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Guide to Adenomyosis: Definition, Symptoms, Diagnosis and Treatments

adenomyosis

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Adenomyosis is very often defined as endometriosis inside the uterus

Introduction:

In fact, it is an abnormality of the junction zone between the endometrium (mucous membrane that lines the inside of the uterus) and the myometrium (muscle of the uterine wall). This abnormality will allow the endometrial cells to infiltrate the muscle layer of the uterus. It can be superficial (thickening of the area up to 12 mm) or deep (and painful).

It is a frequent and benign condition in the medical sense, i.e. it is not life threatening. Nevertheless, some forms of adenomyosis can be extremely painful and disabling in everyday life.

There are 3 types of adenomyosis:

– Focal adenomyosis: One or more foci that develop in a very localized part of the myometrium with or without a connection to the uterine cavity.

– External adenomyosis: Deep pelvic endometriosis infiltrates the myometrium. There is a correlation between pelvic endometriosis and adenomyosis. But there is no rule: a woman can have adenomyosis without having endometriosis. And vice versa.

– Diffuse adenomyosis: Numerous foci are scattered over the entire muscle of the uterine wall in a relatively uniform manner. Diffuse adenomyosis is generally more severe and more difficult to treat than the previous two.

Adenomyosis affects 13% of the French female population. In 25% of cases, the women affected are between 36 and 40 years old. In 6 to 20% of cases, adenomyosis and endometriosis are associated.

The different symptoms of adenomyosis

– Menorrhagia: long, bleeding periods, usually lasting more than 7 days. This symptom is encountered by 50% of women with adenomyosis.

– Dysmenorrhoea: painful periods due to contractions of the uterus. This symptom is experienced by 30% of women with adenomyosis.

– Metrorrhagia: Dark colored blood loss outside the menstrual period. These microbleeds are responsible for inflammatory phenomena leading to pain. This symptom is encountered by 20% of women with adenomyosis.

– Dyspareunia: severe pain during sexual intercourse.

– Fertility problems, although many patients report successful pregnancies. Adenomyosis can also decrease the rate of embryo implantation and increase the risk of spontaneous miscarriage.

These symptoms can be increased by sexual intercourse or sports. Adenomyosis is also frequently associated with uterine fibroids, which are also a cause of bleeding and pelvic pain.

However, two thirds of women with adenomyosis have no symptoms.

Diagnosis

A definite diagnosis of adenomyosis requires microscopic analysis of the uterus, and therefore a hysterectomy (removal of the uterus), which is unthinkable in young women who want to become pregnant.

However, certain imaging tests can be used to diagnose and determine the extent of adenomyosis without a hysterectomy. These examinations can also be used to look for any associated pathologies (external endometriosis, uterine fibroids, etc.). Generally, the diagnosis of adenomyosis is made by :

– A pelvic ultrasound scan through the vagina, which allows the detection of signs of adenomyosis (overall increase in the size of the uterus, asymmetric uterine walls, inflamed or thickened myometrium, etc.) and/or an associated pathology (external endometriosis, uterine fibroids, etc.).

– A pelvic MRI may complete the diagnosis if there is a suspected associated endometriosis.

– A biopsy of the uterine muscle allows the definitive diagnosis of adenomyosis to be made.

Treatments

Treatment is tailored to the patient’s age, plans, response to treatment, extent of lesions and symptoms. For example, an asymptomatic adenomyosis in a 40-year-old woman who has no desire to become pregnant will be monitored, but not necessarily treated.

For women with a desire to become pregnant, the medical treatment of adenomyosis is aimed at controlling the symptoms and not at eradicating the disease.

The principle of the treatment is, as for endometriosis, to block ovulation and suppress menstruation, allowing the endometrium to atrophy and reducing or eliminating microhemorrhages. The results of medical treatment are nevertheless very variable, with bleeding and pain persisting despite well-conducted treatment.

In forms of focal adenomyosis, it is possible to consider excision of the focus, while preserving the uterus, using a technique similar to that used for fibroids. The Osada technique is one such technique, but it is generally performed by opening the abdomen (laparotomy). The removal is often incomplete, but allows improvement of symptoms and enables pregnancy to be achieved in women who wish to become pregnant.

For women who do not wish or no longer wish to become pregnant, the most effective surgery for adenomyosis is hysterectomy (after failure of medical treatments), with a disappearance of bleeding and a good improvement in pain.

In diffuse forms of adenomyosis, certain techniques for destroying the endometrium make it possible to destroy the microcysts located in the myometrium when they are not very deep. This technique also destroys the healthy endometrium and is therefore only suitable for women who do not wish to become pregnant. In addition, it can also leave the deeper foci in place, which can lead to a recurrence of symptoms in the short to medium term.

Causes of adenomyosis

Overall, we believe that adenomyosis is related to relative hyperoestrogenism, i.e. an overproduction of oestrogen in the endometrium, which allows it to proliferate in the uterus. However, it is not yet known exactly what triggers this hyperoestrogenism.

When Adenomyosis occurs in women over 40 years of age, it can be seen as a process of ageing of the uterus.

When it occurs in young women, adenomyosis can be considered a pathology.

Adenomyosis is most common in women who have had several children or who have a very large endometrium (uterine lining) (this is called endometrial hyperplasia).

It is not known today whether surgery or caesarean sections can lead to adenomyosis. On the other hand, in interviews with patients with adenomyosis, we find women who have had placentas with abnormalities.

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