Jenny Niedenfuehr, MPH, CHES®, CPH

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Adenomyosis
This page will present adenomyosis, which is defined as a disease where the endometriosis glands and stroma grow and insert themselves into the myometrium of the uterus (Schrager et al., 2022; Naftalin et al., 2016). Adenomyosis is a challenging disease to assess, identify, and even manage (Loring et al., 2021). It can be identified by imaging, but also through myometrial biopsies for women who wish to keep their uterus (Loring et al., 2021). Alternatively, hysterectomy, the removal of the uterus is the most invasive method of identifying and diagnosing adenomyosis (Loring et al., 2021). At least 2/3 of patients with adenomyosis will experience symptoms, where the most common symptom is heavy bleeding and cramping (Schrager et al., 2022; Vannuccini et al., 2019). Although the disease generally appears in the late years of child-bearing, people may also develop it earlier. In addition, endometriosis and adenomyosis can co-exist simultaneously. In a review by Gonzalez et al. (2012), the authors suggested that deep infiltrating endometriosis can be used as a marker for adenomyosis.
More than often, adenomyosis is assessed by MRI or ultrasound (ordered by an ob/gyn or an endometriosis specialist) where the thickness of the junctional zone is measured. The sensitivity and specificity ranges from 86%-100% (Chamie et al., 2009). A junctional zone that is greater than or equal to 12 mm is characterized as a uterus with adenomyosis (Landi et al., 2008). In addition, areas with low intensity that have poorly defined borders on T2- weighted sequences are defined as another criterion for diagnosis (Landi et al., 2008; Stratton et al., 2002). Overall, the current treatments for adenomyosis are very limited and more research needs to be dedicated towards improving the quality of life for people with both endometriosis and adenomyosis.
There are two types of adenomyosis:
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Diffuse: Scattered lesions within the myometrium (middle layer of the endometrium wall)
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Focal: Masses of lesions within the myometrium
Symptoms (You can have very few of these symptoms listed and still have adenomyosis)
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Menorrhagia (heavy bleeding)
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Long periods of bleeding
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Blood clots larger than a quarter
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Dysmenorrhea
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Abdomen pain, pelvic pain not on cycle
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Thick, boggy uterus (seen through ultrasound, MRI with/without contrast, and through laparoscopy)
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Bloating
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Dyspareunia (pain with sex)
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Fatigue
How is it diagnosed?
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Transvaginal ultrasound (Mz, 2019)
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Abdominal ultrasound (less accurate)
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MRI with/without contrast - Junction zone greater than or equal to 12 mm (Landi et al., 2008)
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Most reliable signs for MRI diagnosis: Click this link
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Myometrial biopsy
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Laparoscopy with a qualified specialist
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Gold standard: Histological examination of hysterectomy specimen after hysterectomy is performed (Naftalin et al., 2016)
Treatments:
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Hormonal treatments (IUDs, birth control pills)
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Pain management
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Pelvic floor PT
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Hysterectomy: Removal of the uterus, which is the last resort
References
Chamie LP, Blasbalg R, Gonçalves MO et al (2009) Accuracy of magnetic resonance imaging for diagnosis and preoperative assessment of deeply infiltrating andometriosis. Int J Gynaecol Obstet 106:198–201
Landi S, Mereu L, Pontrelli G et al (2008) The influence of adenomyosis in patients laparoscopically treated for deep endometriosis. J Minim Invasive Gynecol 15:566–570
Gonzales, M., de Matos, L.A., da Costa Gonçalves, M.O. et al. Patients with adenomyosis are more likely to have deep endometriosis. Gynecol Surg 9, 259–264 (2012). https://doi.org/10.1007/s10397-012-0746-4
Loring, M., Chen, T. Y., & Isaacson, K. B. (2021). A Systematic Review of Adenomyosis: It Is Time to Reassess What We Thought We Knew about the Disease. Journal of minimally invasive gynecology, 28(3), 644–655. https://doi.org/10.1016/j.jmig.2020.10.012
Mz Y, Ming X (2019) Application of high intensity focused ultrasound in the treatment of adenomyosis. Chin J Gynecol Obstet 35(05):522–527
Schrager, S., Yogendran, L., Marquez, C. M., & Sadowski, E. A. (2022). Adenomyosis: Diagnosis and Management. American Family Physician, 105(1), 33–38.
Stratton P, Winkel CA, Sinaii N et al (2002) Location, color, size, depth, and volume may predict endometriosis in lesions resected at surgery. Fertil Steril 78:743–749
Vannuccini, S., & Petraglia, F. (2019). Recent advances in understanding and managing adenomyosis. F1000Research, 8, F1000 Faculty Rev-283. https://doi.org/10.12688/f1000research.17242.1
Yeh, C. C., Su, F. H., Tzeng, C. R., Muo, C. H., & Wang, W. C. (2018). Women with adenomyosis are at higher risks of endometrial and thyroid cancers: A population-based historical cohort study. PloS one, 13(3), e0194011. https://doi.org/10.1371/journal.pone.0194011
