Overview

Because adenomyosis doesn't often create symptoms, many women are unaware they have it. 20% to 65% of females may be affected by the illness.

Endometrial tissue, which ordinarily lines the uterus, develops into the muscular uterine wall, causing adenomyosis. Each menstrual cycle, the dislocated tissue behaves normally, swelling, degrading, and bleeding. There may be an enlarged uterus and painful, lengthy periods.

Adenomyosis normally goes away after menopause, but doctors are unsure of what causes it. Hormonal therapies can aid women who have significant pain from adenomyosis. Adenomyosis is treated by having the uterus removed (hysterectomy).

Your symptoms, how severe they are, and whether or not you have finished having children will all influence how you are treated for adenomyosis. 

 

How common is Adenomyosis?

Because of historical underreporting and underdiagnosis, it is difficult to determine accurate demographics and illness prevalence. Recent evidence suggests a frequency of 20% to 35%, whereas estimates range from 5% to 70%. The traditional description of adenomyosis as a condition affecting multiparous, premenopausal women in their thirties to forties reflects an inherent bias towards women who have hysterectomies. Ultrasound and MRI diagnostic criteria have improved, providing additional knowledge about afflicted populations.

Juvenile cystic adenomyosis, an uncommon type of the condition, is characterized by more extensive bleeding inside myometrial cysts and is commonly found in women under the age of 30. Surgery, either a myomectomy or hysterectomy, is usually necessary for symptoms that do not respond to medication treatment.

Conditions that enhance estrogen exposure (such as higher parity, early menarche, brief menstrual cycles, raised body mass index, usage of oral contraceptives, use of tamoxifen) and previous uterine surgery are risk factors for adenomyosis (dilation and curettage, cesarean section, myomectomy, etc.).

 

What is Adenomyosis?

An issue with the female reproductive system is called adenomyosis. The uterus enlarges and thickens as a result.

The uterine wall's inside is lined by endometrial tissue (endometrium). When this tissue penetrates the myometrium, the uterus's outer muscle walls, adenomyosis results. This additional tissue might result in the uterus growing by two or three times its original size, which can cause irregular uterine flow and uncomfortable periods. 

 

Difference Between Adenomyosis & Endometriosis

Adenomyosis and endometriosis both involve the endometrial tissue. Both conditions might be uncomfortable. With adenomyosis, heavy menstrual bleeding is more likely to happen. These illnesses can be distinguished based on where the endometrial tissue is growing.

• Adenomyosis: 

Endometrial tissue grows into the muscle of the uterus.

• Endometriosis: 

Endometriosis is a disorder in which tissue that resembles the uterine lining develops on other regions of the body. You may encounter uncomfortable sensations as a result of this tissue's unnatural growth, which may have an effect on your regular activities. Some endometriosis sufferers experience difficulties becoming pregnant.

Your uterus's inside lining is called the endometrium. You lose this tissue when you are menstruating. Imagine layers of tissue accumulating along the uterine interior as endometrium. These layers separate from the uterine walls during your menstruation and exit your body. The endometrium supports the early stages of development if you become pregnant.

Endometrial-looking tissue develops on other organs or tissues when you have endometriosis. This tissue may develop in your chest, pelvis, or abdomen. Due to its hormonal sensitivity, this tissue might swell up throughout your menstrual cycle. Ovarian cysts, superficial lesions, deeper nodules, adhesions (tissue that links and binds your organs together), and scar tissue can all be brought on by these patches of endometrial-like tissue.

 

How Adenomyosis Developed?

Cross section through the uterine wall of a 30-year-old woman's hysterectomy specimen who complained of persistent pelvic discomfort and unusual uterine hemorrhage. The serosa is at the bottom of the picture, and the endometrial surface is at the top.

Different symptoms are brought on by misplaced endometrial tissue development in the myometrium.

The prostaglandins that are generated by healthy endometrial tissue are what trigger uterine menstrual contractions. The primary symptom of this illness, which is caused by elevated prostaglandin levels, is dysmenorrhea. Estrogen also controls endometrial development, and several therapies aim to lower its levels to relieve symptoms.

Due to enlarged endometrial tissue, larger degree of vascularization, abnormal uterine contractions, and elevated levels of prostaglandins, estrogen, and eicosanoids, individuals with adenomyosis commonly have severe monthly bleeding. 

 

Histopathology of Adenomyosis

A pathologist will use microscopic examination of tiny tissue samples from the uterus to identify adenomyosis. These tissue samples can be taken either immediately after a hysterectomy or after a uterine biopsy. Laparoscopic surgery via the abdomen or hysteroscopy through the vagina and cervix can both be used to acquire uterine biopsies.

When the pathologist discovers invasive clusters of endometrial tissue within the myometrium, the diagnosis is made. There are a variety of diagnostic criteria that may be applied, but commonly they demand for either a minimum invasion depth between 2.5 and 8mm or endometrial tissue to have invaded more than 2% of the myometrium.

• Gross Findings:

1. 1. Enlarged uterus
   2. Thickened uterine wall with trabeculated appearance
   3. Hemorrhagic pinpoint or cystic spaces throughout wall

• Microscopic Findings:

1. 1. Endometrial glands and stroma haphazardly distributed throughout myometrium
   2. Concentric myometrial hyperplasia frequent around adenomyotic foci
   3. Variants: Gland-poor, stroma-poor, intravascular

• Differential Diagnosis:

1. 1. Adenomyoma
   2. Myo-invasive endometrial endometrioid carcinoma (vs. stroma-poor adenomyosis)
   3. Low-grade endometrial stromal sarcoma (vs. gland-poor and intravascular adenomyosis)

 

What are the Risk Factors?

Age

According to various studies, the average age of women having hysterectomy for adenomyosis is over 50 years old, and between 70 and 80 percent of them are multiparous and in their fourth or fifth decade of life. The condition may, however, produce dysmenorrhea and persistent pelvic discomfort in teenagers and women of earlier reproductive ages than previously believed, according to emerging findings utilizing MRI criteria for diagnosis. According to these observations, the clinical age at which adenomyosis manifests may be much younger than previously believed, and early-stage adenomyosis may have a distinct clinical phenotype than late-stage illness.

 

Multiparity

Women with adenomyosis tend to have many pregnancies. Due to the trophoblast's intrusive nature on the expansion of the myometrial fibers during pregnancy, adenomyotic foci may be included in the myometrium, which may aid in the creation of adenomyosis. In addition, the hormonal environment of pregnancy may stimulate the formation of islands of ectopic endometrium and adenomyotic tissue may have a greater ratio of estrogen receptors. In contrast, there can be a rise in multiparous women's acceptance of hysterectomy.

 

Prior uterine surgery

There is conflicting evidence about whether women with adenomyosis have a significantly higher likelihood of having had uterus surgery in the past. The theory that adenomyosis occurs from endometrial gland invasion of the myometrial layer has been confirmed by clinical evidence, with some investigations showing that surgical disruption of the endometrial-myometrial barrier increases the incidence of adenomyosis.

 

Smoking

There is conflicting evidence showing a link between smoking and adenomyosis. On the one hand, smokers appear to have a lower risk of adenomyosis than women who never smoked. This conclusion can be attributed to hormonally influenced processes as smoking has been linked to lower blood estrogen levels and adenomyosis has been hypothesized to be an estrogen-dependent condition.

In contrast, there is also proof indicating there is no connection between smoking and adenomyosis. Furthermore, two investigations also found that women with adenomyosis had a greater prevalence of smoking history than did controls. As a result, additional research into the connection between smoking and adenomyosis is needed.

 

Ectopic pregnancy

A pregnancy could form inside the myometrium if an implant is placed in an adenomyosis focus. Additionally, it has been demonstrated that smoking cigarettes is a separate, dose-related risk factor for ectopic pregnancy. Since adenomyosis may be a risk factor for the development of intramural ectopic pregnancy, it has been postulated that women with adenomyosis are more likely to have a history of ectopic pregnancy. Thus, the larger percentage of women with a history of smoking may also be a contributing factor to the increased likelihood of ectopic pregnancies in women with adenomyosis. However, there is still a need for further data to support the assumptions that adenomyosis is more likely to be associated with ectopic pregnancy and smoking history.

 

Depression and antidepressant use

Studies on both humans and animals have shown novel correlations with adenomyosis, such as an elevated risk of depression and greater antidepressant usage. It's possible that aberrant prolactin dynamics are the cause of this connection.

 

Tamoxifen treatment

Adenomyosis is very uncommon in postmenopausal women, however tamoxifen-treated breast cancer patients have been shown to have a greater frequency of the condition. Tamoxifen's active metabolite, hydroxytamoxifen, inhibits the estrogen receptor in breast tissue. It acts as an agonist in tissues, including the endometrium, and adenomyosis can form or become reactivated. As a result, adenomyosis may be more frequent in tamoxifen-using women than is widely believed, and it may be the cause of postmenopausal bleeding in these individuals. 

 

What Causes An Adenomyosis?

However, it seems that uterine lining damage or disturbance is a substantial risk factor for adenomyosis. Adenomyosis is more likely to develop in a woman who has experienced at least one pregnancy or loss than in a woman who has never been pregnant.  If you underwent a surgical pregnancy evacuation or underwent a cesarean delivery, your risk is even higher.

Adenomyosis often develops after the age of 30, with the peak age of diagnosis being between the ages of 40 and 50.

Teenage females can get adenomyosis, although it is far less prevalent in them. However, a teenager with really painful periods who does not react to standard therapies should most definitely be diagnosed.

A uterus with adenomyosis will become larger because the lining of the uterus has penetrated the muscular layer. This size growth is diffuse, which means that it affects the whole uterus, much to how the uterus grows in the first trimester of pregnancy. Your doctor may be able to see that your uterus has become larger during a pelvic check. This alteration is referred to as globular.  The severity of the symptoms increases when adenomyosis progresses deeper into the muscle wall.

 

Adenomyosis Signs & Symptoms

While many adenomyosis patients have no symptoms, those who do may endure severe dysmenorrhea and excessive monthly flow. When you are given an adenomyosis diagnosis, it is not unusual to simultaneously receive an endometriosis or uterine fibroids diagnosis. The symptoms of painful periods and profuse menstrual flow may become more severe when these benign gynecologic disorders are combined. 

 

How Adenomyosis Diagnosed?

The size and location of an adenomyosis' invasion into the uterus might differ greatly. As a result, there aren't any recognized pathognomonic signs that would allow for a non-invasive MRI diagnosis of adenomyosis. However, non-invasive imaging methods including transvaginal ultrasonography (TVUS) and magnetic resonance imaging (MRI) can be used to guide treatment options, assess response to treatment, and strongly suggest the diagnosis of adenomyosis. In fact, the only two feasible methods for making a pre-surgical diagnosis are TVUS and MRI.

• Transvaginal ultrasonography:

An inexpensive and widely accessible imaging technique called transvaginal ultrasonography is frequently used to assess gynecologic complaints early on. Similar to MRI, ultrasound imaging uses no radiation and is safe for examining the pelvic and female reproductive systems. Transvaginal ultrasonography is thought to have an overall sensitivity of 79% and specificity of 85% for detecting adenomyosis.

Common transvaginal ultrasound findings in patients with adenomyosis include the following:

• globular, enlarged, and/or asymmetric uterus
• abnormally dense or especially varied density within the myometrium
• myometrial cysts - pockets of fluid within the smooth muscle of the uterus
• linear, acoustic shadowing without presence of a uterine fibroid
• echogenic linear striations - bright lines or stripes
• anterior/posterior wall asymmetry
• diffuse spread of small vessels within the myometrium

 

Less common findings:

• Lack of contour abnormality
• Absence of mass effect
• Ill-defined margins between a normal and abnormal myometrium

During transvaginal ultrasound, the power Doppler or Doppler ultrasonography feature can be utilized to assist distinguish between adenomyomas and uterine fibroids. This is so because the capsule of uterine fibroids frequently has blood arteries around it. Adenomyomas, on the other hand, have many blood arteries throughout the tumor. Doppler ultrasonography also helps to distinguish between blood moving through arteries and the static fluid that makes up myometrial cysts.

By using MRI and three-dimensional transvaginal ultrasound (3D TVUS), the junction zone (JZ), a tiny, unique hormone-dependent area at the endometrial-myometrial interface, may be evaluated. Disruption, thickness, expansion, or invasion of the junctional zone are characteristics of adenomyosis.

• Magnetic resonance imaging:

Due to the greater capacity of MRI to objectively distinguish between various forms of soft tissue, it offers a somewhat higher diagnostic capability than TVUS. The increased spatial and contrast resolution of MRI makes this possible. According to estimates, MRI has a 74% sensitivity and 91% specificity for detecting adenomyosis.  The junctional zone is the primary area of investigation during MRI diagnosis. On both T1 and T2 weighted sequences, the junctional zone of the uterus will be enlarged and show a darker or weaker signal.

Three objective measures of the junctional zone can be used to diagnose adenomyosis.

1. A thickness of the junctional zone greater than 8–12 mm. Less than 8 mm is normal.
2. A junctional zone width being greater than 40% of the width of the myometrium.
3. Variability in the width of the junctional zone being greater than 5 mm.

On the T2 weighted scans, one will frequently observe foci of hyperintensity (bright spots) that correspond to smaller cystically dilated glands or more severe locations of microhemorrhage scattered among the thicker, darker signal of the junctional zone.

Calcified uterine fibroids do not restrict MRI as other causes do (as is ultrasound). Adenomyosis is particularly easier for MRI to distinguish from several little uterine fibroids.

 

Treatment options for Adenomyosis

Treatment for minor cases of adenomyosis may not be necessary. If your symptoms interfere with your everyday activities or quality of life, the doctor could suggest treatment choices.

The following are some treatments for adenomyosis that try to lessen its symptoms:

• Anti-inflammatory medications:

Ibuprofen (Advil, Motrin, Midol) and other anti-inflammatory drugs might ease painful cramps while simultaneously reducing blood flow during your period.

Your physician will provide you guidance on how frequently to take these drugs. Taking an anti-inflammatory medicine two to three days prior to the onset of your period and continuing it throughout it is one feasible routine.

Before taking anti-inflammatory drugs when pregnant, see your doctor. They could advise you to stay away from certain drugs depending on which trimester you're in.

• Hormonal treatments:

Hormonal treatments can help to control the estrogen that may be contributing to your symptoms. They include:

• gonadotropin-releasing hormone (GnRH) analogs like leuprolide (Lupron)
• oral contraceptives like birth control pills
• progestin-only contraceptives like a pill, an injection, or an intrauterine device (IUD)

 

• Endometrial ablation:

Techniques to eliminate or destroy the endometrium are used in endometrial ablation. With a quick recovery period, it is an outpatient operation.

However, because adenomyosis frequently invades the muscle more profoundly, this operation might not be effective for everyone. Only those who are past childbearing or don't want to get pregnant are advised to use it.

• Uterine artery embolization:

A condition called uterine artery embolization stops certain arteries from providing the afflicted region with blood. When the adenomyoma's blood supply is interrupted, it shrinks. Uterine fibroids are frequently treated with this surgery.

A hospital is where the operation is carried out. Usually, you have to spend the night after. It doesn't leave scars in the uterus because it's minimally invasive.

• Ultrasound-guided focused ultrasound surgery:

Focused ultrasonic surgery guided by ultrasound employs highly concentrated, precisely focused waves to heat up and kill the desired tissue. Ultrasound scans are used to continuously check the temperature.

Early research has demonstrated the efficacy of this method in treating symptoms. However, additional study is required.

• Hysterectomy:

Only a hysterectomy, which involves the whole surgical removal of the uterus, may totally treat adenomyosis. It is only utilized in extreme situations and in persons who don't want to have children in the near future because it is seen as a serious surgical operation.

Adenomyosis is unaffected by your ovaries. Your doctor and you will talk about whether there are any other factors that would make them better off being removed (particularly if you are postmenopausal) or left in place. 

 

Potential Complications of Adenomyosis

Your lifestyle may be negatively impacted by adenomyosis symptoms. Some people may be unable to participate in common activities, such as sexual activity, due to heavy bleeding and pelvic discomfort.

Adenomyosis patients are more likely to develop anemia, which is brought on by blood loss and can lead to iron deficiency.

Iron levels can be lowered in the body as a result of blood loss brought on by adenomyosis. The body can't produce enough red blood cells to deliver oxygen to the body's tissues without sufficient iron. This may make you feel drained, lightheaded, and moody.

Additionally, adenomyosis has been associated to irritability, melancholy, and anxiety.

 

Conclusion

Adenomyosis is a medical disorder that causes the uterus to thicken as a result of the proliferation of cells that proliferate abnormally among the cells of the uterine wall (myometrium) on the inside of the uterus (endometrium). Endometrial tissue is entirely functioning in people with this disease, but also misplaced. Every menstrual cycle causes the tissue to thicken, shed, and bleed.

Though it can also afflict younger women, the illness is most frequently diagnosed in women between the ages of 35 and 50. Adenomyosis patients frequently have painful menstrual periods (dysmenorrhea), excessive menstrual flow (menorrhagia), or both. Other probable symptoms include pain during sex, persistent pelvic pain, and urinary bladder irritation.

Basal endometrium reaches hyperplastic myometrial fibers during adenomyosis. The basal layer does not experience the normal cyclic alterations associated with the menstrual cycle, in contrast to the functional layer. Adenomyosis can focally affect the uterus, resulting in an adenomyoma. The uterus enlarges and weighs more with broad involvement.

Endometriosis and adenomyosis can coexist, although endometriosis patients have endometrial-like tissue that is totally external to the uterus. The tissue in endometriosis resembles the endometrium but is distinct from it. Though they frequently happen individually, the two disorders are frequently observed together. Adenomyosis was once known as endometriosis interna before it was identified as a different illness. Adenomyometritis, a less popular term, is a more precise term for the disorder, indicating uterine involvement.