Adenomyosis, a disease often confused with endometriosis and uterine fibroids

What is adenomyosis?

Adenomyosis is a benign condition in which the uterine wall thickens due to invasion by endometrial tissue. Adenomyosis is common in women in their childbearing years, between 30-40 years of age, and is associated with high oestrogen production. This is why during menopause, there is a chance that the disease may regress.

Often misdiagnosed as uterine fibroids or endometriosis, adenomyosis is a disease that closely resembles endometriosis in its painful manifestation during the menstrual cycle and its effects on fertility.

The most common manifestations of adenomyosis are:

  • Menorrhagia: prolonged menstruation (more than 5-7 days) with heavy bleeding;
  • Dysmenorrhea: severe abdominal pain during menstruation;
  • Dyspareunia: pain during sexual intercourse

Why does adenomyosis occur and what should be done when it is detected?

Adenomyosis and endometriosis are “associated” disorders, and we have many theories that attempt to explain why these two diseases occur as long as we do not know the aetiopathogenesis.

But one thing is certain, they both develop as an abnormal location of the endometrium, i.e. the uterine lining.

Adenomyosis means the invasion of the endometrium in the thickness of the uterine wall, i.e. in the myometrium, and endometriosis means uterine lining implanted elsewhere other than in the uterus.

They coexist in most cases and especially in cases of deep endometriosis, such as rectovaginal septum endometriosis, bowel endometriosis, or deep endometriosis nodules in the bladder wall or round ligament insertion.

Deep endometriosis lesions occur as an extension into the uterus and create adenomyosis in the uterine wall.

Adenomyosis is more harmful than endometriosis because, unlike endometriosis lesions, which can be removed and can thus be treated even if they are on the colon or bladder, adenomyosis lesions (which may also be diffused throughout the uterine wall) can only be removed by removing the uterus. For a young woman in her fertile period or prior to it, you can’t perform that.

There are several forms of adenomyosis:

  1. Focal adenomyosis, which ultrasonographically mimics a uterine fibroid;
  2. Diffuse adenomyosis, i.e. encapsulating the uterine wall over a significantly wider area;
  3. Localised cystic adenomyosis, which is easily operated and looks like a cyst inside the uterus;
  4. Diffuse cystic adenomyosis, for which unfortunately the only treatment option is to remove the uterus.

But when do we treat adenomyosis?

  • Adenomyosis is treated when it is symptomatic with severe pain and bleeding or when it causes infertility.
  • There are forms of adenomyosis that affect the internal uterine wall, i.e. towards the uterine cavity, and then the patient is bleeding
  • Other forms of adenomyosis that affect the outer uterine wall and are usually associated with deep parametrial or intestinal endometriosis, that does not cause bleeding, but does cause pain.

As a result, we need to know when to treat adenomyosis, whether it is symptomatic or when it causes infertility.

Adenomyosis in the context of infertility:

In order to increase a woman’s chances of becoming pregnant, treating endometriosis and adenomyosis in the context of infertility requires careful consideration because it is noticeable that adenomyosis causes a uterus to become contractile, making it unfriendly for the implantation of a pregnancy, and even if you use IVF, the embryo may not catch.

On the other hand, operating on a large area of adenomyosis involves massive destruction of the uterine wall. So, it is very important what decision is made based on the patient’s wishes as well as the adenomyosis symptoms. There are many women who have adenomyosis, but it is asymptomatic.

How is intraoperative fibroid differentiated from adenomyosis?

The distinction between fibroid and adenomyosis is very simple, but more often than not an inexperienced doctor can be misled.

Fibroid comparable to an orange in a peel: cut the peel off, take the orange out, sew the peel back on.

If you wish to remove adenomyosis, you can, but you will be left with “a hole” in the uterus and no walls to close that area. Adenomyosis just destroys the uterine wall.

Indeed, nowadays there are all sorts of methods whereby you adapt depending on the local situation.

An experienced surgeon makes sure that he/she performs a good quality suture, so that the tissue is not in tension. Since getting pregnant is the goal of conservative surgery, it is important that there is no bleeding right after the procedure.

The differences between adenomyosis and uterine fibroid are as follows:

  • Fibroid does not hurt, but it can cause bleeding if it develops into the uterine cavity
  • Adenomyosis on the other hand gives great pain and heavy bleeding.

Treatment methods for adenomyosis:

  1. First, medication is prescribed in an attempt to protect the uterus from damage as much as possible.
  2. If the pharmacological therapy is unsuccessful or the doctor determines that it is ineffective, the patient will undergo surgery after she gives her consent.  During this procedure, the uterus must be kept in place as much as possible, especially if the patient is young and desires to have children.

The first line by which adenomyosis must be addressed or attempted to be addressed is medical treatment, surgical treatment being reserved for cases that do not respond to medical therapy, still experiencing bleeding and pain. In the case of localised adenomyosis, adenomyomectomy excises the adenomyosis nodule without greatly affecting the structure of the uterus and in this way the patient’s fertility is improved.

It’s always good to be informed before making a radical decision, to be aware of everything that is involved and for the doctor to be familiar with this pathology and to consider all the prospects.

A perfectly superposable principle for adenomyosis: If the doctor knows that by surgery he is doing more harm than good, it is better to avoid performing it.