Adenomyosis vs Leiomyoma: Clinical Symptoms and Treatment Approaches
Adenomyosis and leiomyoma (uterine fibroids) present with distinct clinical symptoms and require different treatment approaches, with adenomyosis typically causing more pelvic pain while leiomyomas more commonly cause bulk-related symptoms and abnormal uterine bleeding patterns. 1
Clinical Symptoms
Adenomyosis
- Presents with more severe pelvic pain and dysmenorrhea compared to leiomyomas 2, 3
- Often causes diffuse abnormal uterine bleeding rather than heavy menstrual bleeding 1
- More frequently associated with postmenopausal bleeding when coexisting with leiomyomas 3
- Symptoms may be less responsive to conservative treatments 4
- More common in parous women with lower BMI compared to those with only leiomyomas 2
Leiomyoma (Uterine Fibroids)
- Primarily causes heavy menstrual bleeding, especially with submucosal location 1, 5
- Creates bulk-related symptoms including pelvic pressure, urinary frequency, and constipation depending on location 1
- Can cause reproductive issues including infertility and pregnancy complications 5
- Symptoms vary based on location (subserosal, intramural, or submucosal) 1
- Typically presents with larger, more discrete masses compared to adenomyosis 2
Diagnostic Approach
Imaging Modalities
- Transvaginal ultrasound (TVUS) is the first-line imaging modality for both conditions 1
- MRI is the most accurate modality for differentiating between adenomyosis and leiomyomas 6
- On MRI, adenomyosis appears as diffuse or focal thickening of the junctional zone, while leiomyomas appear as well-circumscribed masses 1
- Doppler ultrasound shows different vascular patterns: adenomyosis has resistive index >0.7 and pulsatility index >1.2, while leiomyomas show resistive index <0.7 and pulsatility index <1.2 1
Treatment Approaches
Adenomyosis Treatment
- Medical management includes progestin IUDs and oral GnRH antagonist combinations for symptom control 7
- Uterine artery embolization (UAE) shows early success but has 40-50% recurrence rates at 2 years 1, 8
- Surgical options often involve hysterectomy for definitive treatment in women who have completed childbearing 4
- Conservative surgical approaches like endomyometrial ablation or laparoscopic myometrial excision may be effective in >50% of patients but have limited long-term data 4
Leiomyoma Treatment
- Medical management includes GnRH agonists (with add-back therapy to prevent bone loss) which can reduce fibroid volume by 35% 5
- Minimally invasive options include:
- Surgical options include:
Special Considerations
Coexisting Conditions
- Adenomyosis and leiomyomas frequently coexist, complicating diagnosis and treatment 2, 3
- When both conditions are present, women typically have more pelvic pain despite smaller fibroid burden 2
- For women with both conditions who desire uterus preservation, UAE can improve quality of life, especially when fibroids predominate 7
Fertility Implications
- Women should wait 2-3 months after myomectomy before attempting pregnancy 5
- UAE is not recommended as first-line treatment for women seeking pregnancy due to increased risks of miscarriage (35%), cesarean sections (66%), and postpartum hemorrhage (13.9%) 7
- Intramural fibroids negatively affect fertility, but treating asymptomatic fibroids does not necessarily improve fertility outcomes 5
Common Pitfalls
- Misdiagnosis is common due to overlapping symptoms and frequent coexistence of both conditions 6
- Adenomyosis is often not diagnosed until after hysterectomy 4, 2
- Pretreatment with GnRH agonists before myomectomy may make small intramural leiomyomas difficult to palpate during surgery, leading to incomplete removal and apparent "rapid recurrence" 1
- Long-term GnRH agonist therapy without add-back results in approximately 1% bone loss per month 5