The term adenomyosis refers to a series of changes that occur strictly within the uterus, which lead to the presence of the uterine lining (endometrium) within the muscular layer of the uterus (myometrium). For this reason, adenomyosis is incorrectly termed “internal endometriosis”. When it occurs in women over the age of 40, adenomyosis can be considered an aging process of the uterus. When it occurs in young women, in association with endometriosis, accompanied by painful symptoms or abundant bleeding during or outside of menstruation (meno- or metrorrhagia), adenomyosis can be considered a pathology.
The etiology of adenomyosis is not completely understood. The most accepted theory is that the myometrium is progressively invaded by the endometrium in the form of numerous invaginations shaped like a finger glove, which then branch out into microcysts.
These microcysts made up of endometrium, the overall surface of which is enlarged, have several consequences. The first is an increase in the amount of blood lost during menstruation (menorrhagia), and the second is the elimination of the blood contained in these cysts outside menstruation, in the form of dark blood (metrorrhagia). These microhemorrhages are responsible for inflammatory phenomena leading to pain. This bleeding and pain can also occur when there is an increase in abdominal pressure, which compresses the uterus, for example during sexual intercourse or sports.
The above-mentioned phenomena also lead to a modification in the appearance of the uterus, which gradually fills with blood. This causes an overall increase in uterine volume, which takes on a rounded appearance and buff color, and also a softer consistency. These elements can be checked during a clinical examination for example.
The symptoms of adenomyosis are similarto those of the often associated endometriosis. There are painful phenomena such as dysmenorrhea (pain during menstruation), deep dyspareunia (pain during sexual intercourse) and inter-menstrual pain (between periods).
Menorrhagia and metrorrhagia are also common, whether spontaneous or caused by increased abdominal pressure.
Adenomyosis is also frequently associated with uterine fibroids, which are also a source of bleeding and pelvic pain.
Diagnosis of adenomyosis is histological, i.e. it requires a microscopic analysis of the uterus and consequently a hysterectomy, which is not feasible in young women who wish to become pregnant.
However, today, accurate diagnosis of adenomyosis can be made using imaging examinations such as pelvic ultrasound and pelvic MRI.
Several forms of adenomyosis have been described, including diffuse forms (microcysts are distributed relatively evenly around the uterine cavity), or focal forms (foci of adenomyosis with or without a connection to the uterine cavity).
Adenomyosis is frequently found in cases of endometriosis of the rectum or bladder where uterine lesions appear in continuity with ectopic lesions of the rectum and/or bladder.
Medical treatment of adenomyosis is aimed at controlling the symptoms and not the disease anatomically. The principle of treatment is, as with endometriosis, to block ovulation and suppress menstruation, allowing the endometrium to shrink or microhemorrhages to disappear. The results of medical treatment are nevertheless very variable, with bleeding and pain persisting despite well-directed treatment.
Surgical treatment is either conservative (conservation of the uterus) or radical (hysterectomy or removal of the uterus). Conservative techniques aim to destroy the areas of adenomyosis in the most targeted way possible so as to reduce symptoms.
In diffuse forms of adenomyosis, some endometrial destruction techniques can destroy localized microcysts in the myometrium if not very deep. However, this technique is not recommended for women who wish to become pregnant since it also destroys healthy endometrium. In addition, it can also leave the deeper foci in place, which may cause a recurrence of symptoms in the short or medium term.
In forms of focal adenomyosis, it is possible to envisage removal of the original site, while preserving the uterus, using a technique similar to that used for fibroids. The Osada technique is one such technique, generally performed by opening the abdomen (laparotomy). The exeresis is often incomplete but allows improvement in symptoms and pregnancy for women who wish to conceive.
The most effective surgery for adenomyosis remains hysterectomy, resulting in the elimination of bleeding and an improvement in pain. It is of course reserved for patients who no longer wish to become pregnant and after failure of medical treatments.
In women who wish to conceive, surgery most often concerns the endometriosis only, while adenomyosis remains in place. This situation can lead to persistent dysmenorrhea, deep dyspareunia or intermenstrual pain. A hysterectomy can be performed in a second instance, once pregnancy(s) has been achieved and significant improvement in pain and quality of life
27-59%
of women with adenomyosis have severe Dsymenorrhea
42-60%
of women with adenomyosis have menorrhagia
49%
of women with deep endometriosis have adenomyosis
Source : Protopapas et al, Facts Views Vis Obgyn, 2020, 12 (2): 91-104
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