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Thoughts on Adenomyosis
Author: Nicholas Fogelson, MD
One of the most common reasons for heavy and painful bleeding in women is Adenomyosis. It is a condition where the muscle of the uterus (the myometrium) has been invaded with tissue normally making up the lining of the uterus ( the endometrium ).
The most common story for adenomyosis is a woman who has had several children, who with each successive child has had worse and worse pain with bleeding, which gets heavier over time as well. Commonly I hear "it really started after <child name> was born". This is unlike endometriosis, where symptoms usually start at a young age, often with the first menstruation. Women with adenomyosis often have normal and minimally symptomatic period for most of their life, and develop problems later after they have children.
To better understand adenomyosis, think of a layer cake, with alternating layers of sponge, jelly, and frosting. When you first cut into such a cake, you can see these layers completely separated, and no parts of one layer are mixed into the other layers. Now imagine taking a spoon and taking some big chunks of cake, mixing it up, and then putting it back, mixing up the layers.
The uterus is also like a layer cake. The inner layer is the endometrium, the proliferative layer that grows and sloughs off with each menstrual cycle. This tissue is very responsive to the hormones estrogen and progesterone, and will grow and bleed every month in a regular and controlled fashion as long as there are regular cycles of estrogen and progesterone influencing it. The middle layer of the uterus is the myometrium, a thick layer of visceral or smooth muscle. The uterus also has an outer layer called the serosa, which is a layer of skin similar to what coats the inner walls of the pelvis, also called visceral peritoneum.
As long as these layers stay nice and separated (and the uterus is not affected by other structural issues like fibroids), the uterus will function well. But it turns out that over the course of a woman's life, these layers often get mixed up, leading to adenomyosis. Just like the mixed up cake, it doesn't look right, and it doesn't work right. At least the cake will still taste good.
The most common reason for adenomyosis is resulting from pregnancy. Each time a woman is pregnant, the fetus grows a placenta that adheres to the uterine wall. In fact, it doesn't just stick - it actually invades the uterine wall just like a cancer would invade tissue (and in fact it uses many of the same genetic mechanisms to do this that a cancer uses). When this invasion occurs, part of the endometrium and myometrium is actually consumed and replaced with a rich network of vessels than intertwine with the vessels of the baby, in effect fusing the uterus and the placenta into a single structure.
Once the baby is born, the placenta will release. Where it previously lay will now be a crater in the uterine wall, with exposed myometrium and interrupted endometrium. Effectively, someone came along with a spoon and took a big scoop out of the cake. The body will heal this hole, but unfortunately we are not as good at laying down these perfect layers the second time, and often the endometrial layer gets mixed into the myometrial layer - creating adenomyosis. With successive pregnancies this can get worse and worse, and in some cases a uterus can get quite taken over by adenomyosis.
Because this endometrial tissue is responsive to hormones just like the rest of the endometrium, during the menses a woman may bleed directly into the uterine muscle. It also increases the blood flow requirements for the uterus, leading to increased volume of bleeding. It also may interfere with the ability of the uterus to fully contract, also increasing bleeding. In effect, the more pregnancies a woman has, the worse the uterus works. Cleary, this occurs in varying degree from woman to woman, but all women have at least some adenomyosis after a term pregnancy.
The good news is that adenomyosis is actually quite treatable, particularly in a woman who has completed childbearing. In women who want to have more children, there are also medical therapies that may benefit them.
The most effective medical therapy for adenomyosis is a progesterone IUD, like a Mirena. A progesterone IUD in the uterus will release progesterone directly into the uterine wall, in effect exactly where the action is. This will suppress growth of the endometrium, as well as the ectopic endometrial tissue in the uterine wall, suppressing the activity of the adenomyosis. In many women, this can completely address the symptoms such that no other treatment is required.
In women where this does not work well, systemic hormones can also be tried.
For women who have completed childbearing, I often recommend a hysterectomy. In this day and age, we can complete a minimally invasive hysterectomy that is quick to recover from, and completely addresses adenomyosis with no chance of recurrence. With the uterus gone, the adenomyosis is gone. Endometriosis can also be addressed at the time of hysterectomy, if it is present.
There are also sort of middle of the road procedures such as a endometrial ablation. This attempts to burn the lining of the uterus to decrease bleeding. In my practice, I do not recommend these procedures, as they are less effective than a hysterectomy and still ruin the uterus for childbearing. In my mind they are an inferior treatment that is nearly as expensive. In fact, I have done a lot of minimally invasive hysterectomies for women who have had previous endometrial ablation. In the day and age where a hysterectomy was a very major surgery with long recovery, it made sense to consider an ablation, which is quick and easy to recover from. But with today's minimally invasive techniques for hysterectomy, it makes little sense to burn out the uterine lining rather than just removing the uterus entirely, as the hysterectomy works 100% of the time and is still pretty quick to recover from.
The one other thing to discuss about adenomyosis is the idea of congenital adenomyosis. This would be adenomyosis that doesn't come from pregnancy, but rather is something a woman is born with. This is probably much more akin to endometriosis within the wall of the uterus, laid down as an error in embryogenesis. When I was in training this wasn't an entity that people really believed in, but as I have practiced in the pelvic pain world I have definitely seen women who had all the symptoms of adenomyosis but did not ever have children, and in fact after a hysterectomy the uterus indeed showed signs of adenomyosis.
No matter where it comes from, the great thing about adenomyosis is that its very treatable, and with hysterectomy there is a basically 100% cure rate. And as a doctor that works in pelvic pain, one of the most complex disease states with many different partially effective treatments, its great to have something that can always be treated successfully.
If you think you have adenomyosis and could benefit from our care, please give us a call at 503-715-1377 and we would be happy to help.