Adenomyosis is a condition where the endometrial tissue, which normally lines the uterus (womb), grows into the muscle wall of the uterus. The condition was previously believed to be an extension of endometriosis. But it is now known to be a separate condition as the tissue only grows on the inside of the uterus, at a depth of at least 2.5mm into the outer muscular layer.

There are three types of adenomyosis:

  • Focal - A distinctly separate mass in the middle layer of the uterus wall (myometrium).
  • Extensive/diffuse - Growth of the endometrial tissue over a wide area.
  • Adenomyoma tumours - These non-cancerous tumours mimic fibroids and can be microscopic or large enough to be visible. They can occur with both focal and extensive/diffuse adenomyosis.

Adenomyosis affects 1 in 10 women. It can affect any female of reproductive age, as long as they have periods, and is most common in women over 30 that have had more than one child. It commonly occurs alongside fibroids, coexisting in 35-55% of cases; and endometriosis, coexisting in 20% of cases.

The pain that comes with suffering from adenomyosis can be very intense, spreading from the pelvic area into the legs. It can lead to very heavy periods (menorrhagia) and can cause fertility problems such as a difficulty conceiving and a risk of miscarrying. If you do not seek any treatment, your symptoms will likely increase in intensity until you reach menopause, at which point they stop.

Adenomyosis can be difficult to diagnose from its symptoms alone as it frequently occurs alongside fibroids and endometriosis, which have similar symptoms. It is sometimes only found when reviewing the uterus following a hysterectomy - which will have resolved the adenomyosis. If your doctor suspects you are suffering, they may diagnose you through an MRI, transvaginal ultrasound or hysteroscopy. Treatment for adenomyosis normally includes a programme of hormone therapy and painkillers.

What are the Symptoms of Adenomyosis?

The symptoms of adenomyosis are caused by the increased surface area of endometrial tissue. There is more lining available to bleed each month, and the increased pressure of the tissue can cause discomfort. The severity of symptoms correlates to how far the adenomyosis has progressed. 1/3 of women suffering with adenomyosis will not experience any symptoms.

Unlike endometriosis, the symptoms of adenomyosis do not fluctuate with the menstrual cycle as they are not associated with cyclic ovarian hormone production. However, the condition does clear when you go through the menopause.

Symptoms include:

  • Heavy periods (menorrhagia)
  • Pain before and during your periods (dysmenorrhea)
  • Periods that are longer, and often heavier, than normal (menometrorrhagia)
  • Pain during sex
  • Pain during bowel movements
  • Heaviness and pressure in the abdomen - Due to an enlarged and tender uterus.
  • Low energy
  • Urge incontinence
  • Overactive bladder (OAB)

What Causes Adenomyosis?

The reason adenomyosis occurs is not yet clearly understood, and remains a popular topic of clinical research. It is known to be not contagious and cannot spread to others, but it also cannot be prevented. You are considered at a higher risk of developing adenomyosis if you:

  • have a maternal family member which suffers - Adenomyosis is thought to be hereditary. It may be passed from your mother, or her mother.
  • experienced a traumatic childbirth - When the uterus lining attempts to heal itself, it can begin to grow inwards rather than outwards. Therefore if your uterus suffered trauma during childbirth, you can develop adenomyosis.
  • have chronic endometriosis - Adenomyosis occurs alongside endometriosis in 20% of cases.

To read about other causes of pelvic pain, visit the Causes and Diagnosis of Pelvic Pain page.

How to Treat Adenomyosis

Treatment for adenomyosis aims to relieve the symptoms and increase your fertility, where possible. If you are also suffering from fibroids or endometriosis, your treatment plan will look to treat both conditions alongside each other.

If your symptoms are very mild, or you are nearing the menopause (when your symptoms will stop), you may decide not the seek treatment. If you wish to fall pregnant in the future, you may avoid some treatments as they come with a risk of infertility.

Available treatments include:

  • Non-hormonal medicines - Your doctor can prescribe these medications to reduce your pain and the quantity of bleeding during your period.
  • Hormonal medicines - In a similar way to treating endometriosis, medicines, such as the combined contraceptive pill and progestogen only pill, aim to control your period. You can have GnRh hormones injected to create a false temporary menopause in your body. These shrink the endometrium lining temporarily.
  • Anti-inflammatory drugs - To reduce the quantity of bleeding during your period, and associated pain (dysmenorrhea).
  • Destroy the endometrium - Through a heated fluid, microwaves or electrical current.
  • Surgery - With all surgeries, there is a risk that your symptoms return after a short period, or do not go away at all. You may require further procedures to get the results you expect. All pelvic surgeries also come with a risk of infertility due to the proximity of the pelvic organs.
    • Hysterectomy - The standard surgical adenomyosis treatment is hysterectomy, to remove the uterus and associated endometrial tissue. Concerns have been raised about whether a hysterectomy is an appropriate procedure to diagnose and treat adenomyosis, as less invasive procedures are now available.
    • Uterine artery embolisation - Through an injection in the patient's groin, a thin tube is passed through the arteries and into the blood vessels. The blood supply is then blocked as small particles are injected through the tube. The aim is to cut the blood supply to the adenomyosis to reduce its symptoms. For most, the procedure is effective in the short and medium term. However, it can lead to menopausal symptoms in some women. Long term (9-27 months), most women require a second procedure as their symptoms had returned. Other risks include nausea, vomiting, fever, cramping and in some cases the particles can travel to other organs - cutting their blood supply.

To read about other treatments available for pelvic pain, visit our pelvic pain treatment page.

Sources

Badawy, A. M. Elnashar, A. M. Mosbah, A. A. (2012). Acta Obstetricia et Gynecologica Scandinavica.Aromatase inhibitors or gonadotropin‐releasing hormone agonists for the management of uterine adenomyosis: a randomized controlled trial. [online] 91(4), 489-495. [viewed 14/05/18]. Available from: https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/j.1600-0412.2012.01350.x

Byun, J. Y. Kim, S. E. Choi, B. G. Ko, G. Y. Jung, S. E. Choi, K. H. (1999). RadioGraphics. Diffuse and Focal Adenomyosis: MR Imaging Findings. [online] 19: ps16-s170. [viewed 08/05/18]. Available from: https://pubs.rsna.org/doi/pdf/10.1148/radiographics.19.suppl_1.g99oc03s161

Bedaiwy, M. A. Falcone, T. (2007) General Gynecology. Chapter 13 – Endometriosis and Adenomyosis. [online] Mosby, p321-345 [viewed 08/05/18]. Available from: https://www.sciencedirect.com/science/article/pii/B9780323032476100139

Bradley, L. D. (2009). Hysterectomy. Chapter 3 – Indications and Contraindications for Office Hysteroscopy. [online] Mosby, p19-38 [viewed 08/05/18]. Available from: https://www.sciencedirect.com/science/article/pii/B9780323041010500096

Guy’s and St Thomas’ NHS Foundation Trust. (2017). Adenomyosis. [online] Guy’s and St Thomas’ NHS Foundation Trust, 2017. [viewed 14/05/18]. Available from: https://www.guysandstthomas.nhs.uk/resources/patient-information/gynaecology/adenomyosis.pdf

NHS Trust. (2015). MRI scan: Overview. [online] National Health Service Trust, 2015. [viewed 09/05/18]. Available from: https://www.nhs.uk/conditions/mri-scan/

NHS Trust. (2015). Ultrasound scan. [online] National Health Service Trust, 2015. [viewed 09/05/18]. Available from: https://www.nhs.uk/conditions/ultrasound-scan/

NICE. (2013). Uterine artery embolisation for treating adenomyosis. [online] National Institute for Health and Care Excellence, 2013. [viewed 08/05/18]. Available from: https://www.nice.org.uk/guidance/ipg473/resources/uterine-artery-embolisation-for-treating-adenomyosis-pdf-474723261637

Streuli, I. Dubuisson, J. Santulli, P. de Ziegler, D. Batteux, F. Chapron, C. (2014). Expert Opinion on Pharmacotherapy. An update on the pharmacological management of adenomyosis. [online] 15(16), 2347-2360. [viewed 14/05/18]. Available from: https://www.tandfonline.com/doi/full/10.1517/14656566.2014.953055?

Takebayashi, T. Fujino, Y. Umesaki, N. Ogita, S. (1995). Gynecologic and Obstetric Investigation. Danazol Suspension Injected into the Uterine Cervix of Patients with Adenomyosis and Myoma. [online] 39(3), 207–211. [viewed 14/05/18]. Available from: https://www.karger.com/Article/Abstract/292410

Tsui, K-H. Lee, W-L. Chen, C-Y. Sheu, B-C. Yen, M-S. Chang, T-C. Wang, P-H. (2014). Taiwanese Journal of Obstetrics and Gynecology. Medical treatment for adenomyosis and/or adenomyoma. [online] 53(4), p459-465. [viewed 14/05/18]. Available from: https://www.sciencedirect.com/science/article/pii/S1028455914001703