Definition

The condition known as adenomyosis occurs when the endometrium, the uterus' innermost layer, grows and spreads into the myometrium, the uterine wall's muscle tissue. A woman's uterus consists of three different layers, which, from the outermost layer to the innermost, are:

• Perimetrium: The outer layer that produces lubricating fluid to reduce tension and covers some pelvic organs.
• Myometrium: The second layer of the uterus, consisting of smooth muscle and playing a role in uterine contractions.
• Endometrium: The innermost layer of the uterus, which typically thickens during the menstrual cycle.

Adenomyosis may result in the enlargement and thickening of the uterus. This condition can lead to abdominal cramps similar to those experienced before menstruation, bloating, and heavy menstrual bleeding.

Adenomyosis commonly occurs in women aged 40 to 50 years, although younger women can also experience it. While adenomyosis is a benign condition and not life-threatening, the pain and bleeding can significantly affect a woman's quality of life.

It is estimated that about 20% to 65% of women worldwide suffer from adenomyosis. Many women may be unaware they have adenomyosis because not all cases cause symptoms.

Causes

The exact cause of adenomyosis is still unknown. However, some studies suggest that adenomyosis may be triggered by hormonal imbalances, including:

• Estrogen: A group of hormones important in the development of female reproductive functions and sexual activity.
• Progesterone: A hormone that plays a role in the menstrual cycle and maintaining early stages of pregnancy.
• Prolactin: A hormone involved in milk production and breast tissue development.
• Follicle Stimulating Hormone (FSH): A hormone involved in developing the body's reproductive processes.

Risk Factor

Since the exact cause of adenomyosis is still unknown and is thought to be related to hormonal imbalances, factors that may increase the risk of adenomyosis include:

• Previous pregnancies or childbirth
• Obesity
• Smoking
• Age 35 to 50 years
• Alcohol consumption
• Family history of adenomyosis
• History of uterine surgery
• Cesarean section
• Dilation and curettage, a procedure to widen the cervix and scrape the endometrial lining
• Use of contraceptive pills
• Short menstrual cycles
• Early menarche (first menstruation)

Symptoms

Women may not be aware that they have adenomyosis because it can occasionally show no symptoms. It is estimated that up to 33% of women with adenomyosis are asymptomatic. When symptoms occur, they may include:

• Heavy and prolonged menstruation
• Sharp, knife-like pain
• Severe abdominal cramps during the menstrual cycle
• Pelvic pain
• Pain during sexual intercourse
• Increased abdominal pressure, causing bloating and fullness

The long and heavy menstrual bleeding is thought to be due to a combination of factors such as:

• Increased surface area of the endometrial lining
• Increased vascularization (formation of blood vessels)
• Abnormal uterine contractions
• Increased levels of prostaglandin and estrogen hormones

Diagnosis

Medical Interview and Physical Examination

The doctor will typically ask about:

• Complaints of lower abdominal pain and reproductive issues
• Menstrual history
• Past medical history
• Family medical history
• History of previous surgeries
• Use of contraceptives

The doctor and medical staff will check the patient's vital signs, such as blood pressure, respiratory rate, pulse, and body temperature. The doctor will then perform a local examination of the vaginal area to check for bleeding or lumps in the reproductive structures. Additionally, the doctor will examine for any changes in the shape of the uterus.

Additional Examinations 

Supportive examinations can help establish a diagnosis. The types of examinations that can be performed are:

• Pelvic ultrasound
• Sonohysterography or uterine ultrasound
• Uterine MRI
• Biopsy of uterine tissue samples

A biopsy is the most recommended supportive examination for detecting adenomyosis. It involves taking a small tissue sample from the uterus to be examined under a microscope by a pathology specialist. Other supportive examinations are generally performed according to the indications given by the examining obstetrician.

Because its symptoms are similar, adenomyosis is often diagnosed as uterine fibroids. However, the two conditions are not the same. Uterine fibroids are benign tumors that grow in the uterine wall, while adenomyosis originates from the innermost uterine lining that extends into other layers of the uterus.

Management

Treatment of adenomyosis depends on the symptoms and severity. Over-the-counter pain relievers like paracetamol and warm compresses may help with mild pain. If symptoms persist, the following treatment options are available:

• Pain relievers

Doctors may prescribe stronger pain relievers if over-the-counter medications are ineffective. These are usually recommended to be taken one to two days before menstruation and continued for the first few days of menstruation.

• Hormonal therapy

Severe and painful menstruation can be controlled with hormone therapy, such as an IUD that releases levonorgestrel or contraceptive pills. All treatments should be supervised by an obstetrician.

• Uterine artery embolization

This procedure reduces blood flow to adenomyosis, causing the size to decrease and symptoms to improve.

• Endometrial ablation

This destroys the uterine lining affected by adenomyosis and is effective only if adenomyosis has not deeply penetrated the myometrium.

• High-Intensity Focused Ultrasound (HIFU)

This technique uses a special ultrasound device to destroy endometrial tissue.

• Hysterectomy

This is the last option by removing the uterus. A hysterectomy may be considered if bleeding does not stop and symptoms do not improve. Patients should understand that after this procedure, they are unable to conceive and will not menstruate.

Complications

Adenomyosis can lead to several complications, including:

• Severe bleeding, which can cause fatigue and anemia
• Difficulty in achieving pregnancy, although this needs further study
• If adenomyosis occurs during pregnancy, complications such as miscarriage and preterm labor may occur

Prevention

Since the exact cause of adenomyosis is unknown, there are no specific preventive measures. However, being aware of adenomyosis symptoms allows for timely medical consultation. Regular gynecological check-ups can also help anticipate adenomyosis.

Additionally, adopting a healthy lifestyle can help, including:

• Eating a balanced diet to maintain a healthy weight
• Staying hydrated
• Avoiding smoking and alcohol
• Getting 7-8 hours of sleep daily

These habits help maintain overall health, which may reduce the risk of conditions like adenomyosis.

When to See a Doctor?

If your condition does not improve due to persistent pain or continuous bleeding outside the menstrual cycle, causing:

• Weakness
• Pale skin
• Cold skin
• Lower abdominal pain that does not improve with pain relievers

Seek medical attention or visit the emergency room for immediate help.

If your condition is stable but you experience persistent pain, visit a clinic and consult with a nearby obstetrician for outpatient treatment. The obstetrician will determine the appropriate management and therapy for your adenomyosis.

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