • Higher sensitivity and specificity than ultrasound
   • Particularly useful when ultrasound findings are inconclusive
   • Can better visualize the endometrium even in the presence of leiomyomas and adenomyosis 3
   • Essential for planning conservative surgical approaches 4

Classification

Different forms of adenomyosis exist based on anatomical location:

• Internal myometrium lesions
• External myometrium lesions
• Diffuse adenomyosis
• Focal adenomyosis (adenomyoma) 1

Management Options

Treatment should be guided by symptom severity, desire for future fertility, and the presence of coexisting conditions.

Medical Management

1. First-line Treatments:

   • NSAIDs: Can reduce bleeding by 20-40% and help with pain, but less effective than other options 5
   • Progestin-releasing IUDs: Clinically favored due to local mechanism of action, lower systemic hormone levels, long duration, and user independence 3
   • Combined oral contraceptives: Shown to reduce painful and heavy menstrual bleeding 3
   • Tranexamic acid: First-line non-hormonal medication for reducing heavy menstrual bleeding 5

2. Second-line Treatments:

   • GnRH agonists/antagonists with add-back therapy: Effective for reducing bleeding and pain symptoms 5, 6
   • Recent randomized controlled trials demonstrated that oral GnRH antagonist combinations remain effective for heavy menstrual bleeding even with concomitant adenomyosis 3

Interventional Procedures

1. Uterine Artery Embolization (UAE):

   • Evidence supports UAE for patients with adenomyosis who fail conservative measures and desire uterus-preserving therapy 3
   • Prospective cohort studies show improvement in quality of life and symptom scores at up to 7 years follow-up 3
   • Meta-analysis reported short-term (<12 months) and long-term (>12 months) symptom improvement in 94% and 85% of cases, respectively 3
   • Hysterectomy rate for persistent symptoms after UAE is approximately 7-18% 3

2. High-Intensity Focused Ultrasound (HIFU):

   • Uses high-intensity ultrasound waves to thermally ablate affected tissue
   • Limited evidence specifically for adenomyosis 3

3. Radiofrequency Ablation (RFA):

   • May be proposed when medical therapy is ineffective 4

4. Hysteroscopic Procedures:

   • Limited role in adenomyosis management
   • May be considered for focal lesions 4

Surgical Management

1. Conservative Surgical Approaches:

   • Cytoreductive surgery for adenomyosis
   • Effective for improving abnormal uterine bleeding and pelvic pain
   • Should be performed by experienced surgeons in dedicated centers 4
   • Associated with post-operative risks and potential obstetric complications

2. Hysterectomy:

   • Remains the only definitive treatment for adenomyosis 4
   • Should be considered when:
     • Symptoms are severe and refractory to other treatments
     • Fertility preservation is not desired
     • Other treatment options have failed

Special Considerations

Adenomyosis with Concurrent Fibroids

• When fibroids and adenomyosis coexist, treatment becomes more complex
• UAE has shown good results when fibroids predominate 3
• The ongoing QUESTA trial (Quality of Life after Embolization versus Hysterectomy in Adenomyosis) aims to compare UAE and hysterectomy outcomes 3

Fertility Considerations

• For women desiring pregnancy, medical treatments remain the best options 6
• In assisted reproductive techniques, long agonist stimulation protocols and pretreatment with GnRH agonists for deferred embryo transfer may improve pregnancy rates 6

Treatment Algorithm

1. For women with mild to moderate symptoms:

   • Start with NSAIDs and/or hormonal treatments (progestin IUD or combined oral contraceptives)
   • If inadequate response, consider GnRH agonists/antagonists with add-back therapy

2. For women with severe symptoms who desire fertility preservation:

   • Consider UAE if medical management fails
   • Conservative surgical approaches by experienced surgeons may be an option

3. For women with severe symptoms who do not desire fertility preservation:

   • Consider UAE as a uterine-sparing option
   • Hysterectomy offers definitive treatment if other approaches fail

Conclusion

Adenomyosis remains a challenging condition that significantly impacts quality of life. While hysterectomy provides definitive treatment, advances in imaging, medical therapy, and minimally invasive procedures now offer multiple management options for symptom control and uterine preservation.