What is adenomyosis (a gynecologic medical condition)?

From the Guidelines

For a reproductive age patient with adenomyosis and concurrent uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms, and no desire for future fertility, medical management or uterine artery embolization (UAE) is usually appropriate for initial therapy. This recommendation is based on the most recent evidence from the American College of Radiology, which suggests that medical management should be trialed prior to pursuing more invasive therapies 1.

Treatment Options

• Medical management: This includes hormonal treatments such as combined oral contraceptives, progestin-only pills, or the levonorgestrel intrauterine device (Mirena) to reduce symptoms by suppressing the growth of endometrial tissue.
• Uterine artery embolization (UAE): This procedure involves blocking the blood vessels to the uterus to reduce symptoms, and has been shown to improve quality of life and symptom scores in patients with adenomyosis and fibroids 1.
• Surgical options: For severe cases unresponsive to medication, surgical options such as endometrial ablation, uterine artery embolization, or hysterectomy may be considered for definitive treatment.

Diagnosis

Adenomyosis is diagnosed through imaging tests like transvaginal ultrasound or MRI, and sometimes can only be confirmed after hysterectomy through tissue examination.

Symptom Management

For mild symptoms, over-the-counter pain medications like ibuprofen (400-800mg every 6-8 hours) or naproxen (500mg twice daily) can help manage pain and reduce bleeding. It's essential to note that adenomyosis often improves after menopause when estrogen levels decrease, as this hormone stimulates the abnormal tissue growth 1.

Considerations

It's crucial to consider the patient's desire for future fertility when selecting a treatment option, as some treatments may affect fertility. Additionally, the presence of comorbidities such as endometriosis should be considered, as surgical methods for fibroids and endometriosis can be performed simultaneously 1.

From the Research

Definition and Symptoms of Adenomyosis

• Adenomyosis is a benign uterine condition affecting women at various ages with different symptoms, including heavy menstrual bleeding, pelvic pain, and infertility 2, 3.
• One in three patients with adenomyosis is asymptomatic, but the rest may present with symptoms such as heavy menstrual bleeding, pelvic pain, or infertility 3.
• Adenomyosis is distinct from endometriosis, but the two conditions often occur simultaneously 3.

Diagnosis of Adenomyosis

• Diagnosis of adenomyosis begins with clinical suspicion and is confirmed with transvaginal ultrasonography and pelvic magnetic resonance imaging 3, 4, 5.
• Transvaginal sonography and magnetic resonance imaging are diagnostic options for adenomyosis 4.
• The use of pelvic imaging has demonstrated the existence of different forms of adenomyosis, notably allowing distinction between lesions of the external myometrium and those of the internal myometrium 5.

Treatment Options for Adenomyosis

• Treatment options for adenomyosis include medical options, interventional options, and surgical options 4, 6.
• Medical options include non-steroidal anti-inflammatory drugs, tranexamic acid, combined oral contraceptives, levonorgestrel intrauterine system, dienogest, other progestins, and gonadotropin-releasing analogues 2, 4.
• Conservative surgery, such as excision of adenomyosis, is effective for symptom control and possibly for adenomyosis-related infertility 6.
• Hysterectomy is a surgical option for patients with adenomyosis who are not responsive to medical therapy 3, 6.

Management and Outcomes

• The management of adenomyosis should be tailored to symptoms and include medical, interventional, and surgical options 4.
• Outcomes of interest include reduction in heavy menstrual bleeding, reduction in pelvic pain, and improvement in reproductive outcomes 4.
• Conservative surgery for adenomyosis improves pelvic pain, abnormal uterine bleeding, and possibly fertility, with over three-fourths of women experiencing symptom relief after surgery 6.