Adenomyosis: Definition, Diagnosis, and Management
Adenomyosis is a benign uterine condition characterized by the presence of endometrial glands and stroma abnormally located within the myometrium (uterine muscle layer), causing symptoms such as heavy menstrual bleeding, pelvic pain, and potential infertility. 1, 2
Pathophysiology and Mechanisms
- Adenomyosis likely develops through invagination of the basalis endometrium into the myometrium, facilitated by non-cyclic, anti-apoptotic activity associated with relative hyper-estrogenic states 2
- Multiple pathogenic mechanisms have been proposed, including:
- Microtrauma at the endometrial-myometrial interface 3
- Enhanced invasion of endometrium into myometrium 3
- Metaplasia of stem cells in the myometrium 3
- Infiltration of endometrial cells from retrograde menstruation 3
- Aberrant hormonal influences (sex steroid hormone abnormalities) 1
- Inflammation, fibrosis, and neuroangiogenesis contribute to symptom development 1
Clinical Presentation
- Heavy or prolonged menstrual bleeding (abnormal uterine bleeding) 4
- Dysmenorrhea (painful menstruation) 5
- Dyspareunia (painful intercourse) 5
- Pelvic pain 5
- Infertility in some cases 5, 6
- Some women may be asymptomatic 1
- Adenomyosis often coexists with other gynecological conditions such as endometriosis and uterine fibroids 1
Diagnosis
- Traditionally diagnosed through histopathological examination after hysterectomy 1
- Modern diagnosis increasingly relies on non-invasive imaging techniques 1:
- Clinical diagnosis should consider risk factors, symptoms, physical examination findings, and imaging results in an integrated approach 1
- Most commonly diagnosed in multiparous women during their 40s-50s ("transitional years") 2
Treatment Options
Medical Management
- First-line therapy typically includes hormonal treatments 5, 6:
- Progestin IUDs (levonorgestrel-releasing intrauterine devices) have shown significant improvement in pain and bleeding, with effective reduction in uterine volume for long-term management 4, 6
- Combined oral contraceptives help reduce painful and heavy menstrual bleeding 4
- GnRH antagonists are effective for heavy menstrual bleeding even with concomitant adenomyosis 4
- Progestins such as dienogest, danazol, and norethindrone acetate can control pain symptoms through antiproliferative and anti-inflammatory effects 6
- Non-hormonal treatments include nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management 6
Interventional and Surgical Options
- Uterine Artery Embolization (UAE) is effective for women who desire uterine preservation:
- Radiological procedures such as High-Intensity Focused Ultrasound (HIFU) and radiofrequency ablation (RFA) may be considered when medical therapy is ineffective 5
- Hysteroscopic approaches may be suitable for some cases 5
- Conservative surgical treatments can be effective for ameliorating abnormal uterine bleeding and pelvic pain, though they carry some post-operative risks and potential obstetric complications 5
- Hysterectomy remains the only definitive treatment but should be considered when other treatments fail and fertility preservation is not desired 4, 5, 2
Important Considerations
- Adenomyosis treatment should prioritize symptom management and quality of life 4
- Fertility preservation is an important consideration for women of reproductive age 6
- GnRH analogues may be indicated before fertility treatments to improve pregnancy chances in women with adenomyosis 6
- Cytoreductive surgery for adenomyosis can be complex and should be performed by experienced surgeons in dedicated centers, especially with concomitant endometriosis 5
- New treatments are under development based on pathogenetic mechanisms, including selective progesterone receptor modulators, aromatase inhibitors, valproic acid, and anti-platelet therapy 6