Adenomyosis

December 14, 2007

Before one can understand a discussion about adenomyosis, one of the leading causes of pelvic pain, painful periods, and even hysterectomy, it's necessary to understand the anatomy of the uterus.

 

A Review

 

The uterus is the pear-shaped organ that is mostly muscle surrounding a chamber that holds a developing pregnancy or, alternately, holds the tissue that has built up in preparation for a pregnancy. If a pregnancy doesn't implant, this tissue will shed as something seen as the "period." The outside of the uterus is covered by a layer called the serosa, which is actually the covering around the inside of the abdomen-it just flips over the uterus as part of this covering (peritoneum) of the abdomen. (So actually the uterus is not part of the abdomen, lying under the floor covering-the peritoneum-and therefore called "retroperitoneal," as are the kidneys and all of the major blood vessels traveling up and down the body.

So the uterus, being mostly a big muscle, which is important nine months after conception, is surrounded by this very thin layer, the serosa. Covering the underside of this muscle, and therefore surrounding the chamber that holds growing babies, is the "endometrium," and this is the glandular layer of varying thickness which rises and falls in response to the hormone cycle each month in anticipation for a pregnancy. Once a pregnancy occurs, the hormonally stimulated endometrium doesn't shed as a period but thickens to provide a rich bed into which the fertilized eggcan implant. The size of the uterus then expands to accommodate the growing baby, and eventually the thick muscular layer will contract at term in an organized labor to push the baby out. And so it goes.

But in the non-pregnant state the glandular endometrium will fall away each month to "wipe the slate clean," so to speak, and then the process of building up another rich bed for implantation begins again.

So the muscular layer-the myometrium-is important at the end of the pregnancy to effect labor. But it's the endometrium which is important from the very beginning to host the implantation and establish the association between the fetal and maternal circulations for the nourishment of the baby until labor at term.

 

Adenomyosis

 

The leading motivations for hysterectomy are painful periods ("dysmenorrhea") and heavy bleeding ("menorrrhagia"). Besides uterine fibroids ("leiomyomata"), there is another condition commonly associated with these discomforts--adenomyosis.

The word adenomyosis literally means glandular muscle condition (adeno- = gland, myo- = muscle, -osis = condition), and it is a very good word for the affliction. For adenomyosis is a condition in which the glandular layer of the endometrium invades the muscular middle layer of myometrium. It was once thought that this represented a type of endometriosis within the womb itself, but we now know that the two are quite different.

Endometriosis is abnormal endometrium-like tissue in abnormal locations, sent there by abnormal physiologic processes. Adenomyosis, on the other hand, is normal glandular tissue which grows into the muscle probably because of a breakdown in the anatomic separation between the muscle and the endometrium. Most researchers now think this breakdown can be due to trauma, specifically, scraping the womb ("curettage") after a miscarriage, for diagnostic reasons, or for elective abortions. (The study I base this article on* was specifically investigating the increased likelihood of adenomyosis in women who have had pregnancy terminations.  Like most studies, it stands vulnerable to revision by subsequent studies, so always, always beware.)

The depth of invasion of endometrial glands into the muscular myometrium seems to determine how much heavy bleeding there is. But the amount of scattered sites of invasion seems to determine how painful the periods will be.

The bad news about adenomysis is that it's a surgical diagnosis. That is, it's difficult to diagnose without looking at the uterus under a microscope, that is, after it comes out via hysterectomy and the tissue studied microscopically by a pathologist. Ultrasound will sometimes suggest it with a bubbly-like impression in the uterine wall, but this is not the diagnostic standard. Newer approaches, like MRI, are promising, but only so far, as whether a diagnosis is firmly established or not won't change what gets done.  Either the pain will be bad enough to warrant intervention or not.  A history and physical exam may also suggest it with a boggy-feeling uterus on pelvic exam associated with a history of heavy, painful periods.  

 

More bad news...and the good news...

 

The really bad news is that the treatment is surgical as well. Adenonsis generally won't get better until menopause, so if a woman suffereing with adenomyosis is years away from that, she is left with the bitter choice between "living with it" or having surgery. Likewise, if a woman wants another child, the "H"-word isn't an option.

Yes, there are medical approaches, but... they are medical approaches that sound good on paper, but are disappointing in practice.  Certainly if a woman wants more babies, she will pursue this conservative approach.  But in my practice, a women with adenomyosis who is finished her family typically loses patience with failed medical approaches quickly if she knows she doesn't have to champion keeping her womb.

  • Danacrine, a testosterone-like medication, can be used to shrink the glandular structures that have invaded the myometrium (muscle, see above).  This is a second-choice drug used in endometriosis, and it's second choice here, too, because of testosterone-like side effects in some women, such as deepening of the voice, decreased breast size, and hair growth (hirsutism). 
  • Lupron, the first choice drug for endometriosis, can be used for it's same effects on endometrial tissue.  It overshoots the stimulation of the entire menstrual cycle so that the system is overwhelmed and shuts down--a temporary menopause.  But like menopause, this can't be used indefiinitely, because of menopausal symptoms and possible menopausal-like bone loss (osteoporosis). 
  • Birth cotrol pills can make things better or worse, but usually unchanged or worse.

The good news about adenomyosis is that it is a benign condition. It has no malignant potential, the only downside being that it makes periods miserable, either with the amount of bleeding with or without the increase in pain. But you can't go wrong trying conservative approaches in an attempt to avoid or delay surgery.

Adenomyosis is a misery women have exclusive of men, thanks to having a uterus. But then again, look at what women do with a uterus.

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