by Tamer Seckin, MD | Posted on May 15, 2020
Adenomyosis is a benign uterine disorder that causes the endometrial tissue of the endometrial cavity in the uterus to grow into the uterus muscle, subsequently damaging the uterine wall. Adenomyosis frequently coexists with other gynecological diseases, such as endometriosis and uterine fibroids. The difference between adenomyosis and endometriosis is that with endometriosis the tissue grows outside of the uterus. Endometriosis and adenomyosis are both metaplasia conditions, meaning the diseased cells will change when they invade new organs. In the case of adenomyosis, this causes abnormal uterus cell growth. Due to these similarities and subtle differences between adenomyosis and endometriosis, it is often referred to as the “sister” disease of endometriosis.
Like many diseases, a woman can have adenomyosis, yet have no symptoms at all. Others can experience debilitating pain and heavy menstrual bleeding.
In the last decade, an increasing number of studies have identified various causes for adenomyosis. There are new studies that have shown that sex steroid hormone receptors, inflammatory molecules, extracellular matrix enzymes, growth factors, and neuroangiogenic factors play a significant role.
There are many theories and science surrounding adenomyosis that continues to evolve. Until there's more research, there will continue to be multiple theories.
Prior uterine surgery or childbirth causes inflammation of the uterine lining that might cause a break in the healthy boundary of cells that line the uterus. Surgical procedures on the uterus can have a similar effect.
Tissue trauma or any vaginal injury that allows inflammation and can lead to increased macrophages and cytokines to migrate into the myometrium
Stimulation of migratory tissue into the myometrium, due to a high expression of estrogen receptors.
Spread and buildup of myometrium cells through the lymphatic system or through stem cells.
Various hormones -- including estrogen, progesterone, prolactin, and follicle-stimulating hormone -- may trigger the condition.
Recent studies suggest smoking
Pathology has always been considered the gold standard to make the final diagnosis of adenomyosis. Generally, women having hysterectomies would have the tissue removed and examined under a microscope by a pathologist.
Imaging, both MRI and TVUS (transvaginal ultrasonography/ultrasound/sonogram) have emerged more recently as a way for endometriosis specialists to make a non-invasive diagnosis of adenomyosis.
The simplest form of diagnosis is TVUS performed endovaginally. Ultrasound is generally the first-line for imaging and is highly accurate if performed by an expert sonographer. Ultrasounds can show cysts within the uterine muscle, revealing suspected adenomyosis. With the right doctor, an ultrasound can provide a substantial enough approach to identifying adenomyosis, providing a sensitivity rate of 83% and a specificity rate of 85%.
Many specialists will also advise an MRI, to diagnose adenomyosis. An MRI allows a physician to see all the glands of the myometrium, the thickness of the junctional zone (which will be thicker than 1cm in adenomyosis cases), and asymmetric walls. An MRI allows your doctor to see whether or not you have adenomyosis first hand, with a high sensitivity rate of 88% and a specificity rate of 93%. There are also minimally invasive techniques such as historiography, hysteroscopy, cystoscopy, and laparoscopy. However, these are less commonly used for initial diagnosis as they are most often performed in an operating room and are much more expensive.
There are several risk factors that preliminary research is saying increases your risk for adenomyosis.
More recently, research is pointing to adenomyosis being diagnosed with increasing frequency in infertile patients because women are delaying their first pregnancy until their late 30s or early 40s, implying that it does have a negative impact on female fertility.
There are three different classifications for adenomyosis. The classifications are essential as to how the adenomyosis is going to be treated. Focal adenomyosis and adenomyoma, if operated on correctly, in most cases will not require a hysterectomy.
It is common for patients with adenomyosis to have decreased fertility rates and, in some cases, infertility. Infertility is because patients with this disease are more likely to have endometriosis too, which can have detrimental effects when it comes to the reproductive system. When a patient has adenomyosis, the myometrium (the smooth muscle tissue of the uterus) grows. With enough build-up, the myometrium will begin to obstruct the fallopian tubes related to the interstitial part of the tubes on the myometrium itself. A partial blockage of the opening between the uterus and the fallopian tubes will ultimately decrease one's chances of pregnancy, as this is the path that sperm takes to fertilize an egg. It has been reported by the reproductive endocrinology committee at the Japan Society of OB/GYN, as referenced by the Endometriosis Foundation of America, that patients suffering from adenomyosis will have:
The only way to treat adenomyosis is with uterine surgery. However, the symptoms can be managed non-surgically. Which method would be right for you depends on the seriousness of the adenomyosis.
Many of the drugs approved for and used by endometriosis patients are also used to treat adenomyosis, but it is important to note that not every patient is the same. While some patients experience pain relief by taking birth control, others do not. If bleeding is a patient’s primary symptom, birth control pills and/or IUDs may be helpful. Of course, the side effects of the drugs also need to be taken into consideration, as patients react differently to different drugs.
The preferred surgical method is laparoscopic deep excisional adenomyosis surgery (LEAS). The aim of this approach is to prevent the removal of the uterus. Requiring extreme skill in meticulous suturing, uterine muscles need to be reconstructed layer by layer to carry the pregnancy. When adenomyosis is confined to one wall, another conservative technique we could perform is the Osada Procedure, named after a Japanese surgeon who defined the technique.
An alternative surgical method is a hysterectomy or partial hysterectomy. This is when the uterus or part of the uterus is removed. A hysterectomy should be the absolute last resort for every patient. In either approach, any endometriosis - which coexists with adenomyosis in more than half of the cases - must be completely excised.
One method not recommended for treating adenomyosis is uterine artery embolization. Also note that hormonal treatments (such as birth control pills) do not treat adenomyosis, but they will help to manage menstrual cycles.
Unlike many gynecological surgeons, surgeons at the Seckin Endometriosis Center do not always view a hysterectomy as the universal treatment for adenomyosis. In fact, too many patients undergo unnecessary hysterectomies. In cases of focal adenomyosis or adenomyoma, the SEC team will advise a minimally invasive approach avoiding large scar laparoscopic deep excision surgery before a hysterectomy. Only in cases of advanced adenomyosis will Dr. Seckin perform a hysterectomy, because in those cases the abnormal tissue has spread throughout and the uterus is beyond repair.
Removing the uterus with a hysterectomy doesn't solve all the co-morbidities associated with adenomyosis because nearly 50% of women diagnosed have lesions outside the uterus.
A hysterectomy has its limitations when treating adenomyosis that involves peritoneal endometriosis and deep infiltrating lesions related to the bowel, bladder, ureter, and retroperitoneal fibrosis. For these cases, hysterectomy is only a partial solution. Patients will also need to have laparoscopic excision surgery to remove the lesions outside of the uterus.
Too many patients undergo unnecessary hysterectomies. At the Seckin Endometriosis Center, we have a deep respect for the personal journey that comes with deciding to have a hysterectomy. We never recommend this treatment lightly and only see it as the final option after all other courses of action have been exhausted. Because this is such a difficult diagnosis for so many women, we make it our priority to be available to advise and support patients every step of the way.
The removal of the uterus will not address every problem associated with it because about 50% of patients have lesions outside of the uterus as well. A hysterectomy alone addresses neither peritoneal endometriosis nor deeply infiltrating lesions that may associate with the bowel, bladder, ureter disease, and retroperitoneal fibrosis causing neuropathy.
In cases of it, there are too many patients who undergo unnecessary hysterectomies. We know that hysterectomies are very personal, and should only be conducted if necessary. This is why we are always open to discussing every treatment option that is best for your particular case.
Amy O. was 39 years old when she came to Dr. Seckin. She had experienced heavy periods and severe cramping since the age of 12 and was diagnosed with endometriosis and adenomyosis at the age of 29, after having 4 different surgeries. After a 27-year battle with her disease, Amy received her final surgery in July 2016. Read more about how Amy feels now.
You can read more stories of patients, at varying stages, in our testimonial section.
There aren’t enough stars for Seckin Endometriosis. They deserve 100/ 5. I want to make sure every woman right now who is looking for help, who is looking for a doctor and is scared and confused knows this is where you need to be. It doesn’t matter if you have to come from the other side of the United States or from the other side of the world, I can guarantee it will be worth it. Every member of their…
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I was there for hysterectomy but then I found out that I also had endometriosis.My both surgeries went excellent and I feel great!.I am so thankful to Dr.Seckin and all his team for making my journey smooth!
I am a physician who suffered from deep infiltrative endometriosis. I needed laparoscopic surgery, so I went to see my former gynaecologist and he performed the procedure (a surgery which he supposedly does hundreds of times a year) last November. I had severe pain again when I had my period in January and was advised to go on taking a low hormone dose anticoncipient pill. My symptoms came back quickly and got worse in a few months’ time. I went…
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Dr Seckin and his team gave me back my life! Tomorrow will be 1 month since my surgery and I feel great. Dr. Seckin, Dr Liu, and Dr Goldstein are not only beyond words talented and amazing Doctors, but they are also genuinely wonderful and caring people. I cannot say enough great things about Holly, Asiye and Kim as well. They were all caring, kind, patient, and took the time to listen to me and explain anything I needed to…